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The Journal
of the
Michigan State Medical Society
Published under the Direction
of The Council
Publication Committee
G. B. Saltonstall, M.D., Chairman
William Bromme, M.D.
B. M. Harris, M.D.
O. B. McGillicuddy, M.D.
W. S. Stinson, M.D.
T. P. Wickliffe, M.D.
Wilfrid Haughey, B.A., M.A., M.D.
Editor
L. Fernald Foster, M.D., Secretary and Business Manager
Wm. J. Burns, LL.B., Executive Director
VOLUME 56
19 5 7
Copyright 1957 by
Michigan State Medical Society
Printed in U.S.A.
THE JOURNAL
of the Michigan State Medical Society
►LUME 56 JANUARY, 1957 NUMBER I
Contributors to This Issue Table of Contents
V. Hoobler, M.D.
C. G. Johnston
R. C. Moehlig, M.D.
J. Starkman, M.D.
Clinical Evaluation of Sintrom (G-23350), a New
Oral Anticoagulant
J. A. Polhemus, M.D. , W. S. Wilson, M.D., P. W.
Willis III, M.D., J. R. Gamble, M.D. , D. R.
Griffin, M.D., P. E. Hodgson, M.D., and I. F.
Duff, M.D 49
Diuretics in the Treatment of Congestive Heart
Failure
Toshikazu Morita, M.D 52
Interatrial Septal Defect
James B. Blodgett, M.D 57
Familial Heights as a Useful Guide in the Diagnosis
of Genitourinary Anomalies
Robert C. Moehlig, M.D 61
Paroxysmal Tachycardia in Infants
Irving F. Burton, M.D. , and Morris Starkman,
M.D 64
Modern Techniques for the Diagnosis of Pheochro-
mocytoma
5. W. Hoobler, M.D., Robert D. Johnson, M.D.,
and Ray Warzynski, M.D
Cerebral Angiography
H. Harvey Gass, M.D
Anomalous Left Coronary Artery and Endocardial
Fibroelastosis
John F. Sander, M.D., and Ronald C. Peets,
M.D
67
72
80
Diagnosis of the Operable Arterial Lesion
Herbert J. Robb, M.D., and Charles G. J ohnston,
M.D .84
Detecting Glycosuria
Joseph D. Mann, M.D
89
President’s Message:
I Challenge You...
91
Editorial :
Congress and Medical Legislation 92
Jenkins-Keogh 92
Health Reinsurance 93
Medical Education 93
Medical Draft 93
Government Employes’ Insurance 93
Michigan Legislation 94
The Year 1956: Medicare 94
Michigan Clinical Institute:
Heart Association Program 95
Color Television Program 96
Michigan’s Department of Health 98
In Memoriam 100
News Medical 102
Legal Opinions 118
Correspondence 122
The Doctor’s Library 124
You and Your Business 14
Michigan Medical Service 18
Heart Beats 28
Foundation for Eye Care 34
Prevention of Rheumatic Fever 38
PR Report 40
Blue Shield is for Everybody 42
© 1957 by Michigan State Medical Society
ilIARY, 1957
3
THE JOURNAL
of the Michigan State Medical Society
=VOLUME 56 JANUARY, 1957 NUMBER 1 =
PUBLICATION COMMITTEE
G. B. SALTONSTALL, M.D., Chairman Charlevoix
WILLIAM BROMME, M.D Detroit
B. M. HARRIS, M.D Ypsilanti
O. B. McGILLICUDDY, M.D Lansing
W. S. STINSON, M.D Bay City
T. P. WICKLIFFE, M.D Calumet
Office of Publication
2642 University Avenue
Saint Paul 14, Minnesota
Editor
WILFRID HAUGHEY, M.D.
610 Post Bldg., Battle Creek, Michigan
Secretary and Business Manager of THE JOURNAL
L. FERNALD FOSTER, M.D.
Thome Bldg., 919 Washington Ave.
Bay City, Michigan
Executive Director
WM. J. BURNS, LL.B.
606 Townsend Street, Lansing 15, Michigan
All communications relative to exchanges, books for review, manu-
scripts, should be addressed to Wilfrid Haughey, M.D., 610 Post
Bldg,, Battle Creek, Michigan.
All communications regarding advertising and subscription should
be addressed to Wm. J. Burns, 2642 University Avenue, Saint
Paul 14, Minnesota, or 606 Townsend Street, Lansing 15, Michigan.
Telephone Ivanhoe 57125.
© 1957, by Michigan State Medical Society.
Published monthly by the Michigan State Medical Society as its
official journal at 2642 University Avenue, Saint Paul 14, Minnesota.
Entered at the post office at Saint Paul, Minnesota, as second
class matter, May 7, 1930, under the Act of March 3, 1879.
Acceptance for mailing at special rate of postage provided for
in Section 1103 Act of October 3, 1917, authorized August 7, 1918.
Yearly subscription rate, $6.00; single copies, 60 cents. Additional
postage; Canada, $1.00 per year; Pan-American Union, $2.50 per
year; Foreign, $2.50 per year.
PRINTED IN U.S.A.
OFFICERS OF THE SOCIETY
1956-1957
President ARCH WALLS, M.D ..Detroit
President-Elect G. W. SLAGLE M.D Battle Creek
Secretary L. FERNALD FOSTER, M.D Bay CiW
Treasurer „..W. A. HYLAND, M.D Grand Rapids
Speaker K. H. JOHNSON, M.D Lansing
Vice Speaker J. J. LIGHTBODY, M.D... - Detroit
Editor. WILFRID HAUGHEY, M.D Battle Creek
THE COUNCIL
D. BRUCE WILEY, M.D., Chairman, Utica
W. B. HARM, M.D., Vice Chairman, Detroit
L. FERNALD FOSTER, M.D., Secretary, Bay City
Term
District Expires
A. E. SCHILLER, M.D 1st Detroit 1961
0. B. McGILLICUDDY, M.D 2nd Lansing 1960
H. J. MEIER, M.D 3rd Coldwater 1960
RALPH W. SHOOK, M.D 4th Kalamazoo 1961
C. ALLEN PAYNE, M.D 5th Grand Rapids 1961
H. H. HISCOCK, M.D 6th Flint 1961
H. B. ZEMMER. M.D 7th Lapeer 1957
L. C. HARVIE, M.D 8th Saginaw 1957
G. B. SALTONSTALL, M.D 9th Charlevoix 1957
W. S. STINSON, M.D 10th Bay City 1957
W. M. LeFEVRE. M.D Uth Muskegon 1958
B. T. MONTGOMERY, M.D 12th Sault Ste. Marie.. .1958
T. P. WICKLIFFE, M.D 13th Calumet 1959
B. M. HARRIS, M.D Uth Ypsilanti 1959
D. BRUCE WILEY, M.D 15th Utica 1960
G. THOMAS McKEAN. M.D 16th Detroit 1960
W. B. HARM, M.D Uth Detroit 1958
WILLIAM BROMME, M.D 18th Detroit 1959
ARCH WALLS, M.D President Detroit
G. W. SLAGLE, M.D President-Elect Battle Creek
K. H. JOHNSON, M.D Speaker Lansing
J. J. LIGHTBODY, M.D Vice Speaker Detroit
L. FERNALD FOSTER, M.D Secretary Bay City
W. A. HYLAND, M.D Treasurer Grand Rapids
W. S. JONES, M.D Past President Menominee
EXECUTIVE COMMITTEE OF THE COUNCIL
D. BRUCE WILEY, M.D Chairman
W. B. HARM, M.D Vice Chairman
W. M. LeFEVRE, M.D Chairman, County Societies Committee
G. B. SALTONSTALL, M.D Chairman, Publication Committee
RALPH W. SHOOK, M.D Chairman, Finance Committee
K. H. JOHNSON, M.D Speaker, House of Delegates
J. J. LIGHTBODY, M.D Vice Speaker, House of Delegates
4RCH WALLS, M.D President
G. W. SLAGLE, M.D President-Elect
L. FERNALD FOSTER, M.D Secretary
W. A. HYLAND. M.D Treasurer
SECTION OFFICERS
Dermatology and Syphilology
Wm. T. Kruse, M.D Grand Rapids
Chairman
Coleman Mopper, M.D Detroit
Secretary
Gastroenterology and Proctology
N. D. Nigro, M.D Detroit 1
Chairman
E. J. Tallant, M.D Detroit
Secretary
General Practice
F. P. Rhoades, M.D Detroit 2
Chairman
F. C. Brace, M.D Grand Rapids
Secretary
Gynecology and Obstetrics
J. H. Beaton, M.D. Grand Rapids
Chairman
R. W. McClure, M.D Detroit 26
Secretary
Medicine
J. M. Kaufman, M.D Detroit 26
Chairman
J. W. Hall, M.D Traverse City
Secretary
Nervous and Mental Diseases
W. R. Slenger, M.D Ann Arbor
Chairman
S. C. Mason, M.D Ann Arbor
Secretary
Occupational Health
O. J. Johnson, M.D Bay City
Chairman
P. B. Rastello, M.D. Detroit 9
Secretary
Ophthalmology and Otolaryngology
B. C. Wildgen, M.D Muskegon
Chairman (Ophth.)
W. K. Locklin, M.D Kalamazoo
Co-Chairman (Oto.)
H. A. Dunlap, M.D Detroit 14
Secretary (Ophth.)
H. L. LeVett, M.D Lansing
Co-Secretary (Oto.)
Pediatrics
C. E. Booher, M.D Grand Rapids
Chairman
A. M. Hill, M.D Grand Rapids
Secretary
Public Health and Preventive
Medicine
J. D. Monroe, M.D Pontiac
Chairman
J. K. Altland, M.D Lansing 4
Secretary
Radiology, Pathology, Anesthesiology
R. B. Sweet. M.D Ann Arbor
Chairman (Anes.)
E. R. Jennings, M.D Detroit
Vice-Chairman (Path.)
E. O. Pearson, M.D Kalamazoo
Secretary (Rad.)
Surgery
E. T. Thieme, M.D Ann Arbor
Chairman
H. M. Bishop, M.D Saginaw
Secretary
Urology
R. P. Lytle, M.D Detroit 1
Chairman
J. F. Harrold, M.D Lansing
Secretary
Delegates DELEGATES
W. A. Hyland, M.D., Grand Rapids, Chairman 1957
J. S. DeTar, M.D., Milan 1957
C. I. Owen, M.D., Detroit 1957
W. D. Barrett, M.D., Detroit 1958
W. H. Huron, M.D., Iron Mountain 1958
R. L. Novy, M.D., Detroit 1958
TO A. M. A. Alternates
W. W. Babcock, M.D.. Detroit 1957
E. F. Sladek, M.D., Traverse City 1957
O. J. Johnson, M.D., Bay City 1957
William Bromme, M.D.. Detroit 1958
J. R. Rodger, M.D., Bellaire 1958
G. W. Slagle, M.D., Battle Creek 1958
Section Delegate
G. C. Penberthy, M.D. (Surgical Section) Detroit
4
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You and Your Business
1957 MCI, MARCH 13-14-15 and Blue Shield plans for diagnostic out-patient
“HIGHLIGHTS AND KNOW HOW! services.
That’s the modern theme of the 1957 Michigan
Clinical Institute — the best regional “refresher
course” in the country. Each of the 29 speakers
will bring to the Institute an important segment
of NEW clinical information evolved in the past
365 days! Famous teachers will speak only of the
LATEST in medical knowledge and techniques.
“Highlights” will draw a record attendance of
M.D.’s to the 1957 MCI from Michigan, Ohio,
Indiana, Ontario, and Wisconsin.
POPULAR BLOCK-TYPE PROGRAM
The successful “block-system” presentation of
eight important sections of medicine — so attrac-
tive at last year’s Institute — will be featured in
1957 as a novel time-saver for the busy Doctors
of Medicine:
New “Block”
3/13/57 A.M. Surgery
P.M.
3/14/57 A.M.
P.M.
3/15/57 A.M.
P.M.
Program
Trauma
Heart and Rheumatic Fever
Internal Medicine
Obstetrics-Gynecology-Pediatrics
General Medicine
CLOSED CIRCUIT COLOR TV
An outstanding color television program will
be beamed to the Grand Ballroom of the Sheraton
Cadillac Hotel, Detroit, through the co-operation
of The Grace Hospital Staff and Smith, Kline &
French Laboratories of Philadelphia.
(See pages 96-97.)
IMPORTANT HOUSE OF DELEGATES
ACTIONS— 1956
The MSMS legislative body, meeting in De-
troit, September 24-25, 1956, adopted resolutions
(a) urging establishment of departments of gen-
eral practice in medical schools’ curricula; (b)
instructing that a committee be appointed to
study the use of the word “clinic”; (c) instruct-
ing that a permanent advisory committee on fees
be appointed; (d) objecting to Michigan’s At-
torney General’s Opinion that the practice of
psychotherapy is the practice of medicine; (e)
urging expansion of medical school facilities at
Wayne State University; (f) urging adequate
funds to carry out civil defense; (g) directing
The Council to build a new MSMS headquarters;
(h) instructing that a committee be appointed
to study excess beds in tuberculosis sanitoria; (i)
urging total participation of Michigan M.D.’s in
Michigan Medical Service; (j) urging more com-
prehensive prepaid medical care insurance plans
Resolutions re Michigan Medical Service
The more important resolutions concerning
Michigan’s Blue Shield were the following:
Resolution Urging Total Participation of M.D.’s in
Michigan Medical Service
( Substitute resolution approved by 1956 MSMS House of Delegates)
Whereas, there is an apparent lack of full under-
standing and appreciation of the basic principles and
philosophy of Michigan Medical Service, and
Whereas, the survival of the voluntary system of
prepayment medical care depends on unity within this
State Medical Society; therefore be it
RESOLVED, That the House of Delegates recom- j
mend to each county medical society that it include in
its indoctrination of new members a thorough explana-
tion of the principles, practices and objectives of Michi-
gan Medical Service; and be it further
RESOLVED. That this State Medical Society, its
members and officers, assist each county medical society
in its campaign to see that Michigan Medical Service
continues as the most successful medically-sponsored pre-
payment plan.
* * *
Resolution re Comprehensive Prepaid Medical Care
Insurance Plan
(Substitute resolution approved by 1956 MSMS House of Delegates)
Whereas, it is the proper role of medicine to assume
leadership in determining the type and form of pre-
paid medical care plans, and
Whereas, a prepaid medical care plan ideally should
embody within it a sense of mutual responsibility on
the part of the physician and on the part of the |
patient, and
Whereas, a medical care plan should preserve the
traditional right of the patient to select the physician
of his own choosing; therefore be it
RESOLVED, That the Michigan State Medical So- s
ciety approve exploration with Michigan Medical Serv- I
ice of a comprehensive prepaid deductible and/or co-
insurance contract and also the possibility of extension
of the present contract; and be it further
RESOLVED, That the Speaker of this House of !
Delegates be authorized to appoint forthwith a special j
committee to accomplish the following:
A — Meet with the representatives of Michigan Medi-
cal Service to study and develop details and mechanisms.
B — Initiate, as a joint endeavor and in co-operation I
with Michigan Medical Service, necessary studies to
ascertain what would best serve the public.
C — Prepare a complete report for presentation to the
House of Delegates at its meeting in 1957 with the
proviso that copies of this report shall be sent to each
member of the House of Delegates by August 15, 1957.
* * *
Resolution re Michigan Medical Service Annual Report
to MSMS House of Delegates
(Substitute resolution approved by 1956 MSMS House of Delegates)
Whereas, the Michigan State Medical Society estab-
lished Michigan Medical Service with the intention of
providing medical services on a voluntary basis through
a prepayment plan, and
Whereas, the expansion of Michigan Medical Service
( Continued on Page 16)
14
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(Continued from Page 14)
has become a significant factor in the practice of
medicine in the State of Michigan, and
Whereas, the members of the House of Delegates of
the Michigan State Medical Society usually function
as the legally qualified members of the corporation of
Michigan Medical Service on the second day of their
annual meeting and do not have a report submitted
along with the reports of other Society activities as
published in the Delegates’ Handbook; therefore be it
RESOLVED, That the annual report of Michigan
Medical Service be included in the Handbook for
Delegates for informative purposes.
Dues Increase Eliminates Assessment
Two actions of the House of Delegates in-
creased the dues by $10.00, at the same time
abolishing the $10.00 assessment of 1956. The
first was a resolution setting aside $5.00 annual
dues to build and equip a new MSMS head-
quarters building; the second was approval of the
report of the Committee on Study of MSMS
Financial Structure which included a $5.00 dues
increase to permit the continuation of the modern
MSMS program at its current level:
Resolution re New MSMS Headquarters
(Approved by 1956 MSMS House of Delegates)
Whereas, increasing demands for service are being
made upon the MSMS by the medical profession and
the public, and
Whereas, such demands must be met by well-planned
and effectively executed programs, and
Whereas, the administration of such programs must
of necessity center in the Executive Office of MSMS,
and
Whereas, present Lansing facilities for the Executive
Office are already strained to the utmost and unless
expanded shortly will hamper the efficient execution
of MSMS programs, and
Whereas, it is reliably estimated that a proper head-
quarters can be built and equipped for an amount
approximating $300,000, therefore be it
RESOLVED, That a new MSMS headquarters be
built and equipped in Lansing, Michigan; and be it
further
RESOLVED, That for the building of this new
headquarters the sum of $300,000 be raised by:
1. The sale (at the proper time) of our present
headquarters.
2. By the use of present building reserves.
3. By the increasing of dues in the amount of $5
per year, beginning in the 1957 fiscal year, said in-
crease in dues to be used only for the purpose of de-
fraying the cost of building and equipping a new
MSMS headquarters.
* * *
Conclusions of Committee on Study of MSMS
Financial Structure
(Approved by 1956 MSMS House of Delegates)
1. The officers and professional staff of the MSMS
are to be commended for their leadership in a pro-
gram which is sound and well administered.
2. The part-time officers and full-time key profes-
sional staff are under- rather than over-paid. The
AMA delegates and alternates as well as members
of The Council, committees and others active in the
Society make a very valuable contribution to the public
and Society welfare at a significant personal sacrifice
in most instances.
3. Evidence was not produced to justify a reserve
equal to two years of Society operation.
16
4. The current $45 dues and $10 assessment has
placed the Society in good condition financially, with
a reserve anticipated for December of 1956, of ap-
proximately $275,000 to $300,000. During times of
stress, such as tbe last depression or last war, this
will permit Society operation at the current level for
at least three to four years with a curtailment of 25
per cent of income. With a reasonable curtailment of
expenditures, one year’s operation without any income
whatever is possible. By the same token, a reasonable
increase in program is possible with this reserve to meet
any possible emergency in the interval between meet-
ings of the House of Delegates.
5. The $10 assessment levied in 1956 should not
be renewed.
_6. A dues increase of $5 is recommended to protect
this reserve, offset higher costs, to permit a continuation
of program at its current level, and to adequately re-
imburse part-time officers, key full-time staff and others.
HIGHLIGHTS OF THE EXECUTIVE
COMMITTEE OF THE COUNCIL
Meeting of November 14, 1956
Eighty-nine items were presented to the Execu-
tive Committee of The Council at its November
14 meeting in Detroit. Those of chief importance
were:
»
• Discussion of matters referred to The Council
by the 1956 House of Delegates, including 22
resolutions, the reference committee’s report on
the Annual Reports of The Council, and the
reference committee’s report on the recommen-
dations of the Committee to Study MSMS
Financial Structure.
• Medicare Program. A report on the Washing-
ton, D. C., negotiation conference of October
24-25, was presented by Council Chairman
Wiley and by Jay C. Ketchum, Executive Vice
President of Michigan Medical Service. The
Medical Advisory Committee of Michigan
Medical Service was designated, as per the re-
quest of the Armed Services, to review specific
cases (in the nature of a medical advisory
committee) ; Michigan Medical Service was ap-
pointed as agent of MSMS for fiscal arrange-
ments under the Medicare Program and the
MSMS President was authorized to sign the
medicare contract on behalf of the State So-
ciety; a letter explaining the Medicare Pro-
gram, to be signed by President Walls, was
authorized to be sent to all MSMS members,
to be followed by additional detailed informa-
tion.
• President Walls stated he attended a meeting
of the Governor’s Study Commission on Public
Health in Lansing on October 26 (W. S. Jones,
M.D., of Menominee is a member of this Com-
mission) and presented a comprehensive report
on health problems from the viewpoint of the
Michigan State Medical Society.
• Speaker K. H. Johnson, M.D., Lansing, re-
ported on a session of the Steering Committee
to set up a meeting of the Citizen’s Public
(Continued on Page 26)
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Michigan Medical Service
One of the most important phases of Michigan
Medical Service operations — vital to Michigan
doctors and MMS subscribers — is the work of
the Wayne County Medical Advisory Board to
Michigan Medical Society.
The board, representative of nearly every field
of medicine, has for many years contributed in-
valuable service to members of the medical pro-
fession of Michigan and to MMS. In fact, its
labors provide assurance to Michigan doctors that
unusual and complicated medical and surgical
cases receive careful professional consideration
where precedent has not been established in the
MMS payment schedule.
Just how the Advisory Board functions for
MMS is important to all MMS participating doc-
tors in the state. It is important to know what
steps are taken before MMS makes payment to
the doctor for any complex medical or surgical
case requiring more than the usual amount of
professional care or skill.
All cases reported on the Doctors Service Re-
port forms, of course, go through the examina-
tion department of Michigan Medical Service. If,
during this study, a doctor’s service report shows
any unusual type of work, it is referred to the
MMS Medical Director, Dr. Dewey Moll. After
close scrutiny by Dr. Moll and his staff, the
cases requiring consideration by the Advisory
Board are then presented by Dr. Moll to the
Board for prompt atention. Cases are presented
anonymously to the Board, with identity of the
patient and the doctor undisclosed. Only if further
information is needed on the case is the doctor’s
identity made known. The determination of fees
by this Board must be in relation to the income
limits of the contract carried by the subscriber
and must be consistent with the other fee allow-
ances in the $2,500 or $5,000 contracts.
“Fairness to the doctor and the patient is the
paramount aim of the Board,” Dr. I. S. Schem-
beck, Chairman, says. “It is our job to recommend
to the MMS Board equitable payment of fees for
specific cases. These recommendations for pay-
ment are reached only after thorough study by
the Advisory Board of all the facts involved in
each case presented — the extent of the surgery,
length of time required to perform necessary pro-
cedures and any accompanying complications.”
Dr. Schembeck points out that such recom-
mendations for fees can be reached only if the
doctor has submitted a complete report to MMS
of the case in question. He emphasized that
much time and expense can be saved by doctors
and MMS if the doctors make every effort to
submit reports to MMS describing in detail every
aspect of their cases. To go a step further, it is
even recommended that for unusual cases the
doctor send in a copy of his operative notes.
Completeness of reports, Dr. Schembeck ex-
plains, automatically expedites handling of com-
plex cases — thereby hastening payment of the
MMS fee to the doctor.
“We must know just what work the doctor
has done for his patient before we can know
whether payment for such procedure has been
established in the MMS Schedule of Fees, or
whether or not the doctor is entitled to further
payment,” Dr. Schembeck says. He explains that
when the Board receives a report, incomplete in
details, MMS must then write the doctor for
further information, adding up to considerable
delay before a decision can be reached. At times
it has been necessary for MMS field representa-
tives to make personal calls on the doctor to clear
up facts in cases when reports were inconclusive.
However, a recommendation by the Advisory
Board on a specific payment does not have to be
final until the doctor indicates his approval.
Should the participating doctor feel at any time
that the payment recommended by this Advisory
Board for his work is not satisfactory, it is his
privilege to ask for a re-review of the case. The
Advisory Board is always willing to reconsider
any case, according to Dr. Schembeck — in fact,
will consult with the doctor in person at a meet-
ing of the Board if the doctor so desires. Also,
cases which have been paid routinely without the
aid of the Advisory Board will be reviewed by
that Board if the doctor reporting so desires.
The Advisory Board, originally formed more
than fifteen years ago to establish precedent fees,
is still concerned with reviewing cases which are
different from previous claims and are classified
as out of the ordinary procedures.
The Advisory Board has no authority to set
fees, policies or practices of MMS, it can only
recommend certain action. For instance, if an
established fee for a particular procedure ap-
pears to be inequitable as part of the set Schedule
of Fees, the Advisory Board may recommend to
the MMS Board of Directors that such a fee
should be reconsidered and changed as being too
large or too small a payment for such services. The
same action or recommendation may be made
for new procedures as they appear. Actually, each
individual doctor has this same right if he chooses
to have a certain procedure reviewed for modifica-
tion in the fee allowance.
A hard-working group, the Advisory Board
meets two days each month, handling approxi-
mately 2,000 cases each year. Service by the
Board members has always been without remuner-
( Continued on Page 32 )
18
TMSMS
Doctor, would it be helpful to you in your
practice to know that there is a food avail-
able at reasonable prices in the stores
the year round having these attributes:
1. High public acceptance as to flavor and palat-
ability — billions eaten annually.
2. One of the best of the “protective” foods with a
well-rounded supply of vitamins and minerals.
3. Low sodium — very little fat — no cholesterol.
4. Sealed by nature in a dust-proof package.
5. One of the first solid foods fed babies.
6. Can be easily digested by old folks as well as
infants.
7. Can be readily eaten out of hand, in milk shakes,
on cereals, or in salads.
8. Can be baked, broiled or fried.
9. Can be used as an ingredient product in breads,
pies, cakes and desserts.
10. Useful in bland and low-residue diets.
11. Mildly laxative.
12. May be used in the management of both
diarrhea and constipation.
13. Can be used in reducing diets.
14. Can be used in high-calorie diets.
15. Useful in the dietary management of celiac
disease.
16. Useful in the dietary management of idiopathic
non-tropical sprue.
17. Useful in the management of diabetic diets.
18. Valuable in many allergy diets.
19. Belongs among foods useful in certain acute
intestinal infections.
20. A protein sparer.
21. Favorably influences mineral balance.
22. Useful in the management of ulcer diets.
23. One of the easiest foods to eat or prepare.
FOR THE NAME OF THIS FOOD, PLEASE TURN THE PAGE
:
January, 1957
Say you saw it in the Journal of the Michigan State Medical Society
YOU AND YOUR BUSINESS
The answer is
If you would like
1 . The authority for any of the statements
made on the preceding page . . .
2. Additional information in connection with any of them...
3. The composition of the banana
4. The nutritional story of the banana . . .
5. Information on various ways to prepare or serve bananas.
Please feel free to write to
Director, Chemical and Nutrition Research, United Fruit Company
PIER 3, NORTH RIVER, NEW YORK 6, N. Y.
HIGHLIGHTS OF THE COUNCIL
(Continued from Page 16)
Health Advisory Committee for December 5.
Tuberculosis, mental health, local public health
units, and urbanization were to be discussed
at this citizen’s meeting.
• William Bromme, M.D., Detroit, was appointed
as MSMS representative to the Second Nation-
al Conference on Veterans Affairs, January,
1957, Chicago.
• 1957 Michigan Clinical Institute Press Rela-
tions Committee: A. B. Gwinn, M.D., Hastings,
Chairman, H. F. Dibble, M.D., Detroit; L.
R. Leader, M.D., Detroit; J. J. Lightbody,
M.D., Detroit; Ralph W. Shook, M.D., Kala-
mazoo; and C. L. Weston, M.D., Owosso.
• Edward M. Vardon, M.D., Detroit, presented
a Verifax (photographic reproducing machine)
to the Michigan State Medical Society, which
was accepted with high thanks.
• B. L. Masters, M.D., Fremont, presented re-
port on Study Conference for Chairman of
State Rural Health Committees, held at Purdue
University October 19-20; the report was re-
ceived with high thanks.
• F. E. Ludwig, M.D., Port Huron, and H. A.
Towsley, M.D., Ann Arbor, were appointed as
members of MSMS Liaison Committee with
University of Michigan.
• Legal Counsel Lester P. Dodd presented opin-
ions on ten questions of legal import.
• Report of Rheumatic Fever Co-ordinator Leon
DeVel, M.D., Grand Rapids, was approved
with thanks.
• Public Relations Counsel presented a report on
the Gold Medal Award judging committee;
Good Citizenship Get-Out-the-Vote Campaign;
Professional Day of the 1957 Michigan Rural
Health Conference; Hospital-Community Re-
search Project of Michigan State University;
the MSMS public relations library; copies of
“Medicine and the Law” film series (AMA) ;
and on the new M.D. placement pamphlet.
• Committee Reports. The following committee
reports were presented: (a) Formation of
American Association of Medical Assistants;
(b) Committee on Arbitration, meeting of
September 8; (c) Permanent Conference Com-
mittee, October 24; (d) Healing Arts Study
Committee, October 25; (e) Geriatrics Com-
mittee, November 1; (f) Committee to Select
Field Secretary, November 7 ; and (g) Commit-
tee Organization Meeting (for Chairmen),
November 13.
26
JMSMS
One donnagesic Extentab gives 10 to 12 hours of
steady, high-level codeine analgesia. Rebuilding
of effective analgesia with repeated doses is
avoided. Patient comfort is continuous.
There is more pain relief in DONNAGESIC Extentabs
than in codeine alone — codeine analgesia is potentiated
by the phenobarbital present. In addition, phenobarbital
diminishes anxiety, lowering patient’s reactivity to pain.
DONNAGESIC is safer, too, for codeine side effects are
minimized by the peripheral action of the belladonna
alkaloids.
extended action — The intensity of effects smoothly
sustained all-day or all-night by each donnagesic
Extentab is equivalent to, or greater than, the maximum
which would be provided by q. 4h. administration of one-
third the active ingredients.
Donnagesic
xtentabs*
extended action tablets of CODEINE with DONNATAL ®
once every 10-12 hours
and
for all codeine uses
DONNAGESIC No. 1 (pink)
DONNAGESIC No. 2 (red)
CODEINE Phosphate 48.6 mg.(%gr.) 97.2 mg. (IV2 gr.)
Hyoscyamine Sulfate 0.3111 mg 0.3111 mg.
Atropine Sulfate 0.0582 mg 0.0582 mg.
Hyoscine Hydrobromide 0.0195 mg 0.0195 mg.
Phenobarbital 48.6 mg. (3/4 gr.) 48.6 mg. (% gr.)
A. H. ROBINS CO., INC., RICHMOND, VIRGINIA Ethical Pharmaceuticals of Merit Since 1878
*Reg. U. S. Pat. Off., Pat. applied for.
January, 1957
Say you saw it in the Journal of the Michigan State Medical Society
27
Heart Beats
THE MICHIGAN HEART ASSOCIATION
SERVES THE PHYSICIAN
One of the major activities of the Michigan
Heart Association is the support of cardiovascular
research. The Association has awarded grants to-
talling $164,000.00 to 27 scientific investigators in
Michigan to carry out research studies into the
baffling problems of diseases of the heart and blood
vessels. The research work is being conducted
in 8 medical institutions during the twelve month
period ending June 30. 1957.
In addition to its own research program, E. A.
Irvin, M.D., Dearborn, President of the Michigan
Heart Association, points out that the MHA con-
tributes to the national research support program
of the American Heart Association. The national
organization has allocated nearly $1,873,000.00 for
311 grants-in-aid and fellowship awards during
the same period.
$80,686.00 of the research funds allocated by the
Michigan Heart Association have been awarded
from the Association’s Memorial Fund. This fund
was established at the request of many persons
who have wanted an opportunity to provide a
“living memorial” to the memory of a friend,
relative or associate who has been afflicted with
heart disease. Memorial contributions are used
exclusively for heart research studies. The bal-
ance has been allocated from funds contributed
to the Association by the people of Michigan
through “United” fund raising campaigns in many
Michigan communities.
The research investigators receiving funds from
the Michigan Heart Association during the cur-
rent year are as follows :
Dean’s Fund Wayne University
To enable part-time research investigators of proven
ability to devote full-time to cardiovascular research.
Dean’s Fund University of Michigan
To enable part-time research investigators of proven
ability to devote full-time to cardiovascular research.
W. T. Beher, M.D Edsel Ford Institute
Study of Cholesterol Metabolism.
J. B. Blodgett, M.D Grace Hospital
The Fundamental Problem of Exploring Satisfactory
Means of Entrance and Exit through Walls of the
Great Vessels and Heart Itself and Problems of Mitral
Valve Regurgitation.
D. F. Bohr, M.D University of Michigan
A Comparison of Some Basic Characteristics of the
Circulatory System in Response to Renal Ischemic,
Renoprival and Hormonal (DOCA) Hypertensions.
A. J. Boyle, M.D Wayne University
Plasma Colloid Stability in Normal and Atheroscler-
otic Subjects.
T. M. Brody, M.D University of Michigan
Mechanisms of Experimental Heart Failure.
N. E. Clarke, M.D Providence Hospital
The Chemotherapy of Rheumatic Fever.
F. D. Dodrill, M.D Harper Hospital
Mechanical Heart.
I. F. Duff, M.D University of Michigan
Investigation of the Mechanism of Blood Coagulation
with Special Reference to the Problem of Thrombo-
embolic Disease.
J. D. Fryfogle, M.D Mt. Carmel Mercy Hospital
Arterialization of the Coronary Sinus by Communica-
tion to the Left Ventricular Cavity.
F. E. Greifenstein, M.D Wayne University
Study of the Contractile Force of the Heart.
Cameron Haight, M.D University of Michigan
Temporary Occlusion of a Pulmonary Artery as
Means of
(A) Evaluation of the Anticipated Cardiovascular
Responses to Pneumonectomy.
(B) A Study of the Pulmonary Vascular Tree by In-
jection of Contrast Material Beyond the Point of
Occlusion.
H. K. Hellems, M.D Wayne University
The Investigation of the Effects of Exercise and
Commonly Used Cardiovascular Drugs on Myocar-
dial Blood Flow and Metabolism in the Human Sub-
ject.
T. B. Hill, M.D Kent County Health Department
Incidence of Streptococcal Infections in a Rural
School with Study of the Carrier State.
S. W. Hoobler, M.D University of Michigan
Atherosclerotic Vascular Disease.
J. J. Jasper, M.D Wayne University
The Study of Serum Surface Tension in Atherosclero-
sis.
C. G. Johnston, M.D Wayne University
Prosthetic Replacement or Correction of Valvular
Lesions.
J. A. Johnston, M.D Ford Hospital
Studies in Rheumatic Fever.
C. R. Lam, M.D Henry Ford Hospital
Experimental Cardiovascular Surgery.
B. M. Lewis, M.D Wayne University
Diffusion and Distribution Characteristics of the Lung
in Heart Failure.
Y. Morita, M.D. and L. T. Iseri, M.D. ..Wayne University
Metabolic Aspects of Cardiorenal Diseases.
Jan Nyboer, D.Sc., M.D Harper Hospital
The Evaluation of Electrical Impedance Plethysmog-
raphy and Displacement Ballistocardiography.
Prof. F. L. Rights Wayne University
Etiology of Acute and Chronic Pericarditis and Myo-
carditis.
Walter Seegers, M.D Wayne University
Blood Coagulation: Purification of Inhibitors and
Mechanism of Their Action.
D. E. Szilagyi, M.D Henry Ford Hospital
An Investigation of the Use of Plastic Vascular
Prostheses in the Replacement of Long and Narrow
Arterial Segments.
J. L. Wilson, M.D University of Michigan
Investigation of the Effects of Cyanotic Heart Dis-
sease and Its Relief on Cerebral Function.
( Continued on Page 32)
28
JMSMS
In one investigation, 75 adult patients with bacterial pneumonia
were treated with erythromycin. In his summary, the clinician re-
ported: “It is concluded that erythromycin is highly effective in the
treatment of pneumonia due to gram-positive bacteria.”2
This, of course, is only one of many reports showing the effective-
ness of Erythrocin against coccic infections. You’ll get the same
good results (nearly 100% in common, bacterial res- [) n ,,
piratory infections) when you prescribe Erythrocin. VAijuXMX
Erythrocin
(Erythromycin, Abbott)
STEARATE
*AJo S>iAMncd Su£c Ooc«aaju£S'
After a study of 171 patients treated with erythromycin, the investi-
gator wrote: “No serious side effects occurred with prolonged therapy
or with doses up to 8 Gm. per day in the severe infections.”1
Actually, Erythrocin stands on a remarkable record of safety.
After four years, there’s not a single report of a severe or fatal reac-
tion attributable to erythromycin. In addition, you’ll find allergic
manifestations rarely occur. Filmtab Erythrocin n nn
Stearate (100 and 250 mg.), in bottles of 25 and 100. LIJMStMX
® Filmtab — Film-Sealed tablets, Abbott; pat. applied for.
1. Romansky, M.J., et al., Antibiotics Annual 1955-1956, p. 48,
2. Waddington, W. S., Maple, F. C., and Kirby, W. M. M.,
A.M.A. Archives of Internal Medicine, 1954, p. 556.
701051
HEART BEATS
THE MICHIGAN HEART ASSOCIATION
SERVES THE PHYSICIAN
( Continued from Page 28)
Through MHA and AHA research projects,
new findings in the cardiovascular field are made
known immediately to the physicians of the state
so that they may better serve their patients and
their communities.
Professional education is also an important
Heart Association objective and a large selection
of professional education and information mate-
rials are available to the physician with an interest
in cardiovascular disease. Through these mate-
rials, the Michigan Heart Association endeavors
to aid the physician in continuing his self-educa-
tion in the field of cardiovascular disease, and to
assist him in the care of the patient with cardio-
vascular disease.
These professional materials include films,
slides, heart models, three-dimensional cardio-
views, phonograph records, clinical charts, pam-
phlets and books.
The literature runs the gamut from the tech-
nical “Nomenclature for Diagnosis of Peripheral
Vascular Disease” to a well-written, easily read
booklet which the physician can give to his pa-
tients, entitled “Have Fun — Get Well.”
Some of the film and slide titles include: “Con-
genital Malformations of the Heart,” “Surgical
Correction of Mitral Stenosis” and “Roentgeno-
grams of the Heart and Great Vessels.”
Another valuable item available to the physi-
cian is a set of three Cardiac Kits. These kits
consist of slides and phonograph records which ex-
plain the slides. A printed explanation is included
for more detailed reference, or in case a phono-
graph is not available. The three subjects covered
in the kits are: “The Role of the P-A Film of
the Chest in Cardiology” by William R. Christen-
sen, M.D., Professor of Radiology, University of
Utah; “The Prevention of Rheumatic Fever” by
Gene H. Stollerman, M.D., Assistant Professor of
Medicine, Northwestern University; “Functional
Pathology of Occlusive Coronary Disease,” by
Jesse E. Edwards, M.D., Professor of Pathologic
Anatomy, Mayo Clinic and Mayo Foundation.
Various publications about cardiovascular di-
sease are regularly available to physicians. They
include: “Modern Concepts of Cardiovascular
Diseases,” “Heart Research Newsletter” and “The
American Heart.” These publications are sent
to all physicians who are members of the Michigan
Heart Association as part of their membership.
Professional journals available are Circulation and
Circulation Research.
A new two- volume Electracardiographic Test
Book, containing photographs of electrocardio-
grams and questions of electrocardiographic in-
terpretation, is now available. The electrocardio-
grams from the book are available also on slides.
In addition to all of these professional mate-
rials, a vast amount of literature, films and exhibits
are available to the physician for his use with
patients or the lay public in general. A free
booklet on all professional education and informa-
tion aids available may be secured by writing
to the Michigan Heart Association, Doctors’
Building, 3919 John R, Detroit 1, Michigan.
REFRESHER COURSE
Plans for a refresher course in “Cardiology for
the Family Physician” have been completed by
the Michigan Heart Association, in co-operation
with Wayne State University and the Michigan
Academy of General Practice. The course will
consist of five full-day sessions (8:30 a.m. to 5:15
p.m.) from April 22 through April 26, 1957,
incorporating both bedside rounds and lectures.
A registration fee of $25.00 will be charged,
and the course has been approved for twenty-five
hours credit in Category I. For full details, con-
tact either the Michigan Heart Association at the
address listed above or Dean, College of Medi-
cine, Wayne State University, 1401 Rivard Street,
Detroit.
MICHIGAN MEDICAL SERVICE
(Continued from Page 18)
ation. The President of the Wayne County Medi-
cal Society appoints the Board each year. Every
effort is made to see that nearly all fields of
medicine are represented in the group. Also,
should a specific case require medical knowledge
beyond the scope of the Board members, advisory
consultants are called upon for assistance.
Currently, plans are being considered for de-
veloping other Advisory Boards in metropolitan
areas across the State through which MMS hopes
to gain closer contact with and better under-
standing by the local medical groups. Kent
County Medical Society has appointed an Ad-
visory Board to function as does the Wayne Coun-
ty Board but with attention to cases stemming
from Kent and other nearby counties. If work
of the Kent County group becomes successful
in this effort, it .is hoped that other County
Medical Societies will establish similar Advisory
Boards to Michigan Medical Society.
BIRTH RECORDS
The first year when 100,000 births were reported in
Michigan was 1941. Present indications are that the
year 1 956 will see more than 200,000. The maternal
death rate has gone down one half during the same
period — 63 to 34 — a great tribute to the efforts of ma-
ternal health committees and concentrated efforts of
health agencies.
32
JMSMS
for the average
patient in
everyday practice
# well suited for prolonged therapy
O well tolerated, nonaddictive, essentially nontoxic
# no blood dyscrasias, liver toxicity, Parkinson-like syndrome
or nasal stuffiness
# chemically unrelated to chlorpromazine or reserpine
# does not produce significant depression
# orally effective within 30 minutes for a period of 6 hours
Indications : anxiety and tension states, muscle spasm.
Tranquilizer with muscle-relaxant action
DISCOVERED AND INTRODUCED
BY » WALLACE LABORATORIES, New Brunswick. N.J.
2-melhyl-2-n-propyUl, 3-propanediol dicarbamate — l J.S. Patent 2,721,720
SUPPLIED: iOO mg. scored tablets. Usual dose: 1 or 2 tablets t.i.d.
Literature and Samples Available on Request
CM-3706-R2
THE MILTOWN MOLECULE
, 1957
Say you saw it in the Journal of the Michigan State Medical Society
Foundation for Eye Care
Announcement was made November 15, 1956,
of the establishment of the National Medical
Foundation for Eye Care, a non-profit scientific
and educational institution, incorporated in New
Jersey. The Foundation has been organized by
ophthalmologists of the country to provide Ameri-
can ophthalmology with an agency to present to
the public generally and to fellow physicians per-
tinent information on the care and treatment of
the eyes.
Ralph O. Rychener, M.D., Memphis, Tennes-
see, is president of the Foundation; Edwin Forbes
Tait, M.D., Norristown, Pennsylvania, vice presi-
dent, and Charles E. Jaeckle, M.D., East Orange,
New Jersey, secretary-treasurer.
Members of the Board of Trustees, in addition
to the above named, are: Alson E. Braley, M.D.,
Iowa City, Iowa; Frederick C. Cordes, M.D.,
San Francisco, California; Paul Chandler, M.D.,
Boston, Massachusetts, J. Spencer Dryden, M.D.,
Washington, D. C.; Harold F. Falls, M.D. Ann
Arbor; Everett L. Goer, M.D., Houston, Texas;
Erling W. Hansen, M.D., Minneapolis, Minne-
sota; A. I). Ruedemann, M.D., Detroit; Barnet
R. Sakler, M.D., of Cincinnati, Ohio, and Derrick
Vail, M.D., Chicago, Illinois.
In a special statement announcing the Founda-
tion’s establishment, Dr. Rychener declared:
“American ophthalmologists have long recognized an
urgent need for an organization whose principal func-
tion will be to interpret the basic professional and
scientific standards of good eye care for the American
people, both to our fellow physicians and to the
people whom we serve.
“The National Medical Foundation for Eye Care
will seek to serve the public interest by helping the
people to understand the educational qualifications and
the professional functions of physicians specializing in
ophthalmology, and the functions of related technical
and ancillary personnel who assist them. The Founda-
tion will also endeavor to keep our colleagues in the
medical profession informed concerning the problems
confronting ophthalmology in its efforts to fulfill its
mission as a member of the team of recognized medical
specialties serving the American people.”
Dr. Rychener revealed that the Foundation is
now enrolling its charter membership, and he
invited all ophthalmologists and other physicians
interested in eye care to become charter members
of the Foundation.
Applications are available through Dr. Charles
E. Jaeckle, secretary-treasurer, at 136 Evergreen
Place, East Orange, New Jersey. The Founda-
tion is establishing an administrative office in
New York City, and will make available an Af-
filiate Membership for persons other than doctors
of medicine who are interested in aiding the pur-
poses of the Foundation.
The object and purpose of the Foundation is
to advance the public welfare by:
1. Gathering receiving, assembling and study-
ing information relative to eye care.
2. Fostering and/or engaging in investigations
and research in all aspects of eye care.
3. Sponsoring studies of educational, socio-
economic and scientific factors affecting eye care.
4. Issuing reports and otherwise disseminating
information relative to eye care to the general
public and to members of the medical profession
and ancillary workers.
5. Promoting the conservation of vision and
the prevention of blindness through the wider
dissemination of knowledge of the eye, its de-
fects, disfunctions and other diseases and their re-
lation to general health.
6. Promoting a more effective utilization of
the scientific knowledge of ophthalmology and
the other related branches of medicine.
7. Generally performing any act, related to
the foregoing, designed to present to the public
generally and the medical profession, all pertinent
information on the care and treatment of the
eyes.
"WHY TAKE CHANCES"
No practice is too small — no group too large
to benefit from PM's management experience
WRITE OR CALL FOR INFORMATION
•PROF E S S I 0 11 A L
* in a n a g e m e n t
Security Bank Building — Battle Creek
SAGINAW — GRAND RAPIDS — DETROIT
A com PL PTE BUSINESS SERVICE FOR THE 111 E D I CAL PR0FESSI0I1
Affiliated Offices in Other Cities
34
Say you saw it in the Journal of the Michigan State Medical Society
TMSMS
a new maximum in
now available
with new
mint -flavored
SUSPENSION
A savory mint flavor; that adds the fur-
ther certainty of acceptability to anti-
biotic therapy, particularly for that 90 %
of the patient population treated in the
home or office where sensitivity testing
may not be feasible, and where pleasant
flavor can make the difference betv/een
prescription adherence and laxity.
Sigmamycin for Oral Suspension
is available in 2 oz. bottles containing 1.5 Gm. of
Sigmamycin (oleandomycin 500 mg., tetracy-
cline 1 Gm.). When reconstituted each 5 cc. tea-
spoonful contains 125 mg. of Sigmamycin
(42 mg. of oleandomycin as the phosphate salt
with tetracycline amphoteric equivalent to
83 mg. of tetracycline hydrochloride).
PFIZER LABORATORIES, Brooklyn 6, N.Y
Division, Chas. Pfizer & Co., Inc.
PREVENTION OF RHEUMATIC FEVER
the new
B I RTCH E R
cervix
conization
electrodes
shown actual size
HAWKINS* technic
Built by Birtcher of the finest materials to ex-
actly meet the requirements of the technic of
M. C. Hawkins, Jr., M.D., of Searcy, Arkansas,
described in his paper "Re-Evaluation of Coniza-
tion of the Cervix," published in Southern Medi-
cal Journal.
* Described in his paper which will be sent on request
NOBLE-BLACKMER, INC.
267 W. Michigan 28148
Jackson, Michigan
Thirty- three persons died in Michigan in 1955
from rheumatic fever and 849 from chronic
rheumatic heart disease, according to informa-
tion from the Vital Statistics Division, Michigan
Department of Health. This is a rate of 122 per
million per year, out of a total death rate of
approximately 7,000 per million — one death in
sixty.
A report of two years’ experience with a five-
year study of 400 children receiving prophylaxis
at Irvington House, which was made to the Amer-
ican Heart Association in Cincinnati on October
29, 1956, would indicate that prophylaxis still
leaves much to be desired. Ninety-five strepto-
coccal infections were discovered by throat cul-
ture in eighty-seven of the patients, the rate of
incidence being one in six patient years. Thirteen
recurrences of acute rheumatic fever, representing
15 per cent of those who had one or more strep-
tococcal infections, occurred in spite of prophy-
laxis, and the recurrence rate for the entire group
was one per forty-four patient years.
By method of prophylaxis, there were thirty-
six streptococcal infections and nine rheumaitc
fever recurrences among children who had re-
ceived 200,000 units of penicillin orally one-half
hour before breakfast, forty-four streptococcal in-
fections and four rheumatic fever recurrences
among the group receiving sulfadiazine, 1.0 grams
daily in a single dose, and fifteen streptococcal
infections and no rheumatic fever recurrences in
the group receiving 1.2 million units of benzathine
penicillin G intramuscularly at monthly intervals.
The Rheumatic Fever Control Committee,
Michigan State Medical Society, recommends
prophylaxis of one of the above types for dura-
tion of life or until newer knowledge makes the
method obsolete. The Michigan Department of
Health provides benzathine penicillin G for any-
one upon requisition, and the Michigan Crippled
Children Commisison provides payment of a fee
from trust funds for its administration to children
who have been the subject of a court order under
the Crippled or Afflicted Children’s Acts, upon
the request of their family doctor of medicine.
Robert E. Fisher, M.D.
Medical Co-ordinator
Rheumatic Fever Program
38
Of the total AMA budget, not more than 2.5 per cent
is spent on legislative efforts. The breakdown on spend-
ing: 3 per cent to reserves, 9 per cent to supply mem-
bers with information, 19 per cent for public information,
6 per cent for socioeconomic activities, 60 per cent for
publication of journals and other scientific activities,
leaving only 3 per cent for Washington Office, Law'
Department, and legislative activities combined.
TMSMS
Say you saw it in the Journal of the Michigan State Medical Society
...and when Spasmolysis is essential
LOCALIZED MUCOSAL ANALGESIA
Phenylazo-diamino-pyridine HCI — acts solely on the urogenital
mucosa; provides prompt relief from burning, pain and frequency.
LOCALIZED ANTIBACTERIAL ACTIVITY
Sulfacetamide— eliminates mixed infections rapidly because of its
unusual solubility in acid urine common to bacterial invasion of the
urinary tract. No renal damage, concretions or anuria.
RINARY COMPLAINTS
*)f Sterilizes urine in 1 to 3 days
*)f Relieves burning in minutes
vf Effective in 93-98% of cases
sjimUTAcI.
The original Azo-Sulfa Formula*
Antibacterial • Analgesic
Antibacterial • Analgesic • Antispasmodic
—the dual activity of SULFID with the well-known antispasmodic
effect of natural belladonna alkaloids.
FORMULAE:
SULFID— Each coated tablet
contains: Phenylazo-diamino-
pyridine HCI, 50 mg. and Sulfa-
cetamide, 250 mg., in bottles of
100 tablets.
SULFID B-A — Each coated
tablet contains the SULFID
formula with natural belladonna
alkaloids, 0.065 mg., in bottles of
100 tablets.
COMPANY — Columbus 16, Ohio
•Introduced— July, 1954
January, 1957
Say you saw it in the Journal of the Michigan State Medical Society
39
PR REPORT
THE 1957 LEGISLATURE AND HEALTH
As forecast in the December issue of The Jour-
nal MSMS, the Legislature came to Lansing on
January 9, appointed officers, organized commit-
tees and settled down for what appears to be a
six-month session. If recent pronouncements from
the Governor and key legislative leaders are borne
out, medical care, public health and general wel-
fare will be foremost on the lawmakers’ agenda.
The 1956 House of Delegates, recognizing that
a changing world needs new and amended laws,
recommended action by the Legislature relating
to psychotherapy, Wayne State LTniversity Col-
lege of Medicine (expanded teaching facilities),
regulation of ambulance operation, and more civil
defense funds.
The MSMS Legislative Committee (L. A. Dro-
lett, M.D., Chairman) met in Lansing, January
10, to finalize these recommendations into its 1956
program and to review legislation anticipated
from other sources, some of it perennial, some
new.
Of the hundreds of newspaper clippings that
monthly come into the PR department from
all parts of the state, two recent ones bear re-
porting here. In a November editorial, the De-
troit News states, “We hope that next year’s Leg-
islature will give Michigan children the protection
of a compulsory immunization law.”
This attitude was prompted by the recent dis-
closure that 1 7,000,000 perishable doses of Salk
vaccine were going begging and by the November
diphtheria outbreak in Detroit. While the edi-
torial deals primarily with polio and diphtheria,
the tenor of the article indicates that all immuni-
zations are desired on a compulsory basis. A fac-
tor not discussed was whether this all-inclusive
program would be paid for by the state, the fed-
eral government or by the individual family head
who today voluntarily protects his own children
from the uninoculated carrier.
In the same week, the Battle Creek Enquirer
and News editorially takes cognizance of findings
and recommendations of the Governor’s Study
Commission for the Aged and a Legislative Ad-
visory Council on Problems of the Aging. Here
is what the editorial said :
“The legislative group, in a public hearing in Lan-
sing, took note of demands for state aid in the fields
of housing and employment. The Governor’s Commis-
sion recommended that state aid be given the aged for
medical care, including glasses, hearing aids and den-
tures.
“How much dependence and separate maintenance
should government provide ? How much even of se-
curity? In our free enterprise system, the more free
enterprise and private initiative the better.
“Study sponsored by government? Excellent. Care
for needy cases by government? Of course. But tak-
ing over the lives of the elderly with public housing
projects, state medical care and government-made em-
ployment? Certainly not.
“The Legislature can help make older lives more
meaningful. It also has an obligation to do so in
a practical manner.”
NEW FIELD SECRETARY APPOINTED
John K. Pardee, East Lan-
sing, has been named to the
public relations staff of MS-
MS, replacing Warren F. Try-
loff in the Detroit office, who
was transferred to the execu-
tive office in Lansing in De-
cember. As Field Secretary,
he will co-ordinate liaison be-
tween the State Society and
the county medical societies in
southeastern Michigan and the
“thumb” area and will schedule the radio and tel-
evision public service activities for MSMS in that
part of the state.
Mr. Pardee, a political science graduate of
Michigan State University, comes to the State
Society with a wide experience in the health, in-
surance and public relations fields. “Jack” now
lives in East Lansing with his wife (an MSU die-
titian) and their two children and is a member of
Peoples Church there.
His fraternal associations include the Masons,
Lions, Sigma Chi, Alpha Phi Sigma and the
American Legion.
Mr. Tryloff is being promoted after two and
a half years in Detroit to become Associate Pub-
lic Relations Counsel, succeeding A. DeWitt
Brewer who resigned in August to become a Vice
President with the Mt. Clemens Federal Savings
and Loan.
ANOTHER OFFICE OF MEDICAL
EXAMINER ESTABLISHED
Members of the Dickinson County Medical
Society and county morticians worked together in
successful support of the November 6 referendum
in that county which abolished the office of county
coroner and created the office of county medical
examiner. The measure was adopted by a three-
to-one margin.
The question was placed on the ballot by ac-
tion of the County Board of Supervisors at the
request of morticians, who later sought and gained
medical society support.
Until 1953, only Oakland, Genessee and Kent
( Continued on Page 42 )
4-0
JMSMS
Tastiest way to dissolve sore throat symptoms
TROCHES
HYDROZETC
(HYDROCORT1SONE-BACITRACIN-TYROTHRIC1N-
NEOMYCIN-BENZOCAINE TROCHES)
Adult or juvenile, your patients with sore throats
will welcome a course of HYDROZETS. These
newest Merck Sharp & Dohme troches offer anti-
inflammatory, anti-infective and analgesic proper-
ties that promptly alleviate distressing mouth or
throat irritation whether caused by infection,
mechanical injury or allergic reaction. And
HYDROZETS taste so good, it’s hard to believe
they're medicine.
Formula: Each HYDROZETS Troche contains —
2.5 mg. ‘H YDROCORTONE’ to reduce pain, heat
and swelling; 50 units Zinc Bacitracin, 1 mg.
Tyrothricin and 5 mg. Neomycin Sulfate to com-
bat gram-positive and gram-negative bacteria; and
5 mg. Benzocaine for rapid soothing analgesia.
Other indications: As adjunct therapy in aphthous
ulcers, acute and chronic gingivitis and Vincent’s
infection.
Supplied: Vials of 12 troches.
MERCK SHARP & DOHME
DIVISION OF MERCK & CO . INC.. PHILADELPHIA 1. PA.
January, 1957
Say you saw it in the Journal of the Michigan State Medical Society
41
ACETYLCARBROMAL tablets
• Proved safe and effective by 6 years’
clinical use.
• Soothes the central nervous system,
produces calmness without hypnosis.
• Non-toxic, non-cumulative, non-addict-
ing, no known contraindications.
• Does not impair mental or physical
function.
• Orally effective within 30 minutes for
sustained action up to 6 hours.
• Economical.
BLUE SHIELD IS FOR EVERYBODY
In creating and sponsoring Blue Shield, the
doctor has triggered a popular movement that
won’t be stopped until every last potential mem-
ber is enrolled in a pre-payment plan. For your
Blue Shield Plan has not only sold itself — it has
sold the American people on the idea of security
against the economic consequences of unpredic-
table medical needs.
In ten brief years, Blue Shield enrollment has
burgeoned from less than 2 million to more than
37 million people, and about 45 million more
have bought some form of cash indemnity cover-
age for medical-surgical expense through private
insurance companies.
While the job of providing voluntary medical
care protection to the entire American people is
about half done, the demand for this protection
is practically universal.
Studies have shown that people in the lowest
income brackets are not enrolled in as large
proportions as those in the medium income groups.
Enrollment among the aged, the self-employed
and the rural population is also under par.
Blue Shield’s purpose is to help the profession
meet its responsibility to the entire community,
and the Plans are now giving particular attention
to these segments of the population whose poten-
tialities for profitable underwriting do not gen-
erally appeal to insurance companies operated for
private profit.
It’s no longer a question whether people are
going to have voluntary prepayment for medical
care. The real question, today, is whether Blue
Shield can do the job satisfactorily and in good
time.
And the answer lies with the doctor. American
medicine has accomplished a modern miracle in
the achievements of Blue Shield to date. The job
that remains to be done will require as much
imagination, as much bold action and devotion
to the task as was needed to get Blue Shield off
the ground ten years ago. To do this job. Blue
Shield needs the help and guidance of every
American physician.
Indications: Tension, nervousness,
anxiety and muscular spasm.
Supplied: White round tablets
Acetylcarbromal 5 gr. in bottles
of 100, 1000.
Write for samples and literature
There’s Always A Leader
MALLARD, inc
3021 WABASH, DETROIT 16, MICHIGAN
ANOTHER OFFICE OF MEDICAL
EXAMINER ESTABLISHED
( Continued from Page 40 )
Counties, under a special law, had been permitted
to establish a county medical examiner system.
After passage of the State Medical Examiner Law
that year, at the urging of MSMS, it became pos-
sible for other counties to adopt this system if
voters approved the local change.
Since January 1, 1954, when the law took effect,
Wayne, St. Joseph, Allegan, Wexford, Ottawa,
Hillsdale, Van Buren and Marquette Counties
have adopted the new system.
42
Say you saw it in the Journal of the Michigan State Medical Society
TMSMS
nv JOUR N A L
of the Michigan State Medical Society
Issued Monthly Under the Direction of The Council
VOLUME 56 JANUARY, 1957 NUMBER 1
Clinical Evaluation of Sintrom (G-23350),
^ New Oral Anticoagulant
A LTHOUGH anticoagulants are of definite
therapeutic value in a variety of conditions,
re ideal agent has yet to be found. Wright7 has
efined the ideal anticoagulant as having the
allowing properties:
1. Therapeutically active orally or parenterally with-
out untoward reactions.
2. Rapid action.
3. Predictable response to a given dosage in a
patient and between different patients.
4. Prompt termination of its action after discontinu-
ance of the drug or after the administration of
a nontoxic antagonist.
5. The activity of the drug can be determined by
a simple test.
The purpose of this report is to present our
icperience with Sintrom (G-23350), an oral anti-
Dagulant, and to compare it with the ideal anti-
aagulant and with anticoagulants which have
een in use for some time.
Sintrom, nitrophenyl acetyl-ethyl-4-oxycumarin
Fig. 1) is a member of the cumarin series.
From the Departments of Internal Medicine and
urgery of the University of Michigan Medical School,
his study was assisted by grants-in-aid from the Michi-
in Heart Association and the H. R. Rackham School
: Graduate Studies of the University of Michigan,
inancial support and Sintrom were also generously sup-
lied by Geigy Pharmaceuticals. Supplies of Mephyton
ere made available through the courtesy of Merck &
o., Inc.
Presented on Heart Day, Michigan Clinical Institute,
etroit, March 8, 1956. Heart Day was supported by
le Michigan Heart Association.
anuary, 1957
By J. A. Polhemus, M.D., W. S. Wilson, M.D.,
P. W. Willis III, M.D., J. R. Gamble, M.D.,
D. R. Griffin, M.D., P. E. Hodgson, M.D., and
I. F. Duff, M.D.
Ann Arbor, Michigan
It is a stable compound supplied in 4 mg.
scored tablets which are odorless and tasteless
and which are administered without difficulty.
0
SINTROM, NITROPHENYL ACETYL- ETHYL-4-0XYC0UMARIN
Fig. 1.
Extensive animal experimentation2 has shown
Sintrom to be effective in lowering the prothrom-
bin level and to be free of toxicity even after
continuous administration for two to three months.
Reports from European clinics3 indicate that
this drug is effective in man and is free of unto-
ward reactions.
Sintrom was given to seventy patients, fifty-two
of whom had a normal pretreatment prothrombin
concentration (80 per cent or above — Quick
method) and are therefore suitable for purposes
of comparison with results obtained in other pa-
tients treated with indandione derivatives as Di-
paxin, Hedulin or Indon (PID) and cumarin
derivatives as Dicumarol and Tromexan.
Diagnoses of the patients receiving Sintrom
are listed in Table I.
49
CLINICAL EVALUATION OF SINTROM (G-23350)— POLHEMUS ET AL
TABLE I.
DIAGNOSES OF PATIENTS TREATED WITH SINTROM
Diagnosis
Number of Patients
Thrombophlebitis — without emboli
Spontaneous
16
Postoperative
5
Carcinoma
4
Pulmonary emboli
Associated with thrombophlebitis
5
Without apparent thrombophlebitis
2
Myocardial infarction
13
Basilar artery thrombosis
1
Congestive heart failure (prophylactic)
6
Total
52
dose or the total amount of Sintrom required to
reduce the prothrombin concentration to the
therapeutic levels (less than 30 per cent) regard-
less of time was 58 mg. The average patient
reached therapeutic levels in two and one-third
days. Maintenance dosage, usually started on the
third or fourth day of treatment, ranged between
6 to 16 mg. with an average of 11 mg. daily.
The maintenance dose was found to vary greatly
from patient to patient and in the same patient
from day to day.
TABLE II. COMPARISON OF THE RESULTS OBTAINED WITH SINTROM, DIPAXIN, PID, DICUMAROL AND TROMEXAN
Sintrom
Dipaxin
PID
Dicumarol
Tromexan
Patients treated (normal initial prothrombin)
52
64
133
122
50
Mean effective dose
58 mg.
G3 mg.
685 mg.
646 mg.
3120 mg.
Therapeutic effect achieved:
Within 24 hours
2%
5%
18%
14%
12%
82%
Within 48 hours
60%
67%
95%
55 %
Average (days)
2.3
2.3
1.3
2.3
2.1
Average days to recover to 40% or above
1.5
4.1
1.5
5.0
2.5
Incidence of prothrombin:
Escape above 30%
81%
38%
17%
37%
90%
Fall below 10%
27%
10%
10%
15%
20%
Incidence of bleeding
17%
11%
6.5%
11%
9%
Total patients treated
70
104
200
303
100
All patients were evaluated before anticoagu-
lant therapy by members of the anticoagulant
team who then followed the patients daily and
determined the amount of the drug to be given.
A base line prothrombin concentration was ob-
tained prior to instituting therapy and daily
prothrombin determinations (Quick method)
were made while the patient continued to receive
Sintrom and following its discontinuance until
the prothrombin concentration had risen above
40 per cent. The aim of therapy was to maintain
the prothrombin concentration between 20 per
cent (33 seconds) and 30 per cent (22 seconds)
of normal. A single daily dose was usually em-
ployed, as no difference was noted when the drug
was given twice daily. When the clinical condi-
tion warranted an immediate effect on the blood-
clotting mechanism, intravenous and/or subcu-
taneous Heparin was given.
The results obtained with Sintrom and the
previously evaluated anticoagulants are recorded
in Table II.
The usual initial dose of Sintrom was 28 to 32
mg. followed by 16 to 24 mg. on the second
day. The larger doses were usually given to
patients of greater weight, but no definite rela-
tionship between dosage and body weight was ob-
served. The average total dose for the first forty-
eight hours was 46.5 mg. The mean effective
After the therapeutic range had been achieved,
forty-three of the fifty-two patients, or 81 per
cent, escaped at one time or another above the
30 per cent level, and fourteen patients, or 27
per cent, were below the 10 per cent level on at
least one occasion. There was a total of 525
days of maintenance therapy during which the
prothrombin concentration was above 30 per cent
on 143 days, or 27 per cent of the time, and be-
low 10 per cent on eighteen days, or 3 per cent
of the time. Following the discontinuance of
therapy the average time for the prothrombin
concentration to return to above 40 per cent was
thirty-six hours.
Bleeding, limited to mild epistaxis and hema-
turia occurred in nine patients, or 17 per cent.
Though this is slightly higher than found with
the other agents, the number of patients ob-
served was not large enough to make it statis-
tically significant, and it is doubtful if bleeding
is more apt to occur with Sintrom therapy. As
noted with other anticoagulants, bleeding usually
occurred when the prothrombin concentration was
10 per cent or below. The hypoprothrombino-
penia induced by Sintrom was rapidly corrected
by oral or intravenous Vitamin Kj (Mephyton)
(Fig. 2).
No evidence of toxicity was noted though ther-
apy was continued in one patient for fifty-three
50
TMSMS
CLINICAL EVALUATION OF SINTROM (G-23350)— POLHEMUS ET AL
days. Pre-treatment and post-treatment renal and
liver function studies, consisting of creatinine
clearances, urinalyses and Bromsulfalein excre-
tions, were performed in two patients without
parallel the decrease in prothrombin activity as
reflected by the one stage (Quick) and two
stage methods. No significant change in Factor
V could be detected.
DAYS
* VITAMIN K, (MEPHYTON-MERCK) AS *»B20863 44 S THROMBOPHLEBITIS
Fig. 2. The excessive prothrombin time resulting from Sintrom was rapidly reversed by
15 mg. of vitamin Ki orally with prompt cessation of hematuria.
evidence of change. No absolute resistance to
Sintrom was noted.
In addition to daily Quick one-stage prothrom-
bin determinations, several patients had simultane-
ous prothrombin evaluations by the Owren one-
stage P and P method,4 the Ware modification
of the Owren one stage method5 and the two
stage method of Ware and Seegers.6 As previous-
ly reported by Duff,1 when the prothrombin level
was within therapeutic range (10 to 30 per cent)
by the Quick one-stage and two-stage methods,
the corresponding values by the Owren and Ware
methods were definitely below the recommended
safe level. The Quick method of prothrombin
determination, which is the simplest and most
widely used, though not specific, was found to
be satisfactory for control of Sintrom.
Two patients had daily Factor V (Proacceler-
and) and Factor VII (Proconvertin) determina-
tions. A fall in Factor VII activity was noted to
Sintrom was the most potent anticoagulant
evaluated, milligram for milligram. Though it
probably is more rapid in action than Dicumarol
and similar to Dipaxin, it is not as rapid as
Tromexan and PID. The return to normal pro-
thrombin levels following the discontinuance of
drug administration would appear to be as rapid
with Sintrom as with any of the other anticoagu-
lants. Unfortunately in our experience there
does not seem to be a uniform response to a
specific dosage from patient to patient nor in
the same patient. This characteristic makes se-
lection of a maintenance dose difficult and prob-
ably accounts for the high incidence of escape
from therapeutic levels.
Summary
1. Sintrom, an oral anticoagulant, was given
to seventy-two patients. The results in fifty-two of
( Continued on Page 56)
January, 1957
51
Diuretics in the Treatment of
Congestive Heart Failure
/^\NE of the cardinal manifestations of con-
gestive heart failure is edema. The raw
materials for this edema, chiefly sodium and water,
are provided by the abnormal retention, by the
kidney, of these substances. This retention is due
to two factors: decrease in the glomerular filtra-
tion rate, and increase in the tubular reabsorption
of sodium and water. These two factors are more
or less operative in all cases of congestive heart
failure, and are secondary to the failure of the
heart to maintain an adequate circulation.
The primary effort in the therapy of congestive
heart failure, then, should be directed toward
the correction of the damaged pump. Unfortu-
nately, the types of heart disease for which we
have a specific cure are few, indeed. Commis-
surotomy for mitral stenosis, thiamin for beri-
beri heart disease, subtotal thyroidectomy or
therapeutic doses of radioactive iodine for thy-
rotoxic heart disease are examples of specific
corrective measures. For the majority of oases
of heart failure, digitalis is a nonspecific but
highly effective medication to improve the effi-
ciency of the failing myocardium. These spe-
cific measures plus digitalis, then, constitute the
primary weapons against congestive heart failure;
their use usually improves the circulation suffi-
ciently to reverse the mechanisms which caused
the edema, resulting in diuresis.
Frequently, however, a direct approach to the
elimination of the excess sodium and water is
made. This may be accomplished in two ways:
reducing the intake of sodium, and promoting
the excretion of sodium and water. The absorp-
tion of sodium into the body may be reduced by
low-sodium diets and by the use of cation-ex-
change resins. The increased removal of edema
fluid may be accomplished by mechanical means,
From the Departments of Medicine, City of Detroit
Receiving Hospital and Wayne State University Col-
lege of Medicine, Detroit, Michigan.
Supported in part by grants from the National
Institutes of Health ( H- 1471) and the Michigan Heart
Association.
Presented on Heart Day, Michigan Clinical Institute,
Detroit, March 8, 1956. Heart Day was supported by
the Michigan Heart Association.
By Yoshikazu Morita, M.D.
Detroit, Michigan
such as abdominal paracentesis,1 or by diuretics,
which promote increased renal excretion of edema
fluid. In most patients, diuretics permit a more
rapid recovery from congestive heart failure than
would be possible without their use, and in some
patients, diuretics are necessary if any improve-
ment at all is to be noted. The diuretics which
are commonly used in the therapy of congestive
heart failure are shown in Table I.
TABLE I. COMMONLY AVAILABLE DIURETICS IN THE
TREATMENT OF CONGESTIVE HEART FAILURE
I. Organic mercurials
A. Parenteral
B. Oral
II. Acetazoleamide (Diamox)®
III. Aminometramide (Mictine)®
IV. Ammonium chloride
V. Aminophylline
The injectable organic mercurial preparations
are the most effective of the diuretics. Oral
mercurial compounds, Diamox® and Mictine,®
are less effective but useful compounds, since they
may be administered by mouth. Ammonium
chloride and aminophylline are not very potent
diuretics in themselves, but are important ad-
juncts in the optimal use of mercurials, and will
be discussed more in detail below.
Organic mercurial preparations act by depress-
ing the reabsorption of chloride, sodium, and
water by the renal tubules, thereby producing an
increase in the urinary excretion of these in-
gredients of edema. The exact biochemical locus
of action is still in doubt.2,3 It usually promotes
a greater excretion of chloride than of sodium;4’5
the result frequently is a depletion of chloride
from the body. There is also an increased excre-
tion of acid in the urine. These two actions lead
to the development of hypochloremic alkalosis,
which is the most common electrolyte disturbance
produced by the use of a mercurial diuretic. Its
recognition is important in that it results in a
refractoriness to further injections of the same
compound. This refractoriness may be the re-
sult of the decrease in the chloride load filtered
by the glomeruli,6 and/or of the shift of intra-
cellular pH toward alkalinity.7 Correction of this
52
TMSMS
DIURETICS IN CONGESTIVE HEART FAILURE— MORITA
electrolyte disturbance may be simply made by
the administration of ammonium chloride. En-
teric coated tablets, in the dose of 2.0 grams four
times a day, should be given for two to three
days.
A second type of electrolyte disturbance some-
times attributed to the use of mercurials is hypo-
natremia. The appearance of this condition is
usually due in part to other factors, such as
markedly restricted salt intake, extrarenal salt loss,
and internal shifts of electrolytes, and it is difficult
to blame the diuretic alone. Mild hyponatremia
of about 125 to 130 mEq. per liter does not
usually prevent an adequate response to mer-
curials, provided the chloride level is not low.
Severe hyponatremia of less than 120 milliequiva-
lents per liter may reflect an actual deficit of
total body sodium, as may be the case in a patient
who has been eating little and receiving frequent
injections of mercurials. Physical examination
of such a patient would reveal evidence of de-
hydration and possibly collapse, or of normal
hydration. Replenishing the sodium supply may
improve the clinical picture almost immediately.
The following formula may be used as a guide
to determine the amount of sodium to be given
to raise the plasma level by a given amount.
Six-tenths milliequivalent of sodium should be
given for each kilogram of body weight to raise
the plasma sodium level by 1 milliequivalent per
liter. If it is desired to raise the plasma sodium
level in a 70 kilogram man by 10 milliequivalents
per liter, 0.6 x 70 x 10 or 420 milliequivalents
of sodium should be given. The sodium may be
given chiefly as the chloride, bicarbonate or lac-
tate, depending upon the relative deficits of bi-
carbonate and chloride in the plasma. It is
advisable to proceed cautiously when administer-
ing large amounts of sodium; an attempt to
correct the plasma sodium level completely to
normal in one step should not be made. It is
suggested that about one-half of the amount
needed for complete restitution be given as the
first dose. Further doses may be given if a good
clinical response occurs, and incomplete correction
of the hyponatremia is found. A patient with
congestive heart failure, who still has moderate
to marked edema and who has severe hypona-
tremia, probably does not have a deficit of total
sodium, but actually has an excess of total body
sodium. In the extracellular fluid, the excess
of water, however, is relatively greater than the
excess of sodium, resulting in hyponatremia. The
giving of sodium to such a patient is very much
like giving an additional weight for the left hand
to a man who is carrying a heavy package in
his right hand. The added burden, by restoring
better balance, may result in more efficient carry-
ing ability; however, there is the danger that the
man may not be able to lift the total load at all!
In patients with congestive heart failure, the in-
fusion of hypertonic saline may result in a tem-
porary increase in urinary output of water and
sodium; however, usually the net loss of edema
is nil.8 Frequently, patients who develop this
type of electrolyte disturbance are critically ill,
and the giving of hypertonic saline does not
prevent a continuing downhill course.9 It is
possible that in such patients the hyponatremia
is a reflection of decreased osmolarity of the
intracellular fluid, and therefore not amenable
to correction by the addition of sodium to the
extracellular fluid. If it has been decided to
give sodium to the edematous patient with hypo-
natremia, the amount of sodium required should
be calculated from the above formula. Since
water is already present in large excess, the in-
take of water must be kept at a minimum; the
sodium should be given intravenously, slowly,
as a hypertonic solution, such as 5.8 per cent
saline, which contains 100 milliequivalents of
sodium per 100 ml.
A third type of electrolyte disturbance which
may develop during mercurial therapy is hypopo-
tassemia. Under certain conditions, mercurials
may inhibit the tubular secretion of potassium.4’10
However, in most patients with congestive failure,
there is an increase in potassium excretion. This
increased excretion is not very marked in most
patients. Hence, in a patient who is eating nor-
mally, marked potassium depletion does not oc-
cur. Nevertheless, even a modest loss of potas-
sium in a patient who is fully digitalized may
lead to cardiac manifestations of digitalis intoxi-
cation,11 such as frequent ventricular premature
beats. This is due to the opposing effects
which potassium and digitalis exert upon myo-
cardial function.
During the development of congestive heart
failure, there is usually a negative potassium
balance.22 In subjects in whom this deficit be-
comes very large, perhaps due, in part, to poor
intake of food, a marked decrease in intracellular
potassium occurs. Extracellular sodium may
Jan UARY, 1957
53
DIURETICS IN CONGESTIVE HEART FAILURE— MORITA
migrate into the cellular space under such condi-
tions, resulting in hyponatremia. In such cases,
the hyponatremia cannot be corrected until the
intracellular potassium deficit is remedied.12
Diuresis with mercurial plus aminophylline
Rheumatic 8 hypertensive heart disease
Fig. 1. Diuresis produced by the combined use of
a mercurial diuretic plus aminophylline.
Where potassium lack is deemed to be clinically
significant, potassium chloride, enteric coated,
should be given in a dosage of 2.0 grams three
to four times daily until the deficit is corrected.
Before discussing a plan for the use of mercurial
diuretics, the value of aminophylline as an ad-
junct to mercurial diuretics should be discussed.
When given parenterally, aminophylline has two
effects on the kidney: first, it increases renal plas-
ma flow and glomerular filtration rate,8 both of
which are usually depressed in congestive heart
failure; and, secondly, it inhibits tubular reab-
sorption of sodium. The first is by far the more
important factor. Since filtration is the first
step in the production of urine, a diminution of
this function, such as occurs in congestive heart
failure, hinders the removal of sodium and water
and, thus, of edema, by the kidneys. Of the
diuretics commonly used, aminophylline is the
only one which increases glomerular filtration.
Figure 1 illustrates the use of this drug. The
patient was a woman with hypertensive and
rheumatic heart disease, with severe congestive
heart failure. It is to be noted that with amino-
phylline alone or with mercurial alone, there was
no loss of edema, as indicated by daily body
weight measurements; however, the combination
of the two drugs resulted in a good diuretic re-
sponse repeatedly. The increase in glomerular
filtration, brought about by the aminophylline,
plus the inhibition of tubular reabsorption of
salt and water, accomplished by the mercurial,
resulted in diuresis, where either one alone failed.
Table II is a suggested regimen for the use of
injectable mercurial diuretic in congestive heart
failure; it embodies the principles of its use out-
lined above.
TABLE II. SUGGESTED REGIMEN FOR PARENTERAL
MERCURIAL DIURETIC
I. 2 ml. intramuscularly every third morning.
II. If response, as measured by increase in urinary
volume and/or decrease in body weight is poor,
give enteric coated ammonium chloride, 2.0 grams
four times a day, for three days preceding each
dose of the mercurial.
III. It the response is still poor, give aminophylline,
0.5 to 1.0 gram, in 300 ml. of 5 per cent glucose
in water intravenously over a three-hour period,
starting simultaneously with the dose of mercurial.
In more urgent cases, mercurial injections may
be given oftener than indicated; however, more
frequent injections are more likely to lead to
electrolyte disturbances, resulting in refractoriness,
and may result in mercurialism if renal function
is markedly impaired. Aminophylline need not
be given as an infusion, but may be given in one
0.5 gm. dose intravenously about one to two
hours after the mercurial. If intravenous injection
is not feasible, aminophylline, 0.5 gm. in 2 ml.,
may be administered intramuscularly together with
the mercurial in the same syringe13; however, this
is not a recommended procedure, since intra-
muscular injections of aminophylline are painful.
Orally administered aminophylline is poorly ab-
sorbed, and therefore has little beneficial effect.
It should be stressed again that the patient should
be at rest, reclinining, for several hours to obtain
a maximal glomerular filtration rate and maximal
diuresis.
The procedure just outlined is designed for the
initial treatment of a patient with congestive
heart failure. For maintenance, less strenuous
measures may suffice. Many patients may remain
edema-free with digitalis, adequate rest, salt re-
striction, and one of the oral diuretics.
Oral mercurial preparations are not as effective
as their injectable counterparts.14’15 Moreover,
there is a higher incidence of side reactions, not-
ably gastrointestinal disturbances, which attend
their use.16 Gastrointestinal manifestations include
stomatitis and gingivitis, nausea, vomiting, ab-
dominal pain, and diarrhea. Dermatitis, albu-
minuria and hematuria also have been reported.
Mercurials are also prepared as rectal supposi-
54
TMSMS
DIURETICS IN CONGESTIVE HEART FAILURE— MORITA
ories. Their efficacy is of the same order as
hat of the oral diuretics.23
Acetazoleamide, or Diamox. is another recently
ntroduced oral diuretic. This interesting com-
xmnd is an inhibitor of the enzyme carbonic
mhydrase, which is found in the cells of the
•enal tubules. One of the numerous functions
)f the distal renal tubules is the acidification of
mine. This function and the reabsorption of
ome of the sodium in the tubular urine are
ntermeshed in an operation which requires car-
tonic anhydrase for its functioning. In the tubu-
ar cell, this enzyme catalyzes the production of
:arbonic acid from the ever present raw materials,
vater and carbon dioxide. The carbonic acid,
n turn, dissociates to yield hydrogen ion and
ticarbonate ion. The hydrogen ion is secreted
nto the tubular urine in exchange for sodium
on. The operation results in the excretion of
icid and the conservation of sodium ion to the
>ody. When Diamox is administered, this enzyme
5 blocked. The production of carbonic acid de-
ceases and, consequently, the availability of
tydrogen ion in the tubular cell is decreased,
exchange of sodium for hydrogen is thereby re-
luced, allowing more sodium to remain in the
ubular fluid. The result is the excretion of
ncreased amounts of sodium and, with it, water,
"urther, since hydrogen ion secretion is depressed,
he urine becomes less acid, and frequently al-
aline. A consequence of the use of this com-
>ound, therefore, is the production of hyper-
hloremic acidosis.17 This is the exact opposite
if the electrolyte disturbance produced by mer-
urials.
In clinical trials,18’20 Diamox has been found
o be a mild to moderate diuretic. It is said to
le more effective in failure due to cor pulmonale
han in ordinary types of heart failure.19 The
typerchloremic acidosis produced is usually mild
nd asymptomatic; however, it will result in re-
ractoriness to the diuretic action of the drug. In
irder to allow the body to recover from the acido-
is and thus again become responsive to the drug,
he compound should not be given more often
han once every other day. The side effects of
he drug in the doses recommended below are
nild, and consist of paresthesia of the circumoral
rea and the extremities.
Aminometramide, or Mictine, is another useful
>ral diuretic.21 It acts by inhibition of tubular re-
.bsorption of sodium and water, and no electrolyte
disturbance has been reported following its use.
Because the side effects are chiefly referable to
the gastrointestinal tract, the drug should be given
with meals to minimize this. Doses larger than
that recommended below will give a high inci-
dence of undesirable reactions; nausea and vom-
iting were found in 31 per cent of patients re-
ceiving 1.5 gm. of Mictine per day.21 On the
basis of preliminary observations, Rolicton,® which
is closely related chemically to Mictine, seems
to be as effective as, and less likely to cause
nausea and vomiting than, Mictine, when 500
mgm. are given three times a day with meals.
Table III summarizes the doses and suggested
plan for the use of the oral diuretics discussed.
table in
I. Mictine®
200 mg. t.i.d. with meals, every other day
II. Neohydrin®
3 to 8 tablets after breakfast, every other day
III. Diamox®
250 or 500 mg. every other morning
In general, if possible, all diuretics should be
given in the morning, or not later than mid-
afternoon, to allow the patients uninterrupted
sleep at night. In the case of Mictine, gastro-
intestinal disturbances dictate administering the
drug with meals. With oral mercurials, the larg-
er doses indicated should not be continued in-
definitely, since gastrointestinal symptoms of mer-
curialism are more apt to develop. Furthermore,
in patients with elevated blood urea nitrogen or
nonprotein nitrogen, there may be an impaired
ability to excrete mercury, and mercurial diure-
tics, oral or parenteral, should not be used in high
doses. The importance of bed rest for at least
a few hours after administration, to obtain max-
imal effect, has been stressed above.
Summary
In conclusion, diuretics are important, although
secondary, therapeutic measures in the treatment
of congestive heart failure. Parenteral organic
mercury preparations are the most potent diuretics
known. In the absence of severe organic renal
disease, mercurials, used with ammonium chloride
and aminophylline, as indicated, will produce
diuresis in most patients with severe congestive
heart failure. The oral diuretics are less effective
than injectable mercurials; however, in moder-
ately severe cases, their use may reduce or nullify
the requirement for injections. Each of the di-
uretics must be used with a full understanding of
its mode of action and its shortcomings.
[anuary, 1957
55
DIURETICS IN CONGESTIVE HEART FAILURE— MORITA
References
1. Schemm, F. R., and Camara, A. A.: The relief
of resistant edema by utilization of a sump phe-
nomenon. Circulation, 11:411, 1955.
2. Dale, R. A., and Sanderson, P. H.: The mode of
action of a mercurial diuretic in man. J. Clin.
Invest., 33:1008, 1954.
3. Wesson, L. G., Jr., and Anslow, W. P., Jr.: Effect
of osmotic and mercurial diuresis on simultaneous
water diuresis. Am. J. Physiol., 170:255, 1952.
4. Welt, L. G.; Goodyer, A. V. N. ; Darragh. J. H. ;
Abele, W. A. ; and Meroney, W. H. : Site of salure-
tic action of an organic mercurial compound. J.
Appl. Physiol., 6:134, 1953.
5. Schwartz, W. B., and Wallace, W. M.: Electrolyte
equilibrium during mercurial diuresis. J. Clin. In-
vest., 30: 1089, 1951.
6. Goodman, L. S., and Gilman, A.: The Pharmaco-
logical Basis of Therapeutics, 2nd Ed., p. 848.
New York: The Macmillan Co., 1955.
7. Mudge, G. H., and Hardin, B. : Response to
mercurial diuretics during alkalosis: A comparison
of acute metabolic and chronic hypokalemic alka-
losis in the dog. J. Clin. Invest., 35:155, 1956.
8. Weston, R. E.; Escher, D. J. W. ; Grossman, J.;
and Leiter, L. : Mechanisms contributing to unre-
sponsiveness to mercurial diuretics in congestive
failure. J. Clin. Invest., 31:901, 1952.
9. Uricchio, J. F., and Calenda, D. G.: The failure
of hypertonic saline in the treatment of hypona-
tremia and edema in congestive heart failure. Ann.
Int. Med.. 39:1288, 1953.
10. Mudge, G. H.; Ames, A.; Flulks, J.; and Gilman,
A. : Effect of drugs on renal secretion of potassium
in the dog. Am. J. Physiol., 161:151, 1950.
11. Lown, B. ; Salzber, H.; Enselberg, C. D.; and
Weston, R. E.: Interrelation between potassium
metabolism and digitalis toxicity in heart failure.
Proc. Soc. Exper. Biol. & Med., 76:797, 1951.
12. Cort, J. H., and Matthews, H. L.: Potassium de-
ficiency in congestive heart failure. Lancet., 1:1202,
1954.
13. Vogl. A., and Esserman, P. : Aminophylline as
supplement to mercurial diuretics in intractable
congestive heart failure. J.A.M.A., 128:12, 1951.
14. Moyer, J. H. ; Handley, C. A.; Seiber, H. A.; and
Snyder, H B. : Electrolyte, water and mercury ex-
cretion after oral administration of neohydrin.
Arch. Int. Med., 92:847. 1953.
15. Moyer, J. H.; Handley, C. A.; and Wilford, I.:
Results over a two-year period on three experimen-
tal diuretics administered orally to patients with
cardiac failure. Am. Heart J., 44:608, 1952.
16. Evans, J. M., and Massumi, H. A.: The long-term
use of the oral diuretic 3-chloro-mercuri-2-methoxy-
propylurea (Neohydrin) in ambulatory patients.
Ann. Int. Med., 44:124, 1956.
17. Leaf, A.; Schwartz, W. B. ; and Reiman, A.: Oral
administration of a potent carbonic anhydrase in-
hibitor (“Diamox”). New England J. Med., 250:
759, 1954.
18. Reiman, A.; Leaf, A.; and Schwartz, W. B. : Oral
administration of a potent carbonic anhydrase in-
hibitor (“Diamox”). II. Its use as a diuretic in
patients with severe congestive heart failure. New
England J. Med., 250:800, 1954.
19. Schwartz, W. B. ; Reiman, A. S.; and Leaf, A.:
Oral administration of a potent carbonic anhydrase
inhibitor (“Diamox”). III. Its use as a diuretic in
patients with severe congestive heart failure due
to cor pulmonale. Ann. Int. Med., 42:79, 1955.
20. Friedberg, C. K.; Taymor, R.; Minor, J. B.; and
Halpern, M. : The use of Diamox, a carbonic an-
hydrase inhibitor, as an oral diuretic in patients
with congestive heart failure. New England J. Med.
248:883, 1953.
21. Caccamo, L. P. ; Pringle, B. H.; and Hissong, D.
E.: A therapeutic evaluation of l-allyl-3-ethyl-6-
aminotetrahydropyrimidinedione (Mictine), a new
oral diuretic. (To be published).
22. Iseri, L. T. ; Boyle, A. J.; and Myers, G. B. : Water
and electrolyte balance during recovery from severe
congestive failure on a 50 mgm. sodium diet.
Am. Heart J., 40:706, 1950.
23. Makons, N. ; Jennings, P.; Frank, E. H., Jr.; and
Vander Veer, J. B.: A clinical evaluation of the
use of a rectal mercurial diuretic in patients with
chronic congestive heart failure. Am. J. M. Sc.,
231:86, 1956.
SINTROM, A NEW ORAL ANTICOAGULANT
(Continued from Page 51)
these were compared with those obtained in other
patients receiving Dicumarol, Hedulin or Indon
(phenylindandione) , Dipaxin and Tromexan.
2. On the basis of the mean effective dose,
the drug was found to be the most potent of any
of those studied.
3. A maintenance dose was difficult to estab-
lish which resulted in a high incidence of escape
from therapeutic range.
4. Toxicity was not encountered and the in-
cidence of bleeding (17 per cent) was in the
general range reported with other anticoagulants.
5. The excessive effect of Sintrom could be
rapidly reversed by oral or intravenous Vitamin
Kv
6. A decrease in Factor VII activity paral-
leled the hypoprothrombinemia produced.
References
1. DufT, I. F.; Gamble, J. R. ; Willis, P. W., Ill;
Hodgson, P.; Wilson, W. S. ; and Polhemus, J. A.:
The control of excessive effect by anticoagulants.
Ann. Int. Med., 45:955, 1955.
2. Geigy Pharmaceuticals: Personal communication.
3. Moeschlin, S., and Schorno, H. : Clinical experi-
ence with a new 4-oxycumarin derivative — Sintrom.
Schweiz, med. Wchnschr., 85:590-592 (June 11)
1955.
4. Owren, P. A., and Oas, K.: The control of
Dicumarol therapy and the quantitative determina-
tion of prothrombin and proconvertin. Scandinav.
J. Clin, and Lab. Invest., 3:201, 1951.
5. Ware, A. G., and Stragnell, R.: Improved one-
stage prothrombin method. Am. J. Clin. Path., 22:
791, 1952.
6. Ware, A. G., and Seegers, W. H.: Two stage
procedure for the quantitative determination of
prothrombin concentration. Am. J. Clin. Path.,
19:471, 1949.
7. Wright, I. S.: The use of anticoagulants in the
treatment of diseases of the heart and blood ves-
sels. Ann. Int. Med., 30:80, 1949.
56
JMSMS
Interatrial Septal Defect
Course and Surgical Correction
By James B. Blodgett, M.D.
Detroit, Michigan
T NTERATRIAL septal defect is an important
■** cardiac anomaly because it usually causes
death in early adult life and it is subject to surgi-
cal correction. It is one of the most common
of the congenital abnormalities of the heart. Gelf-
man and Levine1 in studying 453 autopsied cases
of congenital heart disease found interatrial septa]
defect present in 39 per cent of all cases and in
25 per cent of the cases over two years of age.
In a clinical study of 1,395 patients with congeni-
tal heart disease, Gasul & Fell2 found interatrial
;eptal defect to be the fourth commonest lesion,
occurring in 9.6 per cent of their series.
The life expectancy in interatrial septal defect
varies as it does with other congenital cardiac de-
pots, but average life expectancy is between thirty-
our3 and forty4 years. Death is preceded by a
lumber of years of increasing cardiac disability.
The pathologic physiology is a consequence of
he anatomic defect and the associated abnormal
oemodynamics. The primary hemodynamic ab-
lormality is an enormous flow of blood from the
eft atrium to the right. This is referred to as a
eft to right interatrial shunt. The great quantity
rf this shunt was demonstrated by Healy, Dow,
iosman and Dexter5 who calculated the volume
}f the flow per minute by obtaining the difference
between the pulmonary flow and the peripheral
low in liters per minute. The flow through the
hunt in their patients was commonly 6 to 8 liters
aer minute and not infrequently as high as 25
o 28 liters per minute. This large volume of
nteratrial flow is added to the normal inflow
af the right atrium. Consequently, the minute
volume flow through the right atrium, the right
/entricle, pulmonary vascular system and the left
itrium is very large. The left ventricular and
irterial flow is reduced in quantity by the inter-
itrial shunt. The increase in pulmonary flow
aroduces the enlargement of the pulmonary vas-
Dr. Blodgett is Associate Surgeon, Grace Hospital and
\ssistant Surgeon, Children’s Hospital Detroit, Michigan.
Presented on Heart Day, Michigan Clinical In-
stitute, Detroit, March 8, 1956. Heart Day was sup-
aorted by the Michigan Heart Association.
January, 1957
culature, as seen by x-ray and also produces the
vascular pulsation which is occasionally seen, and
is known as “hilar dance.” The reduced peri-
pheral arterial flow is the cause of the easy fatigue
in these patients and the general underdevelop-
ment. It has been shown by Edwards,6 Dam-
mann,7 and others, that large increases in volume
of pulmonary flow eventually produce obliterative
vascular changes which increase resistance and
consequently elevate the pulmonary artery pres-
sure. Concomitantly there is elevation in right
ventricular pressure and increased work for the
right ventricle. There follows right ventricular
hypertrophy and dilatation and eventual incom-
petence of both the pulmonary and tricuspid
valves. At some stage in this sequence the right
atrial pressure rises and clinical signs of peripheral
congestive failure ensue. In the late stages, the
right auricular pressure may rise to such levels
that the volume of the shunt is very much re-
duced if not completely eliminated and there is
occasional reversal of the shunt so that blood
flows from the right atrium to the left, with the
appearance of cyanosis. Death is the ultimate
consequence of this pathophysiologic progression.
The anatomic consequence of the interatrial
shunt is enlargement of the pulmonary artery and
its radicals, enlargement of the right ventricle,
the right auricle and left auricle. Apparently, as
the atria dilate, the defect in the interatrial sep-
tum also enlarges, that is, it is stretched along
with the atrial walls and septum. This increases
the amount of the shunt. The mitral valve has
been commonly found to be abnormally small,
but not the seat of pathologic abnormality. The
probable reason for this is that since the flow
through the mitral valve into the left ventricle
has always been small, the valve has not en-
larged at the normal rate. As the individual
grows, there is greater disproportion between the
mitral valve which remains relatively infantile
and the interatrial defect which enlarges as the
atria dilate. The effect of this is an increasing
per cent of left to right shunt.
57
INTERATRIAL SEPTAL DEFECT— BLODGETT
As a means of correction of this anomaly, clo-
sure of the interatrial septal defect is obviously
necessary. Open heart surgery with inflow occlu-
sion may occasionally be necessary, but for the
Fig. 1. Interatrial defects; closed methods of repair.
The four drawings illustrate the placement of the cir-
cumferential suture and the dissection behind the vena
cava into the posterior portion of the interatrial septum,
which permits closure of the defect by tying the suture.
commoner atrial defects the closed method has
proven very safe and effective. The closed
method of interatrial repair depends upon a
technique developed by Sondergaard, presented
by Bjork and Craford.8 Briefly, the method of
Sondergaard depends upon the fact that the pos-
terior portion of the interatrial septum reaches
the atrial wall at a point between the vena cava
and the right pulmonary veins. Thus, by dis-
secting up the vena cava away from the pulmon-
ary veins at the hilum of the lung, the dissection
is carried essentially into the back portion of the
interatrial septum. Once this dissection has been
made, sutures can be placed from the outside of
the atrium, which can close the septal defect.
The needle is guided by the finger introduced
into the right atrium through the auricular ap-
pendage. Through the septal defect both sides
of the interatrial septum can be palpated as the
sutures are being placed. These sutures can be
placed in a variety of ways and the completeness
of the closure can be clearly appreciated by the
palpating finger. The closure can be accom-
plished without interference with the vena caval
inflow and should not of course interfere with
the AV conduction system, or the outflow of the
coronary sinus. Before the closure it is possible
to pass the intracardiac finger through the auricu-
Fig. 2. Interatrial defects; closed methods of repair.
Drawings A and B illustrate placement of mattress su-
tures from the Sondergaard dissection to close the de-
fect. Drawings C and D illustrate the technique of
Lam for closing the defect with the double ended needle.
lar defect and palpate the mitral valve and to
palpate any possible tricuspid insufficiency. As
the defect is closed the distention of the right
atrium becomes noticeably less, and the color of
the blood as the finger is withdrawn from the
right atrial appendage is dark venous in appear-
ance rather than bright red as when the finger
was introduced. We have also noted, in cases
where a pulmonary arterial thrill had been palp-
able, that this has disappeared upon interatrial
closure. Suturing and manipulation from the
right side of the heart is attended with very little
rhythm irregularity and the cardiac function has
been well maintained during surgery. Figures 1
and 2 illustrate three methods of suture place-
ment. All start from the Sondergaard dissection.
The lower two illustrations in Figure 2 show the
method of suture placement devised by Lam9
which uses a double-ended needle. In cases where
the septal wall is thick enough, this method has
been very useful.
The indication for surgical closure of an inter-
atrial septal defect would appear to be the
presence of the defect in any patient who has
58
JMSMS
INTERATRIAL SEPTAL DEFECT— BLODGETT
not progressed to the stage of such elevated ir-
reversible pulmonary hypertension that operation
can produce little or no improvement. Ideally
the closure should be effected before the second-
ary anatomic results of the massive shunt and
chamber enlargement have occurred. There is
no doubt that the operative procedure is easier
and less hazardous when undertaken on the small
hearts of children rather than upon the tremen-
dously enlarged hearts of adults. Our present
feeling is that parents with children who have
interatrial septal defects should be advised to
have operative closure for the following reasons:
1. The expectation is that the individual will
die before the age of forty without closure.
2. Early operation prevents:
(a) Progressive enlargement of the inter-
atrial defect.
(b) Increasing disproportion of the mitral
valve and the defect.
(ci) Progressive pulmonary vascular changes
and pulmonary hypertension.
(d) The clinical complications of the dis-
ease such as recurrent pneumonia, pul-
monary thrombosis, and hemoptysis.
3. The child can regain his normal growth
curve.
4. The operation is technically easier and less
hazardous in childhood.
Surgery is contraindicated if the pulmonary
pressure, as measured by catheterization, is con-
siderably elevated. The reason for this is that
irreversible pulmonary vascular changes have oc-
curred and the right heart symptoms will not
abate as a result of closure of the defect. Pul-
monary hypertension is clinically suggested by
signs of right cardiac failure, a very large heart
and if the patient is over forty years of age.
Case Reports
The following three cases are presented to il-
lustrate the previous points.
Case 1. — This was a forty-two-year-old woman who
had had progressive disability for six years, character-
ized by breathlessness, fatigue, dependent edema and
ascites. She entered the hospital completely incapac-
itated and was maintained in an oxygen tent. Roent-
genogram showed tremendous enlargement of the heart
(Fig. 3). Angiography demonstrated trichamber en-
largement with a very large pulmonary arterial tree.
Catheterization findings by Dr. Harper Hellems showed
that there was a left-right shunt of 4.7 liters per minute
and that the pulmonary artery pressure was 97/36. Op-
eration was carried out April 19, 1955. At this time a
tremendous right auricle was demonstrated. The defect
by palpation was felt to be 4 to 5 cm. in diameter.
There was definite tricuspid regurgitation. The de-
fect was completely closed with mattress sutures.
Fig. 3. Case 1. Preoperative chest
radiograph.
Following operation the patient was improved. Her
respiration was considerably easier. She could be out
of her oxygen tent, was up and around, and the
edema of the extremities cleared somewhat. She was
discharged on the twentieth postoperative day. At
home, the signs of right-sided failure gradually increased,
and the pulmonary symptoms did not reappear. The
patient died suddenly at home four months following
operation.
Comment : This was an advanced phase of inter-
auricular septal defect with high pulmonary pressure.
The operation was undertaken because of the high vol-
ume of the shunt and the precarious condition of the
patient. In the presence of tricuspid insufficiency, clos-
ure of the shunt did not correct the right-sided failure
and operation was too late to be of benefit to this
patient.
Case 2. — This patient is a thirty-six-year-old mother
of five children, who had had progressive symptoms for
four years, consisting of easy fatigue, dyspnea, tachy-
cardia and hemoptysis. On examination, she had signs
of atrial septal defect, and catheterization by Dr. Harper
Hellems proved the presence of the defect. There was
a left to right shunt of 9.1 liters per minute, but the
pulmonary artery pressure was 27/11, indicating not
more than minimal pulmonary vascular obstructive
changes. Operation was carried out June 14, 1955.
The interatrial defect was found to be 2.4 cm. in size.
The mitral valve opening was about a finger and a
quarter in size. The interatrial septal defect was closed
with three mattress sutures. The patient did well fol-
lowing operation. She was discharged on the tenth
January, 1957
59
INTERATRIAL SEPTAL DEFECT— BLODGETT
postoperative day. The x-ray taken two months post-
operatively is reproduced with the preoperative film
(Fig. 4). The transverse diameter had decreased 1.8
cm. Following operation the patient has had occasional
Case 3. — This is a five-year-old girl who had rather
slow physical development and frequent colds. She
was found to have an enlarged heart with a systolic
murmur. Catheterization was carried out January 17,
Fig. 5. Case 3. Chest radiographs. Six days postoperative (It) and two months
postoperative (rt) when heart size was normal.
tachycardia but no pulmonary difficulty, no fatigue, and
felt considerably improved. Two months following op-
eration the patient became pregnant and was delivered
of an eight pound, six ounce, child in breech presenta-
tion. There were no signs of failure during the preg-
nancy or during or following delivery. At present the
patient is caring for her six children and feels well.
Comment : This is an example of an adult in whom
closure of the defect has been corrective, since there
had not been significant increase in pulmonary pressure.
1955, by Dr. Anthony Nolke; angiocardiography was
done February 23, 1955, by Dr. John Hertzler. These
tests were consistent with interatrial septal defect. Op-
eration on January7 9, 1956, demonstrated a defect of
1 J/2 cm. in diameter, well above the tricuspid valve,
which was closed without difficulty with through-and-
through mattress sutures. The murmurs disappeared
She was discharged home on the ninth postoperative
day. The two-months’ follow-up roentgenogram appears
with one taken shortly after operation (Fig. 5). It
shows the change in size and contour of the heart to
( Continued on Page 90)
60
JMSMS
Familial Heights as a Useful Guide
in the Diagnosis of Genitourinary Anomalies
By Robert C. Moehlig, M.D.
Detroit, Michigan
TTAVING observed certain congenital urinary
anomalies in association with familial height,
it was deemed worth while to report these ob-
servations. Many years ago I called attention to
the selective action of the endocrine glands on
various tissues depending upon their embryo-
logic origin.1
In the present article, a brief resume will be
given showing the relationship of the pituitary
gland to the genitourinary tract and the relation
of the familial height to anomalies of this tract.
A potent argument favoring the view that the
pituitary affects mesodermal tissues (of which the
genitourinary tissues are a part) is seen in the
anencephalic fetus with pituitary defects.1 The
pituitary maldevelopment in these fetuses pro-
duces an aplasia of the genitourinary tract with
small kidneys, defects in the genitalia and ad-
renal cortex hypoplasia.
It has been shown that pituitary defects result
in genitourinary defects as well as mesodermal
defects in general. It is also true that pituitary
hyperfunction results in hyperplasia of the genito-
urinary system as well as hyperplasia of the ad-
renal cortex. The adrenal cortex, a mesodermal
derivative, has a selective action on a division of
the mesoderm, namely the mesothelium. From
this are derived the following tissues:
1. Peritoneum.
2. Pleura.
3. Pericardium.
4. Urogenitals: (a) Wolffian body; (b) Kid-
ney; (c) ovary; (d) oviducts, uterus, and
vagina.
5. Striated muscles: (a) Skeletal: (b) cardiac
muscle.
The important feature to be discussed is the
pituitary, the controlling gland of the mesoderm
and the mesodermal subdivision, the mesothelium.
In discussing the relationship between the pi-
From the Department of Medicine, Harper Hospital
and Wayne University, Detroit, Michigan.
January. 1957
tuitary and adrenal cortex I said that anterior
cerebral defects which include pituitary defects are
in turn accompanied by adrenal cortex defects.1
In 1943, discussing renal rickets, I stated that a
congenitally deformed pituitary gland is frequent-
ly associated with congenital cerebral defects such
as anenecephalus and hydrocephalus. Such a
pituitary defect is associated with a secondary
genitourinary tract defect in the form of kidney
malformation, dilatation of the kidney pelves and
the bladder. Agenesis of the adrenal cortex is
also usually present. A further association of the
pituitary to the genitourinary tract and skeletal
system is seen in renal rickets or renal dwarfism.
In this disease, diabetes insipidus is frequently
present, indicating a posterior lobe defect since
these cases respond to vasopressin and are not the
result of the renal defect such as is present in
nephrogenic diabetes inspidus. This presumes
that the anterior pituitary lobe, while defective
in development, is not completely so; otherwise,
there would be no diabetes insipidus. The same
holds true for the kidney, that is some functioning
renal tissue must be present albeit the kidneys are
small and aplastic.
Chown,2 in commenting in his studies of renal
dwarfism, came to the conclusion that the disease
is the result of a pituitary-diencephalon disturb-
ance. He said “The argument in proof of the
thesis that a lesion of the pituitary-diencephalic
mechanism is the primary cause of the symptom
complex called renal rickets is then as follows:
1. Malformation of the pituitary has been found in
these cases;
2. The associated symptoms of the dwarfing infantil-
ism and urinary tract dilatation can be caused
by such a lesion;
3. The nephritis is not primary but is secondary
to an abnormal metabolism, itself the result of
faulty bone growth;
4. The faulty bone growth therefore not being due
to the nephritis, and the remaining symptoms be-
ing due to pituitary-diencephalic disease. It is to
be presumed that the bone disease is due to the
same cause.”
61
DIAGNOSIS OF GENITOURINARY ANOMALIES— MOEHLIG
In reviewing some of the literature on renal
rickets, I was impressed with the fact that devel-
opmental defects of the kidneys, urinary tract and
skeleton are important features of the disease as-
sociated with defects in the pituitary-hypothalamic
region. For instance, hydrocephalus may be as-
sociated with a pituitary defect and this in turn
with an anomalous development and aplasia of
the adrenal cortex, urinary and genital organs.3
Davis, ■' in his study of kidneys and ureters found
coexisting abnormalities of the genital organs. He
reported cases of urinary bladder dilatation and
kidney anomalies associated with hydrocephalus.
Increased intracranial pressure from whatever
cause during the early developmental period of
life results in pituitary disturbance with conse-
quent genitourinary anomalies and defects. Con-
genital hypopituitarism of various degrees, even to
the extent of complete apituitarism, results in
aplasia of the adrenal cortex and the genitourinary
tract.
A congenitally small pituitary or underactive
deformed pituitary is, therefore, most likely to be
associated with maldevelopment of the kidneys
and genitalia, such as aplastic malformations
which usually include the adrenal cortex.
By the same reasoning and based on clinical
evidence, hyperfunction of the pituitary is most
likely to be associated with overdevelopment of
the kidneys, genitalia and adrenal cortex. This is
well illustrated in acromegaly and gigantism. In
these diseases the growth hormone affects the
whole body structure, increasing the size of the
viscera and, of course, this includes the kidneys.
It is known that anterior pituitary extracts can
increase the size of the kidneys.5
If the pituitary activity is reflected in the gen-
itourinary tract, then familial heights may give a
clue to urinary pathology. As we know, the pitui-
tary is a most important factor in the development
of the skeletal system so that heights of the imme-
diate family may guide one in suspecting what
type of genitourinary pathology may be present.
This may be briefly summarized by stating that
familial shortness of stature is associated with
congenital underdevelopment of the kidneys such
as is present in renal dwarfism, and that familial
tallness is associated with overdevelopment of the
kidneys such as supernumerary multiple kidneys,
and multiple ureters. Likewise, polycystic kid-
neys are associated with familial tallness.
The constitutional hereditary background is
shown by the familial heights of greater than
average sampling of the population. In the First
World War the average height of the male recruits
was 67 inches and in the Second World War it
was 68 inches. In the immediate family it is
usually found that the male members are 72
inches or more in height. This could be inter-
preted as indicating a constitutional familial back-
ground of skeletal overactivity as compared with
the normal skeletal activity. This, then could
indicate a pituitary hereditary factor as respon-
sible for the kidney anomalies, if one grants that
the pituitary is necessary for genitourinary de-
velopment. Applying this same principle to the
underdeveloped anomalous defects of the genito-
urinary tract, it is found that this occurs in the
shorter than normal male members of the imme-
diate family. It is of some interest and impor-
tance that individuals with a high arched palate
usually have pituitary disturbances. This holds
for both hypofunction and hyperfunction of the
gland. Elsewhere1 it was stated that, since the
anterior lobe of the pituitary develops from the
roof of the mouth, the high arched palate indicates
a congenital pituitary background that is a pre-
disposition to a disturbance of this gland. It is
seen in individuals with migraine, epilepsy, reti-
nitis pigmentosa, arachnodactyly, and in many in-
dividuals with an allergic condition, the latter
probably being due to a pituitary-hypothalamic
disturbance. Individuals with genitourinary de-
fects have, as a rule, a high arched palate.
It should be stated that the short asthenic built
individual is the one who suffers from underdevel-
opment of the genitourinary tract. However,
short, stocky individuals who have characteristics
of pituitary basophilism are apt to have double
ureters, reduplication of pelves and horseshoe kid-
neys, the same as the individual with a tall back-
ground. This is due probably to the overactivity
of the pituitary before puberty resulting in rapid
ossification and shortness of stature. They are
the pyknic type of individual. As an example of
familial height giving a clue to genitourinary path-
ology is a family of two boys and a girl, each of
whom had two kidneys and two ureters on the
left side and a normal kidney and ureter on the
right.
The genetic constitutional inheritance factor is
shown by the familial heights. Both the father’s
and mother’s height was 72 inches, the two boys
62
TMSMS
DIAGNOSIS OF GENITOURINARY ANOMALIES— MOEHLIG
were 72 inches and 74 inches respectively, and
the girl 71 inches.
The familial height has been very useful in
directing and anticipating genitourinary diagnoses
so that attention is directed to this feature as a
diagnostic aid.
Summary
Based on clinical and embryologic observations
it was found that the state of the pituitary gland
is related to the development of the genitourinary
tract. Congenital defects of the pituitary gland
are associated with congenital genitourinary de-
fects as well as aplasia of the adrenal cortex.
Overactive pituitary function of a congenital
nature is associated with overdevelopment of the
genitourinary tract and adrenal cortex hyper-
plasia. Because of the relationship of the pitui-
tary glands to both the osseous system and the
genitourinary tract, it has been found over a
period of many years that the familial heights
are a useful guide to genitourinary anomalies.
The pituitary’s selective action on mesodermal
tissues (the osseous system, genitourinary tract
and adrenal cortex are mesodermal in origin) fur-
nishes an understanding of these mesodermal
anomalies.
In a general way, it can be said that familial
shortness of stature associated with an asthenic
habitus is accompanied by developmental defects
of the genitourinary tract, such as renal rickets,
aplasia and hypoplasia of the kidneys. However,
familial shortness of stature in asthenic built indi-
viduals with suggestive pituitary basophilism
symptoms results in overgrowth of the genito-
urinary tract, since the overactive pituitary in
these individuals produces early and rapid ossifi-
cation with shortness of stature. They are there-
fore, comparable to the tall individual in respect
to genitourinary anomalies.
Attention was called to the fact that individ-
uals with a high arched palate usually have pi-
tuitary disturbances.
This is true for both hypofunction and hyper-
function. The reason for this high arched palate
is believed to be due to the fact that the an-
terior pituitary lobe develops from the roof of
mouth. Individuals with genitourinary defects,
have, as a rule, high arched palates.
Conclusion
Familial heights are a useful guide in diagnosing
congenital genitourinary anomalies.
References
1. Moehlig, Robert C.: A study of the ductless glands.
Detroit M. J.. 14:268-289, 1914.
Ductless Gland Cell Control. Monograph, Town-
send Press, 1918.
Clinical notes on selective tissue action of posterior
pituitary gland. M. J. & Rec., 120:55-59, 1924
Selective action of suprarenal cortex secretion on
mesothelial tissues. Am. I. M. Sc.. 168:553-564,
1924.
Embryohormonic relations of pituitary gland to
mesenchymal tissues. Ann. Int. Med., 1:400-411,
1927; 1:563-576; 828-834, 1928.
Pituitary gland and suprarenal cortex. Arch. Int.
Med., 4:339-343, 1929.
Renal dwarfism or renal rickets. Am. J. Roent-
genol., 50:582-601, 1943.
Significance of high arched palate. Harper Hosp.
Bull., 4:168-173, 1946.
Hyperthyroidism. Clinics, 1:1115-1167; 2:423-497,
1943.
2. Chown, B. : Renal rickets and dwarfism: A pitui-
tary disease. Brit. J. Surg., 23:552-566, 1935-1936.
3. Krause, E. J.: Die Entwicklungstorungen der Hy-
pophyse. Die Morphologie des Missbildungen des
Menschen und der Tiere. 3:483-524. Jena; G. Fish-
er, 1929.
4. Davis, J. E.: Surgical pathology of malformations
in kidneys and ureters. J. Urol., 20:1-25, 155-183,
283-331, 1928.
5. Putnam, T. J.; Benedict, E. B. ; and Teel, H. M.:
Studies in acromegaly; Experimental canine acro-
megaly produced by injection of anterior lobe
pituitary extract. Arch. Surg., 18:1708-1736 (Apr.)
1929.
964 Fisher Bldg.
Detroit 2, Michigan
TUBERCULOSIS PROBLEM NOT SOLVED
Despite a gratifying decline in the death rate, the
tuberculosis problem in this country will not approach
acceptable solution until the morbidity rate demon-
strates a corresponding decline. Over the last five years,
deaths from tuberculosis have declined between 15 and
20 per cent each year. The morbidity rate, however,
has declined only three to four per cent per year over
the same period of time. At this rate, more than a
quarter century will be required to equal the same per
cent reduction in morbidity that has been achieved in
mortality in the past five years alone. — Annual Report ,
Special Health Services, U. S. Department of Health,
Education , and Welfare, Washington, D. C. (1954-1955)
January, 1957
63
Paroxysmal Tachycardia in Infants
By Irving F. Burton, M.D., and
Morris Starkman, M.D.
Detroit, Michigan
T7ARLIER writers have pointed out that the
' counting of pulse rates in infants is a much
neglected procedure. When the counting is done
routinely, the incidence of cardiac arrhythmias is
found to be higher than the medical literature
would indicate. Of the arrhythmias, the one most
frequently occurring is paroxysmal tachycardia.
Since this type of arrhythmia often terminates fa-
tally, failure to recognize the excessive heart rate
is unfortunate inasumch as the prognosis with
treatment is excellent.
Because of the general unfamiliarity with this
disease, we are presenting four cases and are
taking this opportunity to review this syndrome.
Case Presentation
Case 1. — A thirteen-month-old, white male infant was
admitted to Harper Hospital, July 6, 1955, with the
diagnosis of an acute upper respiratory infection. The
baby had been well until three hours prior to admis-
sion. At that time, the mother had noticed labored
breathing, increased irritability and a short interval of
cyanosis. On physical examination, the infant appeared
acutely ill and in marked respiratory distress. He
seemed very toxic with a fixed apprehensive stare. His
temperature was 102.6° F. by rectum. His respiratory
rate was 40 per minute, regular and with symmetrical
excursion of the chest. Occasional rales were heard in
both bases. The pulse rate was counted at 200 per
minute. The liver and spleen were not enlarged. No
cyanosis or signs of heart failure were apparent. The
balance of the examination was noncontributory. An
electrocardiogram taken on admission showed a tachy-
cardia of 180 per minute of supraventricular origin.
No other cardiac abnormalities were found. The
white blood cell count showed no significant altera-
tion in number or in cell components. Urinalysis, throat
and blood culture and a chest roentgenogram showed
no abnormalities.
The infant was placed in an oxygen tent. 300,000
units of procaine penicillin were administered intramus-
cularly. Digitoxin was administered orally on the basis
of 0.05 mg. per kg. body weight and given in three
doses at eight-hour intervals. The first dose contained
one-half the calculated digitalizing dose. The second
and third doses each contained one quarter of the
calculated dose. One-tenth of the calculated dose per
day was given for maintenance. Within twenty-four
From the Division of Pediatrics, Harper Hospital
Detroit, Michigan.
64
hours, the pulse rate was 110 per minute. The symp-
toms of dyspnea, toxicity, and elevated temperature all
subsided correspondingly. The digitoxin was discon-
tinued on the third hospital day. Subsequent examina-
tions showed no evidence of underlying heart disease.
A second electrocardiogram taken on the fifth hospital
day was normal. The patient was discharged on the
seventh hospital day. No recurrence of this disease has
been noted to the present time.
Case 2. — A three-and-one-half-month-old, white male
infant was admitted to Harper Hospital, July 26, 1955,
with a history of intermittent cyanosis, vomiting, and a
temperature of 104° F by rectum for two days. On
physical examination, the infant appeared acutely ill,
cyanotic, and extremely toxic. His pharynx was mod-
erately injected. His respiratory rate was 48 per min-
ute, regular, and with symmetrical excursion of the
chest. No rales or pulmonary abnormalities were found.
His pulse was counted at 200 per minute. His liver
and spleen were not enlarged. No evidence of heart
failure was noted. The balance of the examination
was noncontributory. An electrocardiogram taken on
admission showed a tachycardia of 200 per minute of
supraventricular origin. No other cardiac abnormali-
ties were found. The white blood cell count showed
no significant alteration in number or cell components.
Urinalysis, throat and blood culture, and a chest roent-
genogram showed no abnormalities.
The infant was placed in an oxygen tent. 150,000
units of procaine penicillin were administered intramus-
cularly. Digitoxin was administered intramuscularly on
the basis of 0.05 mg. per kg. body weight. The same
schedule of administration and dosage was used as in
the first case. Within twenty-four hours the pulse rate
dropped to a normal value, and the other symptoms
correspondingly cleared. The digitoxin was discontin-
ued on the third hospital day. Subsequent examina-
tions showed no evidence of underlying heart disease.
The patient was discharged on the fourth hospital day.
No recurrence of this disease has been noted up to the
present time.
Case 3. — A three-month-old, white male infant wa 3
admitted to Harper Hospital, August 23, 1955, with a
history of the abrupt onset of dysynea, listlessness, pal-
lor, and sweating six hours prior to admission. On
physical examination, the infant appeared acutely ill,
extremely toxic and frighteningly near death. His tem-
perature was 103° F by rectum. His respiratory rate
was 36 per minute, regular and with symmetrical excur-
sion of the chest. His breath sounds were harsh and
bronchial in nature. His pulse was counted at 190-200
TMSMS
PAROXYSMAL TACHYCARDIA— BURTON AND STARKMAN
per minute. His liver and spleen were not enlarged.
Neither cyanosis nor signs of heart failure were noted.
The balance of the examination was noncontributory.
An electrocardiogram taken on admission showed a
tachycardia of 190 per minute of supraventricular origin.
No other cardiac abnormalities were found. The white
blood cell count showed no significant alteration in
number or cell components. Urinalysis, throat and
blood culture, and a chest roentgenogram showed no
abnormalities.
The infant was placed in an oxygen tent. 150,000
units of procaine penicillin were administered intramus-
cularly. Digitoxin was administered intramuscularly
in the same dosage formula and schedule as with the
previous cases. Within twenty-four hours, the pulse
rate dropped to a normal value and the other symp-
toms correspondingly cleared. The digitoxin was dis-
continued on the third hospital day. Subsequent ex-
aminations showed no evidence of underlying heart dis-
ease. The patient was discharged on the fourth hos-
pital day. No recurrence of this disease has been
noted to the present time.
Case 4. — A two-week-old, white male infant was seen
at another hospital three hours following the repair of
a unilateral harelip. He had been given 1/800 gr. of
scopolamine preoperatively. For anesthesia, he had
been given ether by open-drop. On physical examina-
tion, the infant appeared acutely ill and extremely
toxic with marked dyspnea and sweating. His temper-
ature was 104.2°F by rectum. His respiratory rate was
42 per minute, regular and with symmetrical excursion
of the chest. No rales or pulmonary abnormalities
were found. His pulse was counted at 200 per minute.
His liver and spleen were not enlarged. No evidence
of heart failure was noted. The balance of the exam-
ination was noncontributory. An electrocardiogram
taken immediately showed a tachycardia of 200 per
minute of supraventricular origin. No other cardiac
abnormalities were found. The white blood cell count
showed no abnormalities.
The infant was placed in an oxygen tent. 150,000
units of procaine penicillin were administered intramus-
cularly. Digitoxin was administered intramuscularly in
the same dosage formula and schedule as with the
previous cases. The pulse rate dropped to a normal
value on the fourth hospital day and the other symp-
toms correspondingly cleared. The digitoxin was dis-
continued on the fifth hospital day. Subsequent ex-
aminations showed no evidence of underlying heart
disease. No recurrence of this disease has been noted
up to the present time.
Discussion
In 1941, Hubbard1 reported nine cases of par-
oxysmal tachycardia in infants under the age of
one year. He stressed the acute onset of the at-
tack, the alarming clinical picture, and the fre-
quency of fatal termination. In his discussion,
he pointed out that many cases of a malignant
syndrome of unknown etiology in infants reported
in the literature at that time were similar to his
cases but that the heart rate had not been counted.
On this basis, he felt that the syndrome was
much more prevalent than generally reported,
probably being overlooked in many cases. In
1952, Nadas and co-workers2 presented a compre-
hensive article on this subject with a detailed an-
alysis of forty-one cases in infants and children.
They were able to form a concise picture of this
syndrome which will be presented in outline form
and augmented with our own experience.
Age. — Almost all of the cases occurred in in-
fants four months of age or younger. Three of
our cases were four months of age. One patient
was thirteen months of age.
Sex Incidence. — All four of our cases occurred
in males. This observation is in agreement with
other studies indicating that the male is the most
frequently affected.
Etiology. — No apparent single causative factor
precipitated the attacks. Many infants seemed
well prior to the illness. A few had respiratory'
infections which had been considered trivial. One
of our cases had sustained his attack following
the use of scopolamine in preanesthesia medica-
tion. In Nadas’ series, two cases followed anes-
thesia, and one had atropine sulfate as prean-
esthesia medication. Although congenital heart
disease and the Wolff-Parkinson-White syndrome
can be the cause of paroxysmal tachycardia, nei-
ther is etiologically important in this age group.
Clinical Appearance. — The onset was usually
sudden. The infants appeared acutely and criti-
cally ill. They were prostrate with a fixed ap-
prehensive stare and ashen color. Respiration was
rapid and labored. The clinical impression was
that of an acute septic disease. Many had an
elevation of temperature. The urine was usu-
ally normal; the white blood cell count sometimes
showed an elevation. The roentgenogram of the
chest was normal unless there was congestive
heart failure. In advanced cases, there was evi-
dence of heart failure with cyanosis, enlargement
of the heart and liver, pulmonary congestion,
abdominal distension and frequent vomiting.
The roentgenogram of the chest may then have
shown the heart to be enlarged with both ven-
tricles equally involved and congestive changes
present in the lung.
January, 1957
65
PAROXYSMAL TACHYCARDIA— BURTON AND STARKMAN
In all cases, the excessive heart rate was out-
standing. The rate varied in the individual case.
None of the cases had a rate less than 180 per
minute, and some had a rate as high as 330 per
minute. A heat rate of 180 per minute or higher
in an infant should always bring this syndrome to
mind.
The appearance of heart failure is dependent
on the duration of the attack, not on the rate of
the tachycardia. In Nadas’ study, none of the
infants showed evidence of heart failure when
the attack was less than twenty-four hours’ dura-
tion. After forty-eight hours, one-half of the
untreated cases showed signs of failure. In Hub-
bard’s observation, when the syndrome was less
clear and treatment not instituted promptly, the
infants either died in heart failure or recovered
completely, the attack subsiding spontaneously.
Electrocardiogram. — The only significant find-
ing was the tachycardia of supraventricular ori-
gin. If other changes should be present, other
diseases must be considered. In the Wolff-Park-
inson-White syndrome, the characteristic findings
are not present during the attack of paroxysmal
tachycardia but are revealed only in the electro-
cardiogram taken between attacks.3 Repeating
the electrocardiogram in these infants when the
rate becomes normal is important.
Treatment. — Many methods and drugs can be
used for stopping a rapid heart rate. In this
syndrome, digitalis has been the most successful
and the least dangerous of all therapies. Both
Nadas and Hubbard emphasize that the dosage
in infants must be higher on a weight basis than
ordinarily used in older children and adults.
The recommended dose in children under two
years of age is 0.03 to 0.05 mg. per kg. body
weight with complete digitalization in twelve to
twenty-four hours. Not all observers are in
agreement with the larger dose.4 The daily main-
tenance dose is one-tenth of the total digitalizing
dose. The infants are maintained on digitalis two
to seven days or longer following the return of the
normal heart rate. In small infants, digitoxin
intramuscularly is the treatment of choice.
Supportative treatment should also be given.
The infants should be placed in oxygen and given
antibiotics, if they are indicated.
Summary
Paroxysmal tachycardia in infants is presented
as a distinct clinical entity. Counting the pulse
rate is a necessary part of an infant’s examina-
tion.
Acknowledgment
The authors gratefully acknowledge the generous as-
sistance of Dr. Edgar Martmer, chief of the Division of
Pediatrics, Harper Hospital, Detroit.
References
1. Hubbard, J. P. : Paroxysmal tachycardia and its
treatment in young infants. Am. J. Dis. Child.,
61:687 (Apr.) 1941.
2. Nadas, A. S.; Daeschner, C. W.; Roth, A.; and
Blumenthal, S. L. : Paroxysmal tachycardia in in-
fants and children: Study of 41 cases. Pediatrics,
9:167, (Feb.) 1952.
3. Mannheimer, E.: Paroxysmal tachycardia in in-
fants. Acta Ped., 33:38.3, 1946.
4. Ziegler, Robert: Personal communication. (Henry
Ford Hospital, Detroit, Michigan.)
3825 Brush Street
Detroit 7, Michigan
IMMUNIZATION
Diphtheria. — The outbreak of diphtheria in Detroit
in December suggests some needed statewide remedy. It
is not listed as an epidemic but 161 cases have occurred
in six special districts, mostly poor and underprivileged.
The rate of immunization of school children is below
40 per cent. Only six cases have developed in all other
areas where the rate of immunization is mostly around
60 per cent. All doctors treating such children or having
influence in neglected districts should urge and adminis-
ter toxoid protection. Six deaths have been attributed
to a disease rarely seen because of well-known control
methods.
Polio. — This is the recommended season for polio
vaccine shots. The vaccine is accumulating rapidly and
is being left standing on warehouse shelves. Too many
children are still unprotected. The Health Department
and the Council of the Michigan State Medical So-
ciety are urging that everyone through the early thirties
be immunized without delay, and most especially the
youth years. It takes about seven months for maximum
protection. Now is not too late.
66
JMSMS
Modern Techniques for the
Diagnosis of Pheochromocytoma
* I *HE PATIENT with pheochromocytoma pre-
sents a potentially curable lesion. In the past
ten years considerable advances have been made
in the precise diagnosis of this condition. It is
the purpose of this article to review these advances
for the benefit of the practicing physician.
When To Suspect Pheochromocytoma
All patients with essential hypertension should
be viewed as suspects. Cases have been found
among both the sustained and labile types. The
index of suspicion is generally increased when
the patient with hypertension also shows transient
glycosuria or hyperglycemia, or when episodes of
spontaneous sympathetic and vasomotor activity
occur with palpitation, tachycardia, flushing, in-
creased perspiration or tremors. It is important
to recall that the disease may also occur among
apparent normotensives who show blood pres-
sure elevations only with attacks. These attacks
may vary in their symptomatology but usually
include palpitation, flushing, headache, perspira-
tion, tremulousness, and abdominal pain. Pres-
ence of dizziness, numbness and paresthesia of the
fingers and about the mouth denote hyperventila-
tion syndrome and are not characteristically
caused by pheochromocytoma; relation to meals
and relief by ingestion of carbohydrate may de-
note hypoglycemic episodes.
Diagnostic Procedures If Systolic Blood
Pressure Exceeds 200
1. Regitine Test.- — The best screening test when
the blood pressure is substantially elevated (i.e.
exceeds 200/110) consists in the slow intravenous
injection of 5 mg. Regitine®. Intramuscular
injection may lead to a false negative.1
(a) Procedure. — The patient is placed in the
resting recumbent state and the blood pressure is
taken every 30 seconds. When the readings have
From the Department of Internal Medicine, Univer-
sity of Michigan Medical School.
Development of the analytic procedure for catechol
amines was greatly aided by a grant from the Michigan
Heart Association.
By S. W. Hoobler, M.D., Robert D. Johnson, M.D.,
and Ray Warzynski, M.D.
Ann Arbor, Michigan
stabilized, a venipuncture is done but the drug is
not injected until the blood pressure in the oppo-
site arm returns to the previous basal level. The
drug is then given slowly over a 45-second in-
terval, blood pressure and pulse rate being taken
every thirty seconds in the opposite arm for a
period of five minutes.
(b) Interpretation. — A reduction of 25 mm.
in the diastolic blood pressure in at least two suc-
cessive readings is considered a positive response.
(c) False positives. — False positives occur in
patients under the influence of various antihyper-
tensive drugs. They are reported in uremia, but
since this rarely coexists with pheochromocytoma,
it is not usually necessary to test hypertensive
patients with consistently elevated nonprotein ni-
trogen in the blood. In the absence of any of
these explanations, about 10 per cent of the cases
show false positive reactions due, no doubt, to
the fact that Regitine, in addition to its adren-
olytic properties, has weak ganglionic blocking and
direct vasodilator activity. Therefore, a positive
Regitine 'test should be viewed as a screening test
only. It should be repeated and should be
checked with benzodioxane or histamine test.
(d) False negatives. — These are rare. It
should be noted that if the blood pressure is not
greatly elevated, the Regitine test cannot be posi-
tive by definition without inducing considerable
hypotension, since a diastolic blood pressure fall
of 25 mm. is necessary to qualify as positive.
(e) Contraindications. — These are relative but
would include chiefly patients with a history sug-
gestive of cardiac arrhythmias or angina pectoris.
The drug has excitatory properties. Tachycardia
is regularly induced and in at least one instance
angina pectoris has followed testing. It is be-
lieved that this latter effect is transitory, mild
and can be overcome by vasodilators, and that if
the test is really indicated, no harm can come of
the procedure if proper precautions are taken.
January, 1957
67
PHEOCHROMOCYTOMA— HOOBLER ET AL
2. Benzodioxane Test. — This procedure is indi-
cated when the Regitine test has been positive
and the blood pressure is substantially elevated.
Details of the test procedure, as printed by the
manufacturer, have been modified in our clinic
as follows:
(a) Procedure. — The calculated amount of the
drug is taken up in the syringe and after the basal
blood pressure has been determined in the opposite
arm, a venipuncture is performed and the blood
pressure allowed to return to the basal level. The
drug is then injected slowly at a steady rate such
that one-half the dose has been administered in
the first minute. The blood pressures taken every
30 seconds on the opposite arm are then inspected.
If a rise of less than 15 to 30 mm. Hg. systolic
or diastolic has occurred, the remainder of the
dose is given in the second minute. If such a
rise has already occurred, the injection is stopped,
since in all likelihood the test will be negative and
further injection may only cause distressing side
effects (tachycardia and dyspnea) and a further
elevation of the blood pressure. Since the blood
pressure may arise falsely due to anxiety, it is
important that the patient be reassured prior to
the injection and that if possible he should not
know the moment the injection is started. The
more elaborate testing technique of Goldenberg
and Aranow2 was devised for this reason.
(b) Interpretation. — According to the origina-
tors of the test, a positive reaction can be judged
only when it is performed according to their pre-
cise technique. In our experience, any reduction
exceeding 5 to 10 mm. Hg. of systolic and dias-
tolic pressure by our technique should be viewed
as a positive reaction.
(c) False negative reactions. — False negative
reactions occur with greater frequency than with
the Regitine test, probably because the drug has
a concomitant central excitatory and hypertensive
effect, combined with a weaker adrenolytic and
no vasodilator activity.
(d) False positive reactions. — These are said
to occur in uremia.
(e) Contraindications. — The drug should be
given carefully in extremely hypertensive patients
but the procedure outlined above should protect
from serious reactions. The central and cardio-
excitatory effects on the heart rate might be ad-
verse in angina pectoris, but we have had no such
personal experiences.
3. Urinary Catechol Amine Analysis. — Approx-
imately 3 per cent of intravenously administered
adrenaline or noradrenaline can be recovered in
the urine by sensitive bioassay techniques. This
recovery is further reduced if the urine is neutral
or alkaline and subject to oxidation. There is a
wide variation in “normal” 24-hour urine catechol
amine excretion, the limits being approximately
10 to 100 micrograms per twenty-four hours.3
(a) Procedures. — During the collection period
it is important that each urine specimen be im-
mediately acidified to prevent oxidation of cate-
chol amines. Fluorescent contaminants present
in most stoppers must be excluded by covering
with cellophane. After the specimen is collected,
an approximate 100 cc. aliquot may be taken for
chemical or biologic assay.*
(b) Chemical method. — The urine is passed
through an alumina column which adsorbs 90 to
100 percent of catechol amines. It is then eluted
with acetic acid and oxidized by the addition of
potassium ferricyanide at pH 6.5 to adrenachrome.
Ascorbic acid is then added to stop further oxi-
dation and the adrenochrome is rearranged to the
highly fluorescent adrenolutin by the simultaneous
addition of NaOH. The mixture is read in the
Farrand photofluorimeter and compared with a
similar urine sample which, by omitting the as-
corbic acid oxidation, has been permitted to go
to complete destruction of the catechol ring struc-
ture. Although the norepinephrine derivative
possesses only one-fourth of the fluorescent ac-
tivity of epinephrine, the two cannot be sepa-
rated by this test. For consistency, the result
is expressed as micrograms of epinephrine. This
is essentially the method of Von Euler et al4 and
can be performed using any sensitive photofluor-
imeter. Both adrenaline and noradrenaline added
to urine are measured accurately by this proced-
ure. Other related substances may also contrib-
ute to fluorescence. The procedure is not quite
the same as that used by Goldenberg, but on the
basis of considerable experience we believe that a
satisfactory distinction between normal, hyperten-
sive, and pheochromocytoma cases can be made.
♦The sample can be sent in a special mailing car-
ton provided on request from the Hypertension Unit,
University of Michigan Hospital, Ann Arbor, Michigan.
The cost of the test is $15.00.
68
TMSMS
PHEOCHROMOCYTOMA— HOOBLER ET AL
rABLE I. RESULTS OF TESTS IN PROVEN CASES OF
PHEOCHROMOCYTOMA
University Hospital 1956
Cases
Histamine
Test
Regitine
Test
Benzo-
dioxane
24 I
Catechol
Meg/
lour
Amines*
24 hr.
Pre-
Operative
Post-
Operative
W. H.
4-
+
645
512
46
R. J.
+
+
665
502
R. B.
+
+
243**
144
118
*Of 37 normal persons and pheochromocytoma suspects, the mean
;wenty-four hour excretion of catechol amines, expressed in terms of
epinephrine equivalent, was 49.2 micrograms with a range of 9.4 to
107.5. One false positive of 486 is recorded, but subsequent preoperative
values were 87 and 44 mcg/24 hours. A bilateral adrenal exploration
vas negative.
N*This patient had a small area of adrenal medullary hyperplasia at
jperation, but when the adrenal was clamped the blood pressure fell
narkedly. The findings did not resemble the usual pheochromocytoma
rathologically and her status remains in some doubt.
(c) Biological method. — This is a complex pro-
:edure, depending on the contraction of a spirally
tut strip from rabbit or rat aorta when solutions
:ontaining .01 to .0001 micrograms of adrenaline
are compared to the response of the unknown
sample eluted from the alumina column. The
method used in our laboratory is patterned after
the technique of Helmer with certain local mod-
ifications. The test is used when the urine sam-
ple by the chemical method shows a high output
af catechol amines.
(d) Interpretation. — It is evident from the
above that unknown contaminants may produce
either fluorescent or vasoactive compounds which
resemble adrenaline or noradrenaline. No drugs
capable of producing fluorescent end products
should be given during the urine collection. Fur-
thermore, adrenaline and noradrenaline cannot
readily be distinguished by these methods but since
both are found in varying amounts in cases of
pheochromocytoma, this would seem to make
little practical difference.
(e) False positives. — False positives may appear
as experience with the method increases. For
this reason consistency with clinical and pharma-
cologic testing should be insisted on before ad-
vising adrenal exploration. In one such case,
where preoperative catechol amine levels were 486
and 87 micrograms per twenty-four hours, ex-
ploration failed to reveal a tumor in the adrenal
region. A high level is therefore not certainly
diagnostic. In three cases proven at operation,
levels have been consistently high (Table I).
(f) False negatives. — False negatives can occur
if proper precautions are not taken in the collec-
tion. Also, it is possible that during a period of
normotension no elevation of urinary catechol
amines would occur. In such circumstances it
might be better to obtain a specimen during an
attack. For this purpose a four hour urine
collection test has been devised (vide infra) but
we do not yet have sufficient evidence of the
normal range of such short collection periods dur-
ing “attacks” associated with other causes than
adrenaline release. Consequently, normal stand-
ards at present must be inferred from our experi-
ence with twenty-four hour urine samples. On
this basis, a positive test should probably exceed
25 meg. excretion in a four hour collection period.
(g) Contraindications. — None. It is to be em-
phasized, however, that this procedure should be
done only when clinical criteria and pharmaco-
logic testing are compatible, since a negative
Regitine or histamine test is extremely unlikely to
occur in the presence of a pheochromocytoma.
Only when angina pectoris makes the latter tests
dangerous to the patient should urine testing pre-
cede pharmacologic testing.
Diagnostic Procedures If Systolic Blood Pressure
Is Below' 200
1. Histamine Test.5
(a) Procedures. — Histamine acid phosphate
solution is used. 0.0275 mg./cc. (= .01 mg.
histamine base/ce.) is prepared fresh every month
or so and stored in the refrigerator. The dilution
represents 1 / 100th the strength of the 1/1000
histamine usually supplied. After the blood pres-
sure has stabilized, give in 10 to 20 seconds 2.5
cc. (.025 mg. of the base) intravenously, taking
blood pressure every thirty seconds in the oppo-
site arm for five to ten minutes.
The usual response is a flush, vasodilator head-
ache and transient hypotension lasting one to
two minutes, followed by return to normal or
slightly supernormal values in next three to five
minutes. If the subsequent rise exceeds the pre-
injection level by 30/20 mm. Hg., pheochromo-
cytoma is suspected. Leave the needle in the
vein after injection, so as to be prepared to give
Regitine®, 5 mg. intravenously in case of a hyper-
tensive reaction.
(b) False positives. — The reactions may be due
to anxiety and discomfort from the histamine.
January. 1957
69
PHEOCHROMOCYTOMA— HOOBLER ET AL
Rises usually do not exceed that observed by the
cold pressor test. Reassurance, explanation of
symptoms to be expected from test, and repetition
often are needed to exclude. A certain number
occur, nevertheless.
(c) False negatives. — Although rare, these also
occur. Check with the Etamon test (see below).
(d) Contraindications:
( 1 ) Rarely give to patients with systolic
blood pressure over 200 for fear of
excessive hypertension. Have Regi-
tine,® benzodioxane, nitrites present
for antidotes.
(2) Give rarely or never in the presence
of angina or severe asthma. Reduce
initial dose in seriously suspected cases
or severe hypertension.
(3) Always have Regitine® at hand and be
prepared to administer it promptly if
an attack is precipitated. Under these
circumstances there is no need to fear
reactions to this test.
2. T etraethylammonium (Etamon) Test.e
(a) Procedure. — 200 to 300 mg. of tetraethyl-
ammonium chloride (Etamon — Parke Davis) is
given intravenously twenty to thirty seconds after
blood pressure has become basal. The patient will
notice paresthesias, blurring of vision and a mild
tachycardia, and the blood pressure will fall 10
to 40 mm. systolic and diastolic in normals and
mild hypertensives. In uremics and in some elder-
ly patients with arteriosclerosis, more marked
hypotension will occur but can be corrected
promptly with a head down tilt or intravenous
vasoconstrictors. Hence, over the age of fifty a
dose of 200 mg. intravenously is sufficient for most
routine tests. The effects last for 15 to 20 min-
utes, and orthostatic hypotension is the last to go
away. Hence, these patients should be observed
for syncope when they first get up after the test.
(b) Interpretation. — In the presence of pheo-
chromocytoma most but not all patients show a
marked secondary rise in blood pressure after the
period of hypotension. The secondary rise should
exceed the pre-injection blood pressure by 20 to
30 mm. Hg. A moderate rise in blood pressure
occurring in young persons after tetraethylam-
monium, may be the source of a false positives.
The test is not as likely to be positive as the his-
tamine test.
(c) Contraindications. — None except in pa-
tients with extreme arteriosclerosis or angina, who
should receive smaller than average doses. If an
attack is precipitated, the patient should be made
to sit up and hang his legs over the side of the
bed, since orthostatic effects may cancel out part
of the epinephrine-induced hypertension.
Procedure During Acute Attack of
Hypertension
(These first two measures may be done by the
patient after proper advance instructions.)
1. Record pulse, blood pressure.
2. Start a four-hour urine collection for cate-
chol amines.
If the patient can remember the precise time of
preceding voiding, force fluids and continue col-
lection into an acidified bottle up to the fourth
hour. If the exact time of the previous specimen
is uncertain, the patient should void immediately
and discard, then collect the following four hours
of urine. Water should be taken to provide an
adequate four-hour volume.
3. Take an electrocardiogram since transiently
peaked T-waves may be associated with the
hyperpotassemia of epinephrine release (See be-
low) .
4. Draw sample for blood sugar, which may
showr transient elevations, or test for glycosuria.
5. Give 2.5 mg. Regitine intravenously in forty-
five seconds, recording pulse and blood pressure
carefully. Patients in an attack are hypersensi-
tive to Regitine, and a brief but marked response
to a small dose is of diagnostic help.
6. If attack is serious, the further administra-
tion slowly of up to 10 mg. of Regitine should
provide relief.
Clinical Observations
In general, it has been our practice to follow
the outline above. We screen most patients with
labile or established hypertension by means of
pharmacologic tests. In our clinic, 136 tests were
performed in the year 1956. Five apparent false
positives were recorded among eighty-eight hista-
mine tests and six among forty-eight Regitine
tests. When clinical signs or confirmatory pharm-
acologic tests were positive, urinary catechol
amines were determined. Table I reviews the
70
JMSMS
PHEOCHROMOCYTOMA— HOOBLER ET AL
hree positive cases which have been encountered
luring the past year.
Case Report
The patient described below proved of partic-
ilar interest because his presenting complaint
vas recurrence of very brief spells of palpitation
md irregular pulse on exertion.
R. J., a thirty-two-year-old male laboratory worker
or a paint company entered the hospital with the chief
omplaint of “high blood pressure and weak spells”
ince November, 1954. He was essentially well until
hat date, when one afternoon at 3 p.m. he had an
pisode of weakness, pallor, perspiration and dizziness
asting ten to fifteen minutes after hurrying up a flight
if stairs. No similar symptoms occurred until April,
955, when an attack lasted ten minutes and was asso-
iated with an excruciating occipital headache. From
^pril through June, 1955, these episodes occurred about
weekly and almost exclusively in the late afternoon, ex-
ept for one severe headache which awakened him at
i a.m. and disappeared spontaneously in about ten
ninutes. A sequence of events elicited from the patient
ncluded an aura, described as a sensation of “draining
if strength,” followed by a throbbing headache, a
lowing of the pulse and measured rise in blood pres-
ure. At these times his face was observed to be ashen
;rey and his body was drenched with sweat.
Progressive impotence was another presenting symp-
om in this young man. Regitine and histamine tests
lone at another hospital were reported as “inconclu-
ive” and intravenous pyelograms and blood sugar were
lormal. The patient’s father had diabetes mellitus.
Examination revealed a healthy appearing and well
nuscled man with a casual blood pressure of 160/90
md pulse of 60 per minute. The pupils were dilated
md the fundi showed no hypertensive or diabetic ret-
nopathy. Skin was warm and moist. There were no
remors. The thyroid gland was not enlarged. Heart
vas normal in every way, including size, except for
he bradycardia. Liver extended 4 to 5 cm. below the
ight costal margin, but no other abdominal or flank
nasses could be felt. Femoral and peripheral pulses
vere normal.
Laboratory studies showed a normal urine, stool and
Cahn reaction. White blood count was 9,300, and
here was a normal differential, with 18 per cent lym-
jhocytes and 1 per cent eosinophils. Serum creatinine
vas 1.12 mg. per cent, and the clearance was 187
V24 hours. Nonprotein nitrogen was 33 mg. per cent,
fasal metabolic rate was +15 per cent. Bromsulfalein
etention in forty-five minutes was 15.9 per cent. Fast-
ng blood sugar determination showed 129, 111, 107
'Somogyi-Nelson: normal is 60 to 90 mg. per cent).
\ glucose tolerance test run after a standard three-
lay preparation diet gave a diabetic type curve:
asting blood sugar, 107; at one hour, 250; at one and
)ne-half hours, 205; at two hours, 164; at two and one-
lalf hours, 138; at three hours, 119; at three and
>ne-half hours, 104; and at four hours, 69 mg. per
:ent. A 4 plus glycosuria occurred from the first hour
through the second hour. No attack of symptoms of
hypoglycemia appeared at the fourth hour.
While in the hospital his temperature reached 99°
to 99.2° on only two days, pulse varied from 55 to 90
per minute and the blood pressure varied from 105 to
220 systolic and from 70 to 120 diastolic. A charac-
teristic postural change in blood pressure and pulse was
found. The recumbent blood pressure was 175/85 with
a pulse of 72 per minute; it fell to 120/80 immediately
upon standing, with a pulse of 128 per minute and
to 145/110 after standing two minutes. During one
of his attacks the patient noted a dull pain in the left
flank (the side which proved to contain the tumor).
An interesting finding documented both at another
hospital and here were the electrocardiographic changes
during the attack; these included frequent ventricular
premature beats, bradycardia and large narrow upright
T-waves, the latter suggestive of an initial hyper-
kalemia. A subsequent electrocardiogram was entirely
normal after the attack.
Regitine and benzodioxane tests were positive, as well
as the aorta strip test. Catechol amines in the urine
during an attack were 502 meg. and 665 meg. per
twenty-four hour specimen of urine (normal range 10
to 100 meg.). One Regitine test run during an active
phase of the disease showed an unusual response. Just
before the test dose of Regitine, the blood pressure was
running 242-258/100-104 and diaphoresis was evident.
Pulse was very slow, 56 to 60 per minute but no ectopic
beats were present. Thirty seconds after 5 mgs. of
Regitine was given intravenously, the blood pressure
fell from 240/76 to 160/66, then rose abruptly to
,300/142 in association with an agonizing headache and
abdominal pain, pallor and diaphoresis. Pulse rose to
120. The attack subsided in approximately five min-
utes.
On June 28, 1956, after cortisone preparation, a
simultaneous bilateral exposure revealed a tumor of the
left adrenal gland. During manipulation of the tumor
the blood pressure rose to 230/160 and fell to 90/60
as soon as the blood supply to it was clamped. The post-
operative course was uneventful and the microscopic
material was reported as typical for pheochromocytoma.
Three months later the patient was asymptomatic with
a blood pressure of 130/65, and the glucose tolerance
test was no longer diabetic in type.
Comment. — This patient presented four un-
usual features. His presenting symptoms had fea-
tures in common with functional hypoglycemia
and with attacks of premature ventricular beats.
The complaint of impotence and the presence of
an orthostatic blood pressure fall suggested wide-
spread inhibition of sympathetic vasomotor tone.
The development of upright T-waves of the
hyperkalemic type during a paroxysm suggest a
possible diagnostic test during an attack, although
it must be emphasized that T-wave changes may
occur from a variety of causes unrelated to serum
( Continued on Page 83 )
January, 1957
71
Cerebral Angiography
By H. Harvey Gass, M.D.
Detroit, Michigan
A LTHOUGH cerebral angiography is now a
commonplace procedure, prejudice against
its use still lingers in some quarters. In some of
the vascular diseases it is irreplaceable, while in
the problem of brain tumors, especially those lo-
cated supratentorially, it may provide accurate
and easy diagnosis, often making the cumbersome,
time-honored air study unnecessary. The more
one uses cerebral angiography the greater it in-
creases in value, not only for positive identifica-
tion of existent disease, but also as a survey tool
to help exclude the presence of disease resulting
in greater reassurance for both patient and doc-
tor. That there are limitations to its diagnostic
use and associated pitfalls, no one will deny; but
as our familiarity with angiography grows these
become more readily recognized and unsuspected
information about patients is frequently uncov-
ered, such as previously unrecognized vascular
occlusions, vasospastic tendencies, and collateral
circulations. The role of the variability of the
caliber of intracranial vessels and rate of cere-
bral blood flow are virgin fields in which cerebral
angiography may yet find further fruition.
The resistance to the performance of this pro-
cedure which the neurosurgeon still encounters
from time to time frequently stems from early
reports about mishaps associated with its use.
Such accidents were not infrequent during the
period of introduction of this technique. The
high risk conditions were identified which stim-
ulated technical refinements and led to the devel-
opment of increased safety in cerebral angiog-
raphy. Several recent reports attest to this point
of view.1'5 To further dispel unwarranted fear
about this procedure this report is being made on
500 consecutive angiograms, all performed by the
author, with only a single death in which the
procedure can be implicated. Technical points
which have enabled the achievement of this rec-
ord will be discussed.
The 500 cerebral angiograms forming the basis
of this report were done in 364 different patients,
and all were performed percutaneously. The first
sixty-two of these arteriograms were the basis for
an earlier report on the use of urokon in cere-
bral angiography.6 In this series, 474 were car-
otid angiograms and twenty-six were vertebral.
They were performed in fourteen different hospi-
tals in the Detroit area, over half of them being
done in one institution.*
The subjects were male in 289 of the arterio-
grams and female in 211. The age distribution is
given in Table I. Of the entire group, 452 were
done in patients between the ages of twenty and
seventy. The youngest patient was three and one-
half years of age and the oldest seventy-nine. A
total of three arteriograms were done in two pa-
tients aged seventy-nine.
TABLE I. AGES OF PATIENTS
0-9.
10 - 19.
20 - 29.
30 - 39.
40 - 49.
50 - 59.
60 - 69.
70 - 79.
7
28
59
113
128
. 89
. 68
. 13
Total
.500
All the angiograms done on children aged
twelve or under were performed under general
anesthesia except one done on a twelve-year-old
boy who was awake during the procedure. Of
the twenty-eight angiograms done in the age
group ten to nineteen, seven were given general
anesthesia and five were in patients in coma. Of
the total group of 500 angiograms, forty-eight
were done in patients in coma or under general
anesthesia and 452 were done in conscious and re-
sponsive patients.
In 133 of the 364 patients receiving angiograms
gross lesions were demonstrated (Table II).
TABLE II. PATHOLOGIC LESIONS FOUND BY
ANGIOGRAPHY
Lesion No.
Mass 78
Aneurysm _ 29'
Malformation 8
Occlusion * 8
These included seventy-eight mass intracranial
lesions, twenty-nine aneurysms, eight vascular mal-
formations, and eight major vascular occlusions
(either middle cerebral or internal carotid). The
*Mt. Carmel Mercy Hospital.
72
JMSMS
CEREBRAL ANGIOGRAPHY— GASS
anterior cerebral or the posterior cerebral system
may at times not fill in the arteriogram, and such
non-filling alone was not considered diagnostic
of occlusion of these arteries. In addition impor-
tant information was obtained in thirty-nine addi-
tional patients. These included twelve patients
in whom a normal angiogram was relied upon to
rule out a traumatic intracranial hematoma and
twenty-seven patients in whom operative angio-
graphic evaluation was essential, as in postopera-
tive aneurysm patients to verify satisfactory ob-
literation of aneurysms by clips. Thus in 172
of 364 patients, information critical for the pa-
tients’ management or diagnosis was revealed by
the angiogram. In the remaining 192 patients,
normal angiograms were obtained in patients sus-
pected of serious gross intracranial disease. In
twenty-two patients, the angiogram alone without
an air study gave ample information for accurate
localization of an intracranial mass, and in an
additional seventeen patients angiography alone re-
vealed the presence of a surface hematoma. In
none of these thirty-nine patients was the angio-
gram in error.
Ill effects associated with cerebral angiography
may be grouped in the following categories : ( 1 )
discomfort associated with performance of the
test, (2) dye sensitivity, (3) air embolism (4)
hematoma formation in the neck, (5) minor neu-
rologic reactions, (6) major neurologic reactions,
and (7) death. The first four of these did not
present a serious problem in this series, but will
be mentioned in subsequent portions of this paper.
Included in minor neurologic reactions are tran-
sient neurologic incidents completely reversed in
less than twenty-four hours (hemiparesis, hemi-
sensory symptoms, aphasia, hemianopia) , precipi-
tation of a grand mal seizure without subsequent
sequelae, and precipitation of an attack of atypical
migraine (one patient). Such reactions occurred
in conjunction with twenty-six arteriograms. In
three of these patients a brain tumor was present.
The only serious ill effects of cerebral angiog-
raphy in our experience in this group concerns
the major neurological reactions (neurological in-
cident lasting more than twenty-four hours) and
death in which the arteriogram is implicated.
There were six patients in whom major neuro-
logic reactions developed and one patient in whom
death occurred following the angiogram. In the
latter, death in an already critically ill patient
must be considered to have been hastened by the
test. Of the six patients with major neurologic
reactions two had brain tumors, one had a rup-
tured cerebral aneurysm, and three had serious
cerebrovascular disease. Four of these had full
recovery of their neurologic incident in less than
six months even though subsequent craniotomies
were done in two. A fifth patient, a seventy-five-
year-old man with left optic atrophy and mild
mental changes tolerated the left arteriogram
without incident, but on the day following the
right arteriogram, despite demonstration of a right
internal carotid artery occlusion, he developed
weakness of the left upper extremity which was
still present one month later. The sixth patient
was a fifty-seven-year-old man with a malignant
brain tumor, who developed a right hemiplegia
and aphasia without loss of consciousness follow-
ing the arteriogram. By the following day the
hemiplegia had nearly completely recovered, but
not the aphasia. His neurologic status was other-
wise good. Craniotomy was performed on the
next day and the patient expired on the first post-
operative day. This was clearly a surgical death,
and it is felt that the arteriogram was not a sig-
nificant factor as a cause of death. The single
death in this series in which angiography is cul-
pable occurred in a forty-nine-year-old woman
who had a recurrent subarachnoid hemorrhage
one week after the initial bleeding. The arterio-
gram was done on the following morning and
general anesthesia seemed advisable. She ex-
pired twelve hours later never having reacted
from the anesthetic. In this case two safeguards
discussed later were not adhered to: (1) A gen-
eral anesthetic was used which camouflages any
untoward reactions to a previous injection, and
(2) two additional unnecessary injections were
made because of failure of a new radiologic de-
vice.
Thus, there was a total of thirty-three reactions
to arteriograms in this group of 500, an inci-
dence of 6.6 per cent. Only seven of these (1.4
per cent) were serious. The one death consti-
tutes an incidence of 0.2 per cent. It must be
emphasized that this low rate of complications
occurred in a group of patients with a high in-
cidence of serious and critical illness. Omitted
from consideration in this mortality rate are fifty-
four additional patients known to have died at
some time subsequent to the arteriogram. In
forty-nine of these, death was distantly removed
from the arteriogram and in no way could be
January, 1957
73
CEREBRAL ANGIOGRAPHY— GASS
Fig. 1. Arteriogram (lateral view)
made with 3 cc. of 30 per cent uro-
kon. Note “stretched-out” perical-
losal artery indicating hydrocephalus.
Fig. 2. Arteriogram (occipital
view) made with 3 cc. of 30 per
cent urokon. Note elevation of an-
terior cerebral artery caused by pi-
tuitary tumor.
Fig. 3. Normal venogram (lateral
view) made with 3 cc. of 30 per
cent urokon.
considered to be influenced by it. In five patients,
however, death occurred within twenty-four hours
of the arteriogram, but each of these were coma-
tose at the time of arteriography and showed no
evident reaction to it, the cause of the coma in
each being ample cause of his death.
Of the 500 arteriograms, 483 were done with 30
per cent urokon sodium. This became the me-
dium of choice, although it should be stressed
that the safety of this medium rests to a large
measure also on the small quantities per injec-
tion which were used. In ten arteriograms, 35
per cent diodrast was employed in part or all of
the test. In three arteriograms, lesser dilutions
than 30 per cent of urokon6 were used, but the
resulting films were not completely satisfactory.
Four arteriograms in elderly or severely hyperten-
sive patients were done utilizing thorotrast for
some or all of the injections. In no instance was
thorotrast injected unless the needle was can-
nulated far into the artery making extravasation
impossible.
Of great importance in maintaining a safe
technique is the reduction of trauma to the arte-
rial tree not only in performing the arterial
puncture, but by the reduction of the overall irri-
tating stimuli to the intimal surface of the cerebral
vascular system. In this regard, the total num-
ber of injections required for the arteriograms,
the total quantity of contrast medium used, and
the quantity of medium per injection are impor-
tant factors. We have become increasingly im-
pressed with the importance particularly of the
latter, the quantity of medium used per injection,
and have been able to progressively decrease the
amount used down to 5 cc. per injection and
more recently to 3 cc. per injection and still to
obtain good films almost consistently. Only 5 cc.
quantities were used in 408 of the angiograms in
this series, and in a total of 444 angiograms 5
cc. or less were used per injection. Most of those
done using larger quantities were in the first part
of this series (twenty-eight of the first forty-one).
Of the last twenty-nine angiograms done in
this series, twenty-five were performed utilizing
only 3 cc. per injection, and in each good arterial
filling was demonstrated (Figs. 1 and 2). Venous
visualization was also usually adequate (Fig. 3),
but occasionally an injection might have to be re-
peated with a delayed exposure to get a good
venogram unless a serial technique was used.
Sixteen of these last twenty-nine arteriograms re-
quired only two injections of 3 cc. each — a total
of 6 cc. per arteriogram!
The 500 angiograms required a total of 1281
injections. Two injections only were used for
230 angiograms. Eight patients required over
five injections, one patient requiring eight. These
excessive numbers of injections were needed for
detail in multiple phases and/or perspectives in
aneurysms or vascular malformation patients.
In sixty-eight angiograms only a single injection
was used. Occasionally, the test was stopped
after the first injection because of an unfavorable
reaction to that injection, but in the majority of
instances single injections were used for a single
74
JMSMS
CEREBRAL ANGIOGRAPHY— GASS
anterior- posterior view to determine presence or
absence of shift of midline vessels or of a sub-
dural or extradural hemorrhage. Additional in-
jections for lateral views would have been super-
fluous.
Early in this series, several instances of a large
total quantity of contrast medium being used are
on record. In one instance, when injections of
10 cc. quantities were customary, as much as 60
cc. of 30 per cent urokon was used. Most of the
other multiple injection arteriograms, however,
when smaller quantities were used, do not rep-
resent such a large total quantity of medium.
Thus, one arteriogram was done using eight
injections and a total of 40 cc. of media, another
needed seven injections and a total of 35 cc., and
four required six injections and 30 cc. each.
More recently a six-injection arteriogram was re-
quired, in which only 3 cc. per injection was
used, or a total of only 18 cc.
Of the 1281 injections of dye made, thirty-two
were partly or completely extravascular. Such
injections caused immediate increased pain dur-
ing and shortly after the injection. Otherwise
no other ill effects occurred except in one patient
who suffered an immediate minor neurologic re-
action with a quick complete recovery. In none
of these thirty-two cases was thorotrast used. Sev-
eral times x-rays of the neck subsequently dem-
onstrated complete absorption of the dye within
a few hours. An injection of urokon and diodrast
outside the lumen of the carotid artery meets
greater resistance and creates severe local pain in
the neck, ear and jaw which subsides within a few
minutes. An injection outside the lumen of the
vertebral artery causes severe pain in the shoulder
and arm, which likewise usually subsides in a
few minutes. In one such instance, brachialgia
lasted several days probably because an associated
nerve root at that site was irritated by the dye.
Discussion
A good safety record can be maintained by ad-
hering to two prophylactic concepts. The first
is care in selection of patients, and where greater
risk patients must be subjected to the test, rigid
attention to safety features in technique must be
applied. The second is a constant respect dur-
ing technical performance of the test for its po-
tential hazards with corresponding insistence on
efficient, safe technique. Despite faithful appli-
cation of these two principles, some reactions will
still occur, but with proper safeguards they can
ordinarily be rendered innocuous. These conten-
tions do not deny the need for still further tech-
nical improvements. As of this writing, two
major advances are still needed: (1) The devel-
opment of a more perfect contrast medium (one
which will provide good contrast, but which is
still painless, nonirritating, nonradioactive, and
readily excreted or destroyed by the body) ; and
(2) a more dependable simple technique for ver-
tebral angiography.
In accepting a patient for this test, there is
comfort in the knowledge that in most patients
there is a large margin of safety with regard to
neurologic accidents or fatalities. These patients
will tolerate a traumatic arterial puncture, re-
peated large injections of contrast medium, extra-
vascular injections, and sundry other insults with-
out neurologic sequelae. There is a significant
number, however, who beforehand give warning
of potential complications. These include the aged,
the arteriosclerotic, the hypertensive, patients who
have recently bled from aneurysm, and the pa-
tient with a known intracranial mass lesion. Then
there is still another group of patients who give
no such warning, but who for some unknown
reason tolerate a local vascular insult such as
caused by injection of contrast medium less well
than others. Patients in whom this is likely to
occur cannot be recognized in advance, but will
show their intolerance to the procedure by neuro-
logic reactions during the performance of the
test. In both these latter groups a neurologic
reaction following an injection of dye or even
to attempted cannulation of the artery is a danger-
signal for trouble ahead, which if ignored is apt
to lead to a disastrous complication. Thus, a
patient who, following the first injection, is unable
to move the contralateral extremities fully, or who
complains of numbness in those parts, or who is
having speech trouble, when subjected to a re-
peated vascular trauma with another severe in-
jection may have such a transient complication
converted to a more permanent one. It is im-
portant for the operator to know “where his
patient is” after each injection. For this reason
we believe that the procedure should be done
under local anesthetic in a fully-awake patient
whenever possible. It can be made to be nearly
pain free and tolerable under local anesthetic only.
We do not hold with those that believe that the
theoretical benefit of relaxation of cerebral ves-
January, 1957
75
CEREBRAL ANGIOGRAPHY— GASS
sels under general anesthesia overcomes the ad-
vantage of knowing that your patient has not
reacted well to the injection just given. In an
anesthetized patient this reaction is masked. When
it is necessary to do cerebral angiography in an
unconscious patient or in one in whom general
anesthesia cannot be avoided, as in children or
grossly irrational patients (in whom restraining
head and extremity compression straps are in-
adequate), it is important that the number of
injections (small quantities) be kept to a mini-
mum and ample rest periods for recovery be
allowed between injections.
Often, therefore, it is possible to cut short the
usual technique as soon as the problem is solved.
In a stuporous or comatose patient, for example,
in whom a surface hematoma is suspected, who
shows in the first film (an anterior-posterior view)
a significant shift of anterior cerebral arteries to
one side with a pathognomonic free space between
cortical vessels and calvarium indicating a sur-
face hematoma, there is no need to risk a second
injection trauma to obtain a lateral view. Angio-
grams, therefore, should be done only by those
persons who are fully aware of the problems of
the case and who will carry out the definitive
therapy. In this way, injections which will yield
little or no clinical information may be avoided.
Other occasions develop where a purely neuro-
surgical decision of clinical management is made
during the course of the performance of the test
as the wet films are seen following each injection.
These may include cessation of the test, need for
certain oblique views, demonstration of collateral
ability of Circle of Willis, legibility and adequacy
of the films, et cetera. This procedure may be
accepted once by the patient without much com-
plaint, but he is apt to be bitter if a repetition
is needed because of some oversight when it was
first performed. If the responsibility of this test
is placed upon a resident in training, he must be
prepared to make accurate and complete neuro-
surgical diagnosis as he goes along or have each
set of films as they are developed interpreted for
him by someone who can.
Technique
One cannot underestimate the importance of
technique when considering the safety of cerebral
angiography. Unlike some medical investigative
procedures, the outcome of this test may depend
on the care and efficiency with which it is done
by different operators. Safe angiography may be
done in a variety of ways, the differences in tech-
nique depending upon the operator’s preferences,
the radiologic facilities available, and the pa-
tient’s disease. Angiography as done by a single
operator always in the same institution may not
be suitable for the itinerant neurosurgeon who
answers consultations in many institutions. It is
not always feasible or safe to transfer a patient
who may benefit from the information obtained
by the test from one institution to another solely
for the performance of angiography. The tech-
nique which was developed and has been utilized
for most of the patients in this series has proven
itself to be safe, reliable and simple, and easily
adaptable to any general hospital, even though
it is utilized there rarely. Experience with several
specially built units for taking multiple serial
films has failed to prove their value to the author
for routine angiographic diagnosis. In the oc-
casional circumstance where interval exposures
beyond the customary arteriographic and veno-
graphic phases may be needed, they can be
readily obtained by another injection and timing
of exposures earlier or later than is usual. Thus
the elimination of special equipment has enabled
increased utility of this test.
Several features of technique deserve comment.
Especially in hospitals where the personnel are
unfamiliar with cerebral angiography, it is im-
portant that the neurosurgeon take complete
charge of the procedure, especially from the radio-
logic point of view. If he yields to the factors,
patient positions, tube position, cassette position
imposed by a technician inexperienced in this
test and somewhat in variance with his own ex-
perience, he will frequently end up with an under-
exposed film or one showing the head rotated
or not properly centered. If necessary, it is wise
before actual performance to take one or more
exposures of the head in the test position to per-
fect technique. Unnecessary injections which in-
crease both the pain and the hazard may be
reduced by proper planning.
Preference for local anesthesia has already been
stressed in order that greater control over and
prevention of untoward reactions may be achieved
by the operator. With experience the test may
be made to be almost pain free. Ordinarily,
aside from the pain associated with the introduc-
tion of local anesthesia, there is momentary sharp
pain as the needle pierces the carotid artery and
76
TMSMS
CEREBRAL ANGIOGRAPHY— GASS
<«.-■ r*
r:v: 3 the arie: i. uiin.; <■ ct c: .. ,'ieedi e
Fig. 4. Fixing and transfixing the artery.
Imoe
again as the needle is withdrawn at the com-
pletion of the test while pressure is being made
against the puncture site to prevent local hema-
toma. Description of the discomfort associated
with injection varies with the patient and the
amount, the type and rate of injection of the
contrast medium. A rapid injection of 5 cc. of
30 per cent urokon into the common carotid
artery is accompanied by a sudden stinging, burn-
ing sensation in the homolateral side of the face
and behind the eye. It tastes bitter and often
induces the sensation of something flushing
through the mouth, and the patient may desire
to expectorate. A calm stoic patient will report
it not to be painful but to burn as though on
fire for an instant. In a small per cent of patients
a moment or two later there may be nausea or
actual gagging. This pain is considerably re-
duced when only 3 cc. is used, and the patient
verbalizes little distress from the experience.
Although intracarotid injection of thorotrast is
painless, it is retained in the body and may be
seen years later in quantity in liver and spleen,
and its malignancy provoking possibility has been
indicted many times. Moreover, in a percu-
taneous injection any extravasation could lead to
serious late cicatricial changes in the neck. Its
use, therefore, may be justified only in elderly
patients or severe hypertensives where the danger
of immediate reaction is high. The newer media,
hypaque and renograffin, are now receiving trial
and show promise of being less irritating than
30 per cent urokon.
Fig. 5. Cannulating the artery (See text).
The performance of the test involves two steps:
(1) the cannulation of the artery, and (2) the
injection. For carotid angiography it is almost
always the common, which is more accessible than
the internal carotid artery, that is punctured.
The demand for vertebral angiography is infre-
quent and the technique less dependable. Ex-
pertness in performing carotid cannulation ensures
a minimum of pain and a maximum of safety and
success. Although specially designed needles are
preferred by some, an ordinary sharp No. 18
spinal puncture needle has proved adequate in
this series. The operator first aims to transfix
the artery with the needle, bevel down. This
necessitates fixing the artery against lateral or
medial movement with perfect control. If it
January, 1957
77
CEREBRAL ANGIOGRAPHY— GASS
cannot be readily done between the fingers, the
use of an accessory needle placed down to the
transverse process medial to the artery against
which it may be held, is of inestimable value (Fig.
4) . Successful impaling of the artery is deter-
Fig. 6. Angiogram (lateral view)
made with 5 cc. of 30 per cent urokon
showing large arterio-venous malfor-
mation. Note complete filling of early
phase with only 5 cc.
mined by slow withdrawal of the spinal puncture
needle with its stilette out until a show of blood
is seen at the open bore. After transfixation of
the artery has thus been secured, the operator next
aims at cannulating the artery as follows. Further
slow withdrawal of the needle is continued and
while doing so appropriate pressures are exerted
against the needle to cause the artery to be raised
up by the needle point (Fig. 5) until the needle
is felt to “pop"’ into the lumen much as a needle
“pops” through the dura in doing a lumbar punc-
ture. This is accompanied simultaneously by a
pulsating spurt of blood out of the needle, indi-
cating the needle bevel to be entirely within the
lumen of the artery. The needle may then be
threaded up the artery a safe distance to insure
total intraluminal injection of dye, usually one-
fourth to one-half inches or more. The stilette
is then replaced in the needle until the injection
is ready to be made. The needle may be left in
situ as long as needed.
The injections are made by attaching a 10 cc.
plain tip syringe containing the contrast medium
directly to the needle. Continuous irrigation of
the needle system is thus safely omitted. Elim-
ination of the irrigation system not only simplifies
the technique, but enables the use of smaller quan-
tities of dye. It is doubtful that uniformly suc-
cessful angiograms can be obtained with as little
as 3 to 5 cc. of medium if the dead space of irri-
gating tubing is interposed between syringe and
needle. Moreover, facial petechiae which have
been reported after this test do not occur when
the irrigation system is eliminated. Evidently
their occurrence indicates inadvertent injection
of air trapped in the tubing. With the use of
small quantities of dye (3 to 5 cc.), care must
be taken not to allow blood to enter the syringe
in any quantity before the injection is made unless
the bolus of dye is diluted. The operator soon
becomes proficient in how rapidly to inject the
dye and when to make the exposures, and rarely
misses obtaining appropriately timed films, both
in the arteriographic and venous phases.
It is of interest that huge vascular lesions may
be visualized in their entirety in all phases utiliz-
ing 5 cc. of dye or less (Fig. 6). It is also prob-
ably true that such large lesions may have greater
than a 5 cc. total fluid capacity in their arterial
or venous phases yet visualize completely with a
smaller quantity of contrast medium. This may
be due to the fact that the x-ray exposure is not
instantaneous and visualizes the dye as it travels
through the arterial or venous tree for a given
period of time, if only brief. Cinefluorographic
angiography7 has shown with what rapidity blood
flows through the cerebral vascular system. A
quantity of dye insufficient to fill the entire ar-
terial system in a given instance may, therefore,
during a brief but finite interval, which is being
filmed, fill out the entire vascular silhouette.
As a rule it is necessary to make only two in-
jections, the first for an arteriographic view in the
anterior-posterior projection, and the second for
both arteriographic and venous phases in the lat-
eral projection. The two phases may be obtained
by manually changing the cassettes rapidly and
making two properly timed exposures. Individual
circumstances may vary this routine, however,
since at times more than two injections may "be
needed where at other times a single injection for
the anterior-posterior view may solve the prob-
lem in question. Interval phases between and
after the arteriographic and venous phases may be
needed for completeness in arteriovenous mal-
formations or certain vascular tumors, and addi-
tional oblique views are often necessary for com-
plete delineation of aneurysms. Flexibility with
regard to the number of films and views needed
78
JMSMS
CEREBRAL ANGIOGRAPHY— GASS
to answer the special needs of individual cases
should be the keynote, bearing in mind at all
times, however, that the fewer injections made
the less likely the patient will react unfavorably.
Adequate rest periods between injections are or-
dinarily provided if one waits to develop and
view each set of films before proceeding with the
next.
It is wise to take the lateral views on grid
cassettes without turning the patient’s head to
offer less chance for the needle to be dislodged.
This also simplifies the manual changing of
cassettes for the two routine phases. The anterior-
posterior projection, if taken with a 30° to 40°
tilt as used in obtaining an occipital or Towne
view of the skull, is apt to be more informative
than a straight perpendicular projection, since
then a longer view is obtained of the important
midline pericallosal artery as well as the Syl-
vian vessels. Any shift from the midline of the
former vessel is more evident in the longer view
than when it is foreshortened as in a straight per-
pendicular view. Medial displacements of the
Sylvian vessels away from the calvarium are sim-
ilarly more evident in the longer occipital pro-
jection. Moreover, overlapping orbital and front-
al sinus bony detail present in a perpendicular
anterior-posterior film is thrown out of the field
of the arteries in the occipital view.
If the time exposure is kept to one-fourth sec-
ond or less, any movement that the patient may
make in reacting to the injection will occur after
the exposure is complete. He should be fore-
warned when the injection is about to be made.
These precautions usually suffice in obtaining good
quality films without motion, but occasionally head
restraints or even general anesthesia are indi-
cated.
The operator should be protected by a leaded
shield placed over the patient’s chin or neck be-
tween the needle and the rest of the patient’s
head, or by an extension cone or cylinder reaching
nearly to the head which keeps the operator’s
hands out of any direct x-ray beam.
A percutaneous vertebral arteriogram technique
as reliable, safe and simple as the carotid tech-
nique has not been developed. Success in ob-
taining good vertebral angiograms may be expect-
ed about 75 per cent of the time. Myelographic
visualization of the main branches of the basilar
artery system for aneurysms and displacement may
be safely achieved by the use of the technique of
Mellins,8 but this is of limited value, although
not difficult to accomplish.
On withdrawal of the needle following carotid
angiography, immediate firm finger pressure at the
site of puncture for a few minutes, which is some-
what uncomfortable, will prevent any significant
hematoma formation. Greater care in this regard
is needed in hypertensives and in the aged. Al-
though a large number of minor hematomas in the
neck have occurred, which contributes to the neck
soreness which follows the test for a few days,
none in this series has ever caused serious incon-
venience nor have any had to be evacuated. Fol-
lowing vertebral angiography the site of punc-
ture cannot be compressed, yet no ill effects fol-
lowing needle removal have been seen. It is rec-
ommended that the patient remain recumbent for
two hours following angiography.
Summary
The author’s experience with 500 consecutive
cerebral angiograms performed in 364 patients is
presented from the point of view of safety and
yield of information. The total incidence of reac-
tion was 6.6 per cent, but only 1.4 per cent for
serious reactions, and the single death in which
the test might be causally involved constituted
an incidence of 0.2 per cent. Details of technique
which enabled achievement of this record are dis-
cussed, including the recent use of 3 cc. of con-
trast media per injection.
Information critical for the diagnosis or the
management of the patient was obtained in 172
of the 374 patients. In thirty-nine patients an-
giography alone without air study provided ample
information for neurosurgical identification and
localization of an intracranial mass or a surface
hematoma.
Addendum
Since the preparation of this paper, more than
100 additional angiograms have been performed
utilizing 3 to 4 cc. of dye per injection. Not a
single major complication has occurred. Hypaque
sodium (50 per cent) was used in almost all of
this group and when injected into the internal
carotid artery resulted in excellent contrast without
producing pain. In 3 to 4 cc. quantities, it has
become our medium of choice.
( Continued on Page 88)
January, 1957
79
Anomalous Left Coronary Artery
and Endocardial Fibroelastosis
npo THE PHYSICIAN whose practice is con-
■*- cerned with or limited to patients in the ped-
iatric age group, sudden and clinically unexplain-
able death in a previously apparently healthy in-
fant or child is a most distressing happening.
Farber,1 in his timely work on this problem,
refuted the myth of the thymus gland as the
cause in itself of sudden death, and cast serious
doubts on many of the other more or less accepted
reasons for this highly disturbing occurrence. At
the same time, Farber quite definitely established
the roll of various fulminating and unrecognized
infections as the almost universal cause of these
“sudden deaths.”
Recently, Adelson and Kinney,2 in a compre-
hensive study of 126 consecutive cases of sudden
unexpected death in children between the ages of
ten days and two years, have again pointed up
the almost universal role of severe fulminating
infections in all instances of sudden death other
than traumatic.
Two of the less frequently occurring and most
often unrecognized causes for sudden or very
rapidly occurring death in an infant who had pre-
viously given no clinical evidence of disease or
anomaly, are anomalous left coronary artery and
its counterpart in clinical course and manifesta-
tions, endocardial fibroelastosis.
This paper presents a review of the literature
and cases of each of these uncommon conditions
in which the ages, past histories and clinical
courses were remarkably similar, and where diag-
nosis of the cause of their rapid demise was es-
tablished only at the necropsy table.
Historical Data
The first report of anomalous left coronary
artery was by Abrikosoff3 in 1911. It was six
years later that Heitzmann4 reported an identical
case and called attention to the similarity of the
From the Departments of Pediatrics of the St. Law-
rence and Edward W. Sparrow Hospitals, Lansing,
Michigan.
By John F. Sander, M.D.
East Lansing, Michigan
Ronald C. Peets, M.D.
Lansing, Michigan
pathologic findings to those resulting from coro-
nary occlusion in adults. In 1934, this entity was
described in detail by Bland, Garland, and White.0
It was from this report that the anomaly received
its occasional name of “Bland — Garland — White
Syndrome.”
To this date, there have been approximately
forty cases of this anomaly reported in the liter-
ature. All have essentially similar findings.
The companion entity, endocardial fibroelastosis,
was first described in 1818 by Kreysig.6 For a
century it seems to have been either unrecognized
or considered a facet of myocarditis. Then, in
1918, Potoschnig7 reported this condition and sug-
gested that it was noninflammatory and deserved
further investigation. There appears to have been
further lack of recognition of the entity until 1941
when Gross8 reviewed the subject. Investigators
then bestan to consider the condition with the
congenital anomalies of the heart. It was given
its present name by Weinberg and Himmelfarb9
in 1943. Many more cases have been reported
since that time, some of which were suspected
clinically and verified at necropsy.
The Clinical Picture
The symptomatology of these two disorders is
essentially identical. The infant, usually born
normally at full term, appears normal at birth
and for several weeks to months thereafter. Then
the parents note the onset of attacks of pain, espe-
cially at the time of feeding. Respirations become
short and grunty and the infant frequently pulls
up his knees as if having colic. Later there is
sweating, apparent shock and frequently cyanosis.
It is now accepted that these attacks represent
angina pectoris. Physical examination and chest
roentgenogram show evidence of cardiac enlarge-
ment. Electrocardiogram shows signs of myo-
cardial hypoxia as well as left ventricular hyper-
trophy. Cardiac catheterization has been of little
help in distinguishing the two entities.
80
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ANOMALOUS LEFT CORONARY ARTERY— SANDER AND PEETS
Pathology
The findings at necropsy are characteristic.
There is considerable enlargement of the heart,
particularly of the left ventricle, due both to dila-
tation and hypertrophy. In the first condition,
the changes are predominantly in the distribution
of the left coronary artery. The endocardium of
the affected area is usually thickened and gray,
due to associated endocardial fibroelastosis. The
left ventricular myocardium may appear scarred
on gross inspection, and usually will exhibit scar-
ring on microscopic examination. These are typ-
ical of scars due to myocardial infarction and, ac-
cording to Bland et al,5 tend to be concentrated
near the endocardial side of the myocardium of
the left ventricle. The myocardium will frequent-
ly also show focal areas of calcification. These
are generally thought to be necrotic muscle.
Acutely infarcted myocardium is sometimes evi-
dent. Endothelial-lined blood-containing sinus-
oids are frequently present in the myocardium of
the left ventricle and these are quite striking when
seen. The pathologic findings typical of endo-
cardial fibroelastosis are essentially the same but
without the anomalous coronary artery.
We wish to present one case of anomalous left
coronary artery, and two cases of endocardial
fibroelastosis for the record.
Case Reports
Case 1. — K. J., a four-week-old girl, was born nor-
mally of healthy parents. There were no other children.
Her course in the hospital was uneventful. She was
discharged in apparently good condition, and when ex-
amined two weeks later by her physician was in good
condition and had made normal progress. When one
month of age the parents reported that she was very
fussy at feeding time. She would take about one
ounce of formula and would pull up her knees and
“scream” as though in great pain. She was given
an appointment for office examination but shortly be-
fore that time the physician received an “emergency”
call, stating the baby had another episode of severe
pain, had vomited and then stopped breathing. Prompt
and accepted attempts at resuscitation were of no avail.
Necropsy Findings. — Significant abnormalities were
limited to the heart. The pericardial cavity was greatly
distended and contained 85 cc. of blood-tinged fluid.
The greatest transverse diameter was 4 cm.; the weight
42 grams. The coronary arteries were anomalous in
that the left coronary originated from the pulmonary
trunk. The left coronary was limited to the descend-
ing branch. The right coronary originated from the
aortic trunk and was normal. The left ventricular wall
varied in thickness from 5 to 7 mm.; the right 3 to 4
Fig. 1. (above) Case 1. — Myocardium showing the
necrosis and focal calcification in ischemic areas.
Fig. 2. (center) Case 1. — Myocardium showing blood
filled, endothelial lines sinusoids (x 150).
Fig. 3. (below) Case 1. — Papillary myocardium ex-
hibiting necrosis and focal calcification.
mm. The lateral aspect of the wall of the left ventricle
exhibited an area of brownish discoloration 1 cm. in
diameter lying beneath the endocardium and extend-
ing 2 to 3 cm. into the myocardium. The valves were
grossly normal, as were other features of the heart.
Micropathology. — Myocardial fibers were hypertro-
phied, particularly of the left ventricular wall. There
was a moderate an aunt of generalized interstitial edema.
January, 1957
81
ANOMALOUS LEFT CORONARY ARTERY— SANDER AND PEETS
Sections through the wall in the area of the above-
described discoloration revealed several scars particu-
larly beneath the endocardium. In several areas there
was necrosis of the myocardial fibers. There were focal
Fig. 4. Case 2. — Ventricular myocardium exhibiting
endocardial fibrous thickening and vacuolization of un-
derlying myocardium.
areas of calcification among the necrotic muscle bundles.
Many of the papillary muscles exhibited focal areas of
necrosis and calcification. The endocardium in the
areas of myocardial involvement was greatly thickened
due to an excess of fibrous and elastic tissue. There
was no evidence of inflammatory cell infiltration.
Pathologic Diagnosis. — Anomalous origin of left cor-
onary artery from the pulmonary trunk. Coronary
artery insufficiency and acute myocardial infarction.
Cardiac hypertrophy, dilatation and acute congestive
failure.
Case 2. — H. U., a five-month-old, white female child
was born by normal spontaneous delivery after a normal
pregnancy. No physical abnormalities were noted in
the postnatal physical examination. Both parents were
in good health. A two-year-old brother, normal and
in good health, was the only sibling. She was ex-
amined regularly at monthly intervals according to
accepted pediatric standards and her progress was good.
Her mental and physical development were normal. She
had no illnesses until she was five months old, at
which time she had an acute adenotonsillitis, uncom-
plicated. She received penicillin therapy and routine
symptomatic treatment. Her clinical improvement was
prompt and satisfactory for four days, but then she
again became febrile, irritable and anorexic. She vom-
ited persistently. Her physician was called on the
fifth day and when she was seen was extremely and
critically ill. Her color was ashen gray, respirations
were rapid, grunting, and labored. Breath sounds were
bronchial in character over both upper lung fields more
marked on the left. Clinical diagnosis of pneumonia,
and dehydration was made, with the possibility of
previously unrecognized cardiomegaly.
The infant was promptly hospitalized; placed in
oxygen, parenteral fluids started, and she was given
streptomycin-penicillin therapy.
Chest roentgenogram showed marked cardiac en-
largement involving chiefly the left side of the heart,
and bilateral bronchopneumonia.
She remained cyanotic and had increasing respira-
tory distress, even in high oxygen concentration, and
expired six hours after admission.
Autopsy Findings. — Pathology was limited to the heart
and lungs. Both ventricles were markedly dilated.
The mitral valve leaflets and the endocardium showed
white fibrous thickening. Microscopically there was
edema of the interstitial connective tissue, of the myo-
cardium and patchy fibroelastosis throughout. The en-
docardium was thickened by fibrosed elastic fibers.
Bundles of atypical clear cells were found beneath the
endocardum. The mitral valve leaflets were thickened
and showed both fibrosis and degenerative changes.
The lungs exhibited a patchy consolidation of all
lobes, which microscopically proved to be entirely edema.
Pathologic Diagnosis.— Myocardial failure due to en-
docardial and myocardial fibroelastosis.
Case 3. — C. C., a five-months-old, white male infant,
was born by normal spontaneous delivery after a normal
pregnancy. The mother was Rh negative. Cord blood
was Coombs negative and showed a bilirubin of 1.7
mg. per cent. Growth and development were normal
during his five months of life. He became ill during
the day prior to admission with persistent vomiting,
was restless and irritable and cried constantly. The
following day his physician was called and he felt that
the child’s condition was critical, and advised immediate
hospitalization. His temperature was 104° rectally on
admission. He was cyanotic, respirations were rapid
and labored, and breath sounds were bronchial in char-
acter over both upper lobes but more marked on the
left. Parenteral fluids, oxygen and vigorous antibiotic
therapy was started, but he expired one and one-half
hours after admission.
Autopsy Findings. — The pericardial cavity contained
30 cc. of straw-colored fluid. The heart was markedly
enlarged and when emptied of its contents weighed
108 grams, with the greatest transverse diameter being
6.5 cm. The coronary arteries were normal in origin
and distribution. The myocardium was hypertrophied
and flabby. Both ventricles were markedly dilated.
There were no anomalies of the heart or great vessels.
The endocardium was opaque, white and thickened.
Microscopically the myoeardium of the left ventricular
wall showed marked hypertrophy of uneven distribution.
The endocardium of the left ventricle was markedly
thickened. There were numerous trabeculae of dense
connective tissue extending into the myocardium with
partial degeneration of some of the myocardial fibers.
There was no myocardial infarction, nor any inflamma-
tory myocarditis or endocarditis. The lungs, liver,
spleen and kidneys showed marked congestion.
The pathologic diagnosis was congenital endocardial
fibroelastosis with left ventricular cardiac hypertrophy
and acute congestive heart failure.
82
JMSMS
ANOMALOUS LEFT CORONARY ARTERY— SANDER AND PEETS
Comments and Summary
Sudden and unexpected death in an apparently
previously healthy infant or child is a most shock-
ing and distressing occurrence to both the phy-
sician and the family. For years most of these
sudden deaths were attributed to hypertrophy of
the thymus gland and/or status thymico lym-
phaticus. Since 1924 when Farber first refuted
this then current and accepted cause of death,
and established fulminating infection as the most
universal cause of all sudden, other than trau-
matic deaths, numerous articles have been pub-
lished confirming his findings.
Three cases of sudden, unexpected and clin-
ically unexplained death are reported by us,
which are neither on a traumatic or infection
basis, and which indicate that in any similar sit-
uation, the possibility of endocardial fibroelastosis
or anomalous left coronary artery should be in-
cluded by the physician in his differential diag-
nosis.
Acknowledgment
The authors wish to thank Dr. Leo W. Walker
and Dr. Charles E. Black, pathologists at St. Law-
rence and Edward W. Sparrow Hospitals re-
spectively, for their kind help and cooperation in
the preparation of this paper.
References
1. Farber, S.: Fulminating streptococcus i»fections in
infancy as a cause of sudden death. New England
J. Med., 211:154-159, 1934.
2. Adelscn, L., and Kinney, E. R.: Sudden and un-
expected death in infancy and childhood. Pediatrics,
17:663-700 (May) 1956.
3. Abrikosoff, A.: Aneurysma des linken Herzven-
trikels mit abnormer abgengstelle der linken
Karonarterie von der Pulmonalir bei einen funf-
monthahin Kinde. Virchows Arch. f. path. Anat.,
203:413, 1911. (cited by Eidlow and MacKen-
zie.10)
4. Heitzmann, O. : Dru seltene falle von herzmese-
bilding. Virchows Arch. f. path. Anat., 223:57,
1917. (Cited by Eidlow and MacKenzie.10)
5. Bland, E. F. ; White, Paul D.; and Garland, J.:
Congenital anomalies of the coronary arteries; re-
port of an unusual case associated with cardiac
hypertrophy. Am. Heart J., 8:787, 1932-33.
6. Potoschnig, G. : Referred to by Gross.8
7. Kreysig: Referred to by Gross.8
8. Gross, P.: The concept of fetal endocarditis. Arch.
Path., 31:163, 1941.
9. Weinberg, R., and Himmelfarb, A. J. : Endocardial
fibroelastosis. Bull. Johns Hopkins Hosp., 72:299,
1943.
10. Eidlow, S., and MacKenzie, E. R.: Anomalous
origin of the left coronary artery from the pul-
monary artery; report of a case diagnosed clinically
and confirmed By necropsy. Am. Heart J., 32:243,
1946.
DIAGNOSIS OF PHEOCHROMOCYTOMA
(Continued from Page 71)
potassium levels. Finally, the occurrence of an
attack immediately following Regitine at first seems
paradoxical but probably represents a reaction to
the transient hypotension produced immediately
following the injection.
Conclusions
1. A routine screening procedure for the diag-
nosis of pheochromocytoma is presented.
2. Emphasis is placed on the measurement of
urinary catechol amines to confirm apparent pos-
itive pharmacologic tests.
3. Specific procedures to be performed by pa-
tient or physician during a suspected attack are
outlined. The possible diagnostic usefulness of
electrocardiographic changes during an attack are
pointed out on the basis of our experience with
one such case.
References
1. Gifford, R. W., Jr., Roth, G. M., and Kvale, W. F.:
Evaluation of new adrenolytic drug (Regitine)
as test for pheochromocytoma. J.A.M.A., 149:
1628, 1952.
2. Goldenberg, M., Synder, C. H., and Aranow, H.,
Jr.: New test for hypertension due to circulating
epinephrine. J.A.M.A., 135:971, 1947.
3. Goldenberg, M., Serlin, I., Edwards, T., and Rap-
port, M. M.: Chemical screening methods for the
diagnosis of pheochromocytoma: I. Nor-epineph-
rine and epinephrine in human urine. Am. J. Med.,
16:310, 1954.
4. Von Euler, U. S., and Floding, I.: Fluorumetric
estimation of noradrenaline and adrenaline in urine.
Acta Physiol. Scandinav., (Suppl. 1 18) 33:57,
1955.
5. Roth, G. M., and Kvale, W. F. : A tentative test
for pheochromocytoma. Am. J. M. Sc., 210:653,
1945.
6. LaDue, J. S., Murison, P. J., and Pack, G. T. :
The use of tetraethylammonium bromide as a diag-
nostic test for pheochromocytoma. Ann. Int. Med.,
29:914, 1948.
January, 1957
83
Diagnosis of the Operable Arterial Lesion
EPLACEMENT of diseased arteries has be-
come a fairly common practice. Accord-
ingly, many individuals who formerly had to live
with an arterial incapacity may now be safely
and adequately treated by means of surgery. This
development has come within the past few years.
Formerly, such replacement was possible only in
institutions where it was possible to obtain fresh
homografts promptly when needed, and under
aseptic conditions. With the discovery of methods
for preservation and sterilization of homografts,
arterial replacement has become more practical.
Many of the lesions which would be untreatable,
were it not possible to replace the defects result-
ing from resection, have become operable.1 The
conditions which have become suitable for treat-
ment by use of the arterial homograft are briefly
reviewed below, in conjunction with a practical
method for arteriography and reference to a
practical arterial bank.
Aneurysms
Aneurysms are an important group of condi-
tions in which homografting has made remark-
able differences in therapy. They may be clas-
sified according to cause as secondary to trauma,
arteriosclerosis, syphilis, and mycotic disease. Ac-
cording to shape, they may be saccular, fusiform,
dissecting, miliary, or cirsoid. For the purpose
of treatment and diagnosis, they are best dis-
cussed according to location.
Thoracic aneurysms 2,3 are located in the
ascending aorta in 70 per cent of the cases,
according to Kampmeier. The association with
syphilis has been common. They cause symp-
toms by pressure against the esophagus, trachea,
left recurrent laryngeal nerve, and erode into
the vetebrae. Accordingly, symptoms of dys-
phagia, hoarseness, difficult breathing, and back
pain develop. A tracheal tug may exist. Signs
of dullness over the chest and dilatation of the
aortic valve may be present. X-ray studies of
From the Department of Surgery, Wayne State Uni-
versity College of Medicine, Detroit Receiving Hospital,
and Veterans Administration Hospital, Dearborn.
By Herbert J. Robb, M.D., and
Charles G. Johnston, M.D.
Detroit, Michigan
the chest will usually be diagnostic, demonstrating
the size and calcium deposition in the wall.
Transthoracic aortography as well as angiocardio-
graphy have been used. The average survival
after onset of symptoms is six to nine months,
frequently terminating with hemorrhage. In the
past, treatment has been in the form of wiring
or wrapping with cellophane. Currently, resec-
tional therapy with grafting has been reported.
Dissecting aneurysms 4 most frequently begin as
a primary tear of the ascending arota in ad-
vanced arteriosclerosis, dissecting within the layers
of the media. The onset is usually sudden with
agonizing tearing pain in the thorax and inter-
costal distribution. Interference with the blood
supply of the spinal cord may produce paralysis.
Pain often progresses distally with the develop-
ment of shock, and the loss of pulses in variable
peripheral arteries. DeBakey and Cooley have
treated these by the creation of a re-entry pas-
sage into the aortic lumen above with the oblitera-
tion of the false passage below. Results are encour-
aging.
Abdominal aortic aneurysms 5,6 nearly always
develop distal to the renal vessels, and are usually
arteriosclerotic in origin, occurring in the age
group past sixty years. They may extend into
either or both common iliac arteries, on occasion
obstructing one or both ureters. Symptoms may
be minimal, frequently with low back pain. Ab-
dominal pain usually indicates slow perforation
or leakage of the aneurysmal sac of varying sever-
ity and rapidity. They present themselves as
palpable pulsatile masses at the level of the um-
bilicus, usually lying slightly to the left. A hand
placed on each side will give the impression of
width and lateral pulsation. The scout film of
the abdomen may show a rim of calcification, and
the pyelograms lateral displacement of the ureters.
Translumbar aortography may confirm the sus-
picion, although the lamination of clot frequently
prevents adequate filling to indicate the full size
of the aneurysm. Resectional surgery with replace-
84
JMSMS
OPERABLE ARTERIAL LESION— ROBB AND IOHNSTON
ment by a homograft or plastic prosthesis is the
current generally accepted treatment. Survival
is 80 to 85 per cent in elective cases. Acute rup-
ture of the abdominal aneurysm is recognized by
acute abdominal pain and peritoneal tenderness
accompanied by shock in an individual with a
pulsating abdominal mass. Emergency surgery
with the replacement of the aorta gives a variable
50 per cent survival.
Peripheral aneurysms 7 have occurred in all
major arteries of the neck and extremities. They
are secondary to trauma, as gunshot wounds and
stab wounds. Arteriosclerosis is a frequent cause
in the popliteal region. The mycotic variety oc-
curs in individuals with bacterial endocarditis.
A localized, expansile, pulsating, swelling devel-
ops over one of the arteries. Auscultation re-
veals a systolic murmur. Pressure on the artery
proximal to the sac will decrease the murmur,
size, and pulsations. An arteriogram is of value.
Thrombosis, embolism, gangrene, pressure on
veins and nerves, and rupture are possible seque-
lae. Treatment consists of endo-aneurysmor-
rhaphy, or excision with grafting by an autogenous
vein or homologous artery.
Occlusion
Superficial femoral occlusion8’9 may involve all
or only a portion of this vessel, frequently first
developing in the region of the distal adductor
canal and progressing proximally to the deep
femoral artery. Symptoms are those of calf
claudication with mild exercise. Ankle or foot
ulcers may develop and be confused with vari-
cose ulcers. They are frequently on the toes or
on the lateral ankle instead of over the medial
malleolus. The dorsalis pedis, posterior tibial, and
popliteal pulses are absent or feeble. The popli-
teal pulse can frequently be best palpated with
the patient lying on his abdomen and the knees
flexed at 45°, using the foot of the bed to
support the feet so that the hamstring muscles
can be relaxed. Unless there is a higher ob-
struction, femoral pulses will be present and of
good quality. Femoral arteriography will deter-
mine and record the extent of the obstruction.
Replacement or by-pass by a homologous artery
or autogenous vein is indicated if a patent pop-
liteal segment is present.
Iliac and/or femoral occlusion 10 may exist on
one or both sides with or without a patent super-
ficial femoral vessel. All the signs of arterial
insufficiency existing in the superficial femoral
artery occlusion will be present. In addition, the
femoral pulse is absent or feeble, or the throm-
bosed vessel is palpable. The immediate aorto-
gram will show the block and a delayed “aorto-
femoral” arteriogram should demonstrate the col-
lateral and possible distal communication with
the superficial femoral vessel. For years, sympa-
thectomy has been the treatment of choice; but
this was usually only temporarily palliative. Cur-
rently a homologous graft to by-pass the ob-
struction is indicated, providing a patent distal
segment exists. We have used grafts up to 55
cm. with good results to restore arterial flow and
eliminate claudication.
Abdominal aortic occlusion 11 may occur in
varying degrees and extend distal to the renal
arteries with or without occlusion of the iliac
and femoral arteries. As such, it was described
by Leriche in 1940. There is intermittent claudi-
cation of the calves, thighs, buttocks, and lumbar
region with a sensation of coldness and numbness
of the extremities. Impotency may exist with
bilateral, internal iliac involvement. There may
be loss of hair, with skin and muscle atrophy.
Pulses of the femoral, popliteal, dorsalis pedis
and posterior tibial region are absent or occasion-
ally feeble. Oscillometric readings and skin tem-
peratures are useful in determining the degree
of arterial insufficiency. Translumbar aortography
is indicated to determine and record the extent
of obstruction. Resection of the aortic bifurca-
tion with an arterial homograft, or on occasion,
a plastic prosthetic replacement, should be con-
sidered. Thromboendarterectomy is used on oc-
casion. Lumbar sympathectomy may be added
but there is some question of its advantages.
Occlusion of the thoracic aorta 12 occurs as a
coarctation either proximal or distal to the ductus
arteriosus. If the ductus is distal to the coarcta-
tion, it is of the infantile type and prognosis is
poor, usually with death in infancy. If the ductus
is proximal, as in the adult type, the collateral
circulation will develop and prognosis is favor-
able. In the adult type, the lower extremity
pulse and pressure are diminished and the arm
pressure is increased. Cardiac decompensation,
hypertensive headaches and nose bleeds occur.
Notching of the ribs usually does not occur until
after childhood. X-rays of the chest may demon-
January. 1957
85
OPERABLE ARTERIAL LESION— ROBB AND JOHNSTON
strate the rib notching and cardiac enlargement.
Resection and re-anastomosis, with or without
a homograft, is indicated to prevent intracranial
hemorrhage and progressive cardiac failure.
Fistulas
Arteriovenous fistulas 13,14 occur as single or
multiple connections between the arteries or veins,
and may be congenital or traumatic in origin.
In the chronic form, depending on the size of the
fistula, there is a fall in diastolic blood pressure,
increase in venous pressure, dilatation of the
veins, and proximal artery. In the limb, there
will be an increase in temperature, stasis, pig-
mentation and ulceration. Acutely, there may be
a distal decrease of temperature due to the shunt-
ing of the blood away from the distal capillary
beds. The oxygen content of the local veins will
be high. An increase of circulating volume will
occur. Compensatory enlargement of the heart
will occur in large or long standing fistulas, pro-
gressing on occasion to myocardial failure. A
thrill and bruit continuous throughout the cardiac
cycle are present. Compression and closure of
the fistula will lead to a decrease in pulse rate
and elevation of blood pressure. Arteriography
is diagnostic with immediate return of dye to-
ward the heart. Closure will rarely occur spon-
taneously in a large fistula ; death may occur from
cardiac failure. A venesection is to be considered
at the time of closure to prevent severe rise in
diastolic pressure and acute cardiac failure. Bac-
terial endartiritis may occur on occasion. The
effects of an acute arteriovenous fistula14 are
those of hemorrhage, with a drop of blood pres-
sure, increase of pulse rate, decrease of heart
size, increase in venous pressure and increase in
cardiac output.
Embolism
Arterial embolism 15 is most frequent among
individuals with auricular fibrillation. The em-
bolus may follow any arterial path and stop at
a site where the arteries bifurcate and narrow,
as at the distal end of the popliteal, femoral,
aortic or auxiliary arteries. The embolus is a
hard white thrombus distal to which develops
a soft red clot. The part distal to the occlusion
will become pulseless, cool, then blanched and/or
mottled. Effort to move the extremity will demon-
strate weakness and pain. It may later become
numb if the block is complete. Emergency em-
bolectomy is indicated even though some time
has passed when the patient is first seen. Para-
vertebral sympathetic blocks are useful to in-
crease the collateral but should not be depended
upon. Frequently, one femoral pulse is absent;
and exploration of that artery produces a ques-
tionable flow of blood. In such a case, ab-
dominal exploration will usually show a thrombus
at the bifurcation of the aorta lying to one side,
allowing blood to enter the opposite iliac vessel.
Following surgery, a second embolism may occur
requii'ing repeat surgery. Removal of the left
auricular appendage may be indicated to pre-
vent recurrent emboli occurring from this site.
Diagnosis
Aortography16’17’18 is important in the diagnosis
of the above arterial lesions. Numerous modifi-
cations of technique have been used. Briefly our
method is as follows (see diagram) : With the
patient face down on the table, under spinal
anesthesia, we insert a No. 17 gauge, 7-inch
needle four to five fingerbreadths to the left of the
spinus process beneath the twelfth rib, at a 45°
angle with the saggital plane toward the mid-
line. If a transverse process is encountered, the
needle must be backed off. angled superiorly or
86
JMSMS
OPERABLE ARTERIAL LESION— ROBB AND JOHNSTON
inferiorly, and reinserted until it meets the ver-
tebral body. It is then moved anteriorly on the
vetebral body until it passes in front of the verte-
brae. Approximately a 1 cm. thrust will meet
resistance, then loss of resistance as it enters the
aortic lumen. Normally, a 1 to 2-inch pulsation
of blood will appear on removal of the stylet. A
rubber catheter connection is attached and a
4 cc. quantity of 70 per cent Urokon is injected
for a test picture to check the position of the
needle and test the patient for sensitivity. Mild
nausea is frequent. If the needle is in the renal
artery or superior mesenteric artery, it must be
withdrawn and re-inserted, as a full injection
of dye into these vessels may well lead to throm-
bosis and undesirable complications. When the
needle has been thus checked, the Bucky film is
placed so as to include the tip of the needle
and the bifurcation of the iliac vessels on the film.
A 20 cc. quantity of 70 per cent Urokon is in-
jected as rapidly as possible, and an exposure is
taken as the last 3 cc. is injected. The needle
and tubing is filled with physiologic saline until
the film is developed. If the arteries are patent
to the femoral level, a transaortic femoral arterio-
gram or what might be called an “aorto-femro-
gram,” may be taken to demonstrate both super-
ficial femoral arteries down to the popliteal level.
This is usually accomplished by means of a three-
second delay in x-ray exposure after the injection
of the dye when no proximal block is present.
If the block is found at any point from the aorta
distally, a four to eight-second delay of exposure
may be necessary before the dye appears in the
patent artery distal to the block, if such exists.
This radiograph is desirable and can usually be
obtained, as a distal patent artery will fill through
collaterals. If the distal artery is open, surgery
is usually indicated. We have used up to 60 or
80 cc. of Urokon in 20 cc. injections to obtain
the necessary information. Direct femoral arteri-
ography is not often indicated in sclerotic ves-
sels, as injury may be sufficient to cause throm-
bosis. Where necessary, we use a 30 per cent
Urokon solution injected through a polyethylene
catheter which has been inserted through a large
bore No. 16 gauge needle. The needle is then
removed, leaving the polyethylene tube in place.
If necessary, repeated injections may thus be made
without injury to the artery through motion of
the needle.
Treatment
The artery bank19,20 represents a primary pre-
requisite for the treatment of the operable arterial
lesion. Until recently, it was necessary to obtain
homologous arteries for grafting purposes within
six hours after death in bodies without systemic
infection or disease. Transfer of the body to the
operating room and removal of the vessels under
sterile conditions was inconvenient and took more
time than the pathologist and undertaker were
willing to give.
Recently, methods have been devised to sterilize
the homologous artery which is removed at the
routine postmortem examination. We feel that
the most practical artery bank is that developed
by LoGrippo and Szilagyi with the use of Beta-
propriolactone to facilitate sterilization of the ar-
teries. The routine postmortem examination per-
mits have been changed so that special permis-
sion and a signature may be obtained for the re-
moval of arteries to be used as homologous grafts
Permits are requested on all bodies up to sixty
years of age and on all malignant and septicemic
diseases except those which are viral in type. Ves-
sels then may be removed at the time of autopsy
at the discretion of the pathologist, depending
solely on their quality. They are taken from re-
frigerated bodies up to twenty-four hours after
death. The aorta from above the renals is re-
moved, including the bifurcation, and both ilial
and femoral vessels down to the popliteal level.
Polyethylene tubing is best left in the internal iliac,
profundus and popliteal vessels to facilitate em-
balming, and encourage co-operation from the
undertaker. The vessels are then cleaned by the
surgical resident on pathology and placed in
saline solution for transfer to the artery bank;
where, within three to four hours, they are steril-
ized with Beta-propriolactone. The method is rel-
atively simple and requires little more than the
refrigerator for storage, laboratory glassware, and
a controlled temperature water bath, or incu-
bator. Following sterilization, the Vessels are
stored at 4° C. in Hanks solution with penicillin
and streptomycin added. The aortic bifurcation,
right femoral, and left femoral segments are each
stored separately, so that each donor may easily
be used for as many as three or more arterial
grafts. The homografts are usable up to thirty
or forty days, after which they may be lyophilized
for further storage. We have taken vessels from
January, 1957
87
OPERABLE ARTERIAL LESION— ROBB AND TOHNSTON
sixty-two such bodies and have found them in
every case to be sterile, with all qualities remain-
ing necessary for a good homologous graft.
Summary
With the development of a practical method
for the preservation of the homologous artery,
diagnosis of the operative arterial lesion has be-
come important. The clinical history will usually
indicate the presence of probable arterial disease,
but x-ray with arteriography is of greatest value in
the exact location and definition of the lesion.
Surgery of a curative nature can then be planned
and accomplished.
References
1. Johnston, Charles G. and Jordan, Prescott, Jr.:
Cardiovascular surgery in geriatrics. J. A. Geri-
atrics, 2:529-534, 1954.
2. Kampmeier, R. H.: Saccular aneurysms of the
thoracic aorta: 633 cases. Ann. Int. Med., 12:624,
1938.
3. Cooley, Denton A., DeBakey, Michael E.: Total
excision of the aortic arch for aneurysms. Surg.,
Gynec., & Obstet., 101:667, 1955.
4. DeBakey, Michael E.; Cooley, Denton A.; and
Greech, Oscar, Jr.: Surgical considerations of dis-
secting aneurysm of the arota. Ann. Surg., 142:
586-612, 1955.
5. DeBakey, M. E.; Cooley, D. A.; and Greech, O.,
Jr.: Treatment of aneurysms and occlusive disease
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cases. J.A.M.A., 157:203-208 (Jan. 15), 1955.
6. Szilagyi, D. Emerick; Smith, Roger F.; and Over-
hulse, Paul R. : Resectional surgery of the abdomin-
al arota. Arch Surg., 71:491-511, 1955.
7. Matas, Rudolph: An operation for the radical cure
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Surg., 37:161-196, 1903.
8. Szilagyi, D. Emerick, and Overhulse, Paul R.:
Segmental aortic-iliac and femoral arterial occlu-
sion. J.A.M.A., 157: 426-4.33 (Jan. 29), 1955.
9. Crawford, E. Stanley, and DeBakey, Michael E.:
The by-pass operation in the treatment of arterio-
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Surg., Gynec. & Obstet., 101:529-535, 1955.
10. Palma, Edward D.: Femoral and iliac arteriopathy.
Angiology, 5:500-527, 1954.
11. Leriche, R. : LeSyndrome de Fobliteration termino-
arotique par arterite. Presse med.. 48:601-604,
1940.
12. Gross, R. E.: Technical considerations in surgical
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1-8, 1946.
13. Holman, Emile: Arteriovenous Aneurysm; Abnor-
mal Communications between Arterial and Venous
Circulations, p. 224. Chicago: MacMillan Co.,
1937.
14. Branham, H. H.: Aneurysmal varix of the femoral
artery and vein following a gunshot wound. In-
ternat. J. Surg., 3:250-251, 1890.
15. Allen, Edgar V.; Barker, Nelson W.; and Hines.
Edgar A. : Arterial embolism and acute arterial
thrombosis, p. 313-331. Philadelphia: W. B. Saund-
ers, 1949.
16. Smith. Parke G. ; Rush, T. W.; and Evans, Arthur
T.: The technique of translumbar arteriography.
J.A.M.A., 148:255-258 (Jan. 26), 1952.
17. Greenwald, Charles M.; LeFevre, Fay A.; Root,
Joseph C.; and Humphries, Alfred W.: Femoral
arteriography in diagnosis of segmental arterio-
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27) 1955.
18. Pender, John W.. Kirklin, John W. ; and Davis,
George D. : Thoracic aortography. J.A.M.A., 157:
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19. Szilagyi, D. Emerick; Overhulse, Paul R. ; Shon-
nard, C. P. ; and LoGrippo, G. A.: The steriliza-
tion of human arterial homografts with beta-pro-
priolactone. Surgical Forum, 1954.
20. LoGrippo, G. ; Overhulse, P. R.; Szilagyi, D. E. ;
and Hartman, F. W.: Procedure for the steriliza-
tion of arterial homografts with beta-propriolactone.
Lab. Invest., 4:217, 1955.
CEREBRAL ANGIOGRAPHY
(Continued from Page 79)
Acknowledgment
I wish to acknowledge with gratitude assistance given
in the preparation of this report by Drs. Donald R. Sim-
mons, John F. McGuire, Harry Z. Mellins and Mrs.
Clara Ciske.
References
1. Kaplan, A. D., and Walker, A. Earl: Complica-
tions of cerebral angiography. Neurology, 4:643-
654, 1954.
2. Verbrugghen, A.: Complications of diodrast ar-
teriography. Arch. Neurol. & Psychiat., 71: 518-
519, 1954.
3. Lin, P.; Murtagh, F. ; Wycis, H. ; and Scott, M.:
Carotid angiography with urokon, using the Cham-
berlain bi-plane stereoscopic angiographic unit. Re-
port of one hundred cases. J. Neurosurg. 10:367-
371 (July) 1953.
4. Sutherland, D. L. ; Kite, William C., Jr.; Roach
J. F.; and Campbell, E.: A note on the use ol
25 per cent iodopyracet (Diodrast) in cerebral an-
giography. J. Neurosurg., 12:223-225 (May) 1955
5. Sedzimir, C. B. : Towards safer angiography. J
Neurosurg., 12:450-467 (Sept.) 1955.
6. Gass, H. H., and Jacobson, S. D.: The use ol
urokon in cerebral angiography. Am. J. Roentgen
nol., 69: (March) 1953.
7. Gass, H. H. ; Weinberg, S. ; Craig, A.; Thompson
J. ; and Dreisinger, J.: Cerebral angiography re
corded cinefluorographically. J. Neurosurg., 7:139
(March) 1950.
8. Mellins, Harry Z.: Myelographic demonstration o
the vertebral and basilar arteries. A post-graduate
lecture. University of Minnesota Hospital, Novem
ber, 1955 (To be published).
612 Kales Building
Detroit 26, Michigan
88
JMSM‘
Detecting Glycosuria
Comparison of Three Preparations for the
Detection of Sugar in the Urine
HP WO COMMERCIAL preparations designed
to detect glucose in the urine have been in-
troduced recently. The only available informa-
tion regarding these preparations comes from the
sponsoring companies. Both new methods em-
ploy paper strips impregnated with glucose oxid-
ase and an appropriate indicator system. Spe-
cificity, sensitivity and simplicity are claimed by
the manufacturers. We have compared the per-
formance of these preparations with each other
and with a more familiar commercial method
which is essentially the Benedict reaction.
Methods
Urine specimens obtained from hospitalized
patients were studied by three methods — “En-
zyme A”*, “Enzyme B”** and a “Reduction
Method”f. Some specimens were obtained from
diabetic patients, others were secured following
intravenous infusion of glucose and fructose, or
during the course of glucose tolerance tests. A
small percentage were derived from cases of renal
glycosuria or lactosuria. Fermentation studies
were carried out and the patient’s clinical rec-
ords were reviewed when necessary to establish
the cause of the glycosuria. One or more test
was positive in 506 specimens. Blood sugar find-
ings, when available, were correlated with the
urine findings. Tests were performed by sev-
eral different technicians according to the manu-
facturer’s specifications.
Results
In the majority of instances all three tests were
positive. “Enzyme B” was the only positive test
in 15 per cent of the specimens (Table I). In
every such case the degree of positivity was 1+.
All such specimens tested showed a positive fer-
mentation reaction. They were largely obtained
From the Department of Pathology, Butterworth Hos-
pital, Grand Rapids, Michigan.
*“Clinistix” (Ames Company, Elkhart, Indiana).
**“Testape” (Eli Lilly & Company, Indianapolis,
Indiana) .
f“Clinitest” (Ames Company, Elkhart, Indiana).
By Joseph D. Mann, M.D.
Grand Rapids, Michigan
during the course of glucose tolerance tests or
after intravenous administration of glucose. The
“Reduction Method” was the only positive test
in 10.7 per cent of the specimens. Most of these
TABLE I. PERCENTAGE OF POSITIVE TESTS FOR
URINARY SUGAR OBTAINED WITH THREE
COMMERCIAL PREPARATIONS OF
503 URINE SPECIMENS
Method
Per Cent of Tests
Reduction
Enzyme A
Enzyme B
+
+
+
00.6
+*
0
0
10.7
0
+
0
0.0
0
0
+
15.0
+
+
0
0.0
0
+
3.8
0
+
+
9.9
Total
100.0
*Not fermentable or specimen obtained after intravenous adminis-
tration of fructose.
specimens either did not show a positive fermen-
tation reaction or were derived from patients
who had received intravenous fructose. In no
insance was “Enzyme A” the only test positive;
in no case was the “Enzyme A" test positive
and “Enzyme B” test negative. However, the
“Reduction Method” and the “Enzyme B” meth-
ods were both positive while the “Enzyme A”
method was negative in 3.8 per cent of speci-
mens.
The manufacturers of “Enzyme A” do not
claim that the color reaction of their preparation
can be quantitated.!! On the other hand, the
manufacturers of “Enzyme B” supply a color chart
designed to permit semiquantitative reporting of
the test. Comparison of the degree of positivity
reported by the “Enzyme B” method and the
“Reduction Method" reveals a rough correlation
between the two techniques (Table II). The
“Enzyme B” test is somewhat more sensitive and
the units of positivity do not correspond exactly
between the two techniques.
ffPersonal Communication, Ames Company, Elkhart,
Indiana.
January, 1957
89
DETECTING GLYCOSURIA— MANN
TABLE II. COMPARISON OF THE DEGREE OF
POSITIVITY REPORTED IN 506 POSITIVE
URINE SPECIMENS BY THE “REDUCTION
method” AND BY “enzyme b” METHOD
Reduction
Enzyme
B
Degree of positivity f
0
i +
2 +
3 +
4 +
Corresponding
Per Cent Sugar
0
0.1
0.25
0.5
2.0
0
127
3
trace
0 . 25
48*
61
23
5
—
1 +
0.50
0*
10
26
14
—
2 +
0 75
—
—
12
26
8
3 +
1.00
—
—
—
12
41
4 +
2.00
2
82
tAccording to manufacturer’s specifications.
*Not fermentable or specimen obtained after intravenous fructose.
Comments
In this series, “Enzyme B” appeared to be
more sensitive than “Enzyme A.” The “Reduc-
tion Method” compared surprisingly well in sensi-
tivity to the “Enzyme A” test. Both enzymatic
methods appear to be specific for glucose. The
Benedict reaction has the doubtful advantage of
detecting nonglucose reducing substances.
The semiquantitative color chart supplied by
the manufacturers of “Enzyme B” introduces a
problem to the clinical laboratory and to the
clinician. According to the manufacturer’s spec-
ifications and in the actual practice (Table II),
the degrees of positivity obtained by the “Enzyme
B” method are different from the familiar sys-
tem obtained with the Benedict reaction. The
clinician must revise his thinking if the new
standards are employed. The clinical laboratory
must clearly indicate which method is being used
and what the degrees of positivity mean.
For the present, we propose to retain the Bene-
dict positivity scale with which the clinician is
familiar and use also the enzyme test to obtain
additional sensitivity and specificity. Specimens
which are positive by the enzyme test and nega-
tive by the reduction test will be reported as
“faint trace.” Use of the enzyme test will reduce
the need for fermentation tests in the identifica-
tion of sugars in the urine.
Acknowledgment
The technical assistance of Mrs. Miriam DeLange
and co-workers is gratefully acknowledged.
INTERATRIAL SEPTAL DEFECT
(Continued from Page 60)
normal. Eight months following operation the patient
is well with normal examination and function.
Comment : This is an example of an ideal candidate
for this procedure.
Summary
Interatrial septal defect is a frequent congenital
abnormality of the heart. It usually causes death
in the fourth decade due to progressive changes
resulting from the left to right shunting of blood
in the atria. It is surgically correctable, often by
closed procedures. Childhood is the safest and
most effective time for the surgical correction.
The physiology of the defect is discussed. Three
cases are presented to illustrate results of surgical
treatment in the various stages of this anomaly.
References
1. Gelfman, R., and Levine, S. A.: Incidence of acute
and subacute bacterial endocarditis in congenital
heart disease. Am. J. M. Sc., 204:324, 1942.
2. Gasul, B. M., and Fell, E. H. : Salient points in
the clinical diagnosis of congenital heart disease.
J.A.M.A., 161:39, 1956.
3. Schnitker, M. A.: Congenital Anomalies of the
Heart and Great Vessels. London: Oxford Uni-
versity Press, 1952.
4. Roesler, H. : Interatrial Septal Defect. Arch. Int.
Med., 54:339, 1934.
5. Healy, R. F. ; Dow, J. W. ; Sossman, M. C.; and
Dexter, L. : The roentgenographic appearance of
interatrial septal defect. Am. J. Roentgenol., 63:
646, 1950.
6. Edwards, Jessie E.: Pathologic Considerations in
Adjustments between the Systemic and Pulmonary
Circulations. Henry Ford Hospital. International
Symposium on Cardiovascular Surgery, p. 100.
Philadelphia: W. B. Saunders Co., 1955.
7. Dammann, J. Francis, Jr., and Ferencz, Charlotte:
Clinical Anotomic Correlations. Henry Ford Hos-
pital. International Symposium on Cardiovascular
Surgery, p. 86. Philadelphia: W. B. Saunders
Co., 1955.
8. Bjork, V. O., and Crafoord, C. : The surgical clos-
ure of interauricular septal defects. J. Thoracic
Surg., 26:300, 1953.
9. Lam, C. R.: Henry Ford Hospital. International
Symposium on Cardiovascular Surgery, p. 355.
Philadelphia: W. B. Saunders Co., 1955.
JMSMS
90
I Challenge You
To assure the provision of medical care security, in a form
acceptable to both the public and the medical profession, an
awareness of existing approaches, what is being planned, and
a constant re-evaluation, must be maintained.
The time for complacency on the part of our profession is
over. We have reached a crossroads where default in leader-
ship becomes final. Ostrich-like satisfaction with an undis-
turbed status quo can become an enmeshing quicksand.
On the other hand, if we are sincerely to assume our right-
ful and traditional responsibility for determining how our
patients shall receive medical care, we must ascertain what
is desired and needed in the way of medical care security.
Already schemes for such security are in existence, or being
planned, by lay persons and organizations. This is being
(done without prior consultation with the profession and with-
out regard for our plans.
If we were to concede the propriety of non-professional
groups concerning themselves with medical security, we still
would not accept their usurpation of responsibilities which
are solely ours.
A basic difference in viewpoint exists between these groups
and our profession. Their programs at best can only be
financing and administrative mechanisms. They cannot sup-
ply a means of furnishing service because medical care can
be provided only by physicians. It is difficult to see how so
personal a relationship as that of physician and patient can
be equated with the measured cadence of efficiency- tided
automation. Yet that is the essence of what is being advo-
cated by some lay groups. They reject free choice service
in favor of totally group practice. They propose salaried
physicians or a capitation fee and, in doing so, give a newly-
tailored definition of “free choice” to fit the circumstances.
Most members of MSMS are at least vaguely aware that
some of their fellow physicians maintain close contact with
this vital and absorbing subject of prepayment medical care.
Credit is overdue to MSMS officers, Councilors, and mem-
bers of the Michigan Medical Service Board, for their unre-
mitting attention to this subject. But it is not enough that so
small a percentage of our members are conversant with this
tremendous problem. It is of utmost importance that all
members become familiar with it.
I challenge you, as a member of MSMS, to avail yourself
of the plentiful material on the economics of medicine. If the
profession is to withstand powerful onslaughts and unwar-
ranted usurpation upon our ideals and principles of profes-
sional practice, we must have a united front. Only by an
informed membership, only by you knowing what is going
on, can the necessary evaluation of medical care plans meet
the needs of the times.
President, Michigan State Medical Society
ANUARY, 1957
91
Editorial
CONGRESS AND MEDICAL LEGISLATION
The Congress for 1957 will be considering a
host of new bills having a direct or remote inter-
est to the medical profession. This would be a
wonderful time for the doctors to sponsor a few
basic actions which would make the going easier,
would immediately benefit our public, and would
serve to annul the traditional role in which we
have been so frequently cast for the past three
decades.
The profession has made most of its imprint
on the Congress by opposition to certain bills. It
started during the thirties when we had the per-
ennial Wagner, Murray, Dingell bills. That fight
was long and bitter but placed us always “in
opposition.” The late Senator Taft offered his
version of a medical program after consulting with
the late Senator Vandenburg and many of the
doctors. We were asked to make suggestions, and
for a long time it seemed the profession could be
known by what it advocated.
It is late this year, but a program of beneficial
bills could be started any time and would be a
stroke of good business. Several bills of gen-
eral importance could well be promoted.
JENKINS-KEOGH
Another Jenkins-Keogh bill is almost certain
to be introduced in the next session of Congress.
It would benefit almost all self-employed per-
sons. The last session of Congress came near
passing one — failing because someone was not on
the job at a critical moment to include it in an
emergency act which was cleaning up many loose
ends. Under various names, these Jenkins-Keogh
bills have been under consideration for many
years. The advocates of this legislation are ask-
ing only for an equal chance in the income tax
field, with six times their numbers who are em-
ployed in industry.
The American Bar Association and the
American Medical Association have been advo-
cating such legislation as the Jenkins-Keogh bill
since about 1950 and will undoubtedly continue.
Every industry may favor its salaried or wage-
earning people by depositing for them, in addition
to their wages, a set sum (and it can be large)
to buy or provide retirement annuities. Thus
much larger incomes are available beyond the in-
come tax restrictions. The employe pays his in-
come tax (it is withheld), and that tax is only
on the basic rate. The annuity money is not his
until years later, and industry may charge this
amount off as expense just the same as though
it had been used to increase the wage. There
are two benefits to industry, and good laborers
are kept employed because of established benefits
which would automatically be cancelled if a
change of employer occurred.
Income taxes in our modern time have become
so high it is almost impossible for a person after
paying his tax to accumulate enough to establish
income bearing holdings. The tax rate starts at
twenty per cent, and increases with every step
until a maximum of 92 per cent (which is con-
fiscatory) is soon reached. Many of our self-em-
ployed are professional — doctors, dentists, archi-
tects, lawyers, musicians, preachers, and small
business operators. Their earning power is slow
to develop but lasts for relatively few years,
not long enough for them, with the meager
amount left after taxes and living expenses, to
purchase enough endowments so their after re-
tirement income even with the added social se-
curity, can provide even the most modest living.
Our friends in industry who apparently have
been earning about the same or even less than we,
have been provided for out of so-called “expense
of doing business money,” and without tax. That
cost has not helped government and has increased
the cost of doing business. We, the self-employed,
have not benefited but have helped pay.
Our many friends in industry have been able
through their employers’ wise tax-free investments,
to build a substantial retirement annuity which the
self-employed individual should, but is not able,
to do.
The Journal has commented on this subject
at least once a year since September, 1948. The
self-employed are asking no special privilege —
simply to be placed on the same benefit level as
their friends in industry.
92
JMSMS
EDITORIAL
HEALTH REINSURANCE
The President, in his messages on the state of
the nation, for several years has advocated what
was called “reinsurance.” He was interested in
arrangements by which the voluntary medical and
hospital prepayment plans could provide needed
health insurance to persons in the lower income
levels, who were prevented from buying the same
health benefits so many millions of our people
have been doing in ever-increasing amounts. This
proposal was called “reinsurance” and consisted
of advancement by the government of at first
$50,000,000, and contributions by each subscriber
plan of suggested amounts to the common fund
operated by the Department of Health, Education
and Welfare. If service experience provided a
deficit after caring for these persons, the amount
would be forthcoming from the common funds.
It was stipulated that contributions of the sub-
scribers be so arranged periodically that the total
.amount would pay off all amounts advanced,
and the government would have its $50,000,000
' back at the end of five years.
This amounts to a subsidy pure and simple, in-
stead of reinsurance, but demands the subsidy
back at the end of five years. Actually, under
the plan the subscribers, Health Insurance Vol-
untary groups, were being asked to take non-eli-
gible subscribers and pay the losses ultimately
themselves. The only out would be to go through
the form of a subsidy by HEW, but actually to se-
cure the money in some method from the or-
dinary subscribers.
Assistant Secretary Roswell Perkins, author of
the administration’s reinsurance program, is leav-
ing the department. We probably shall not hear
much about reinsurance this session — we hope.
MEDICAL EDUCATION
The costs of medical education have not in
any way decreased. It was estimated a few years
ago that another $10,000,000 is needed every
year by the medical schools in addition to the
amounts now available from tuition and state
supports, private endowment and other sources.
The Federal government has offered to make
funds available. The American Medical Associa-
tion has not objected to one-time provision of
funds for construction, but has been apprehensive
of anything in the nature of a subsidy, fearing loss
of administrative control by the medical schools.
Bills will undoubtedly be introduced which must
be studied for hidden intent. We fear what might
occur in the future if subsidy has encroached on
our most cherished right.
Medical research will naturally come under
medical education and the amounts to be pro-
vided are multiplying each year. For the cur-
rent fiscal year ending July, 1957, the amount
of about $225,000,000 has been appropriated.
MEDICAL DRAFT
The special draft law for doctors of medicine
and dentists is due to expire July 1, 1957. In
the past, it has been extended by simple act of
Congress when a need seemed apparent and the
quota of medical corps officers was difficult to
obtain from the newly graduated; also experienced
officers were in demand. The general draft for
all persons expires at age thirthy-six, or maybe
now twenty-six, but for doctors it starts when they
graduate and extends until they are fifty-one. No
other category of persons is subject to such spe-
cial and exacting control. In justice, the law
should be repealed and should not be reenacted.
It is purely class legislation Some other
method should be used. Many of our doctors
were sent to school by the government and were
required to promise only a short term of duty.
In justice, a sufficiently long enlistment is indi-
cated to reimburse the government for free edu-
cation.
GOVERNMENT EMPLOYES’ INSURANCE
For several years, Congress has been consider-
ing some action to provide health insurance for
its civilian employes but has never seemed to
find the solution. Many bills have been intro-
duced, but always some snag developed or the
impelling interest has faded. The last Congress
might have succeeded but stumbled on the prob-
lem of payroll deduction. Congress asked a study
to be made under the supervision of the General
Accounting Office to determine the added cost
and feasibility of such a service.
Congress is suddenly apprehensive of the added
expense of making payroll deductions in its own
offices to pay for health insurance, but never
hesitated when it appointed every employer of
labor to be its collecting agent in the income tax
withholding burden. Michigan Medical Service
and the Blue Cross might have been serving the
postoffice employes in Michigan for many years,
January, 1957
93
EDITORIAL
if some way could have been arranged for pay-
roll deduction. The department refused, saying
such deductions were illegal, but did withhold in-
come tax. We have suggested to different con-
gressmen that a simple act authorizing payroll
deductions for certain purposes, such as Commu-
nity Chests, national welfare movements or health
insurance, would put the government agencies in
the same relation to their employers as industrial
employes.
We anticipate government will provide for some
form of voluntary prepayment health insurance
of government employes in the coming session of
Congress. We believe this to be very proper, but
we suggest our representatives in Congress
be guided in their efforts so that our medically
sponsored plans will be given a chance. The
wording and intent of the bill may be of signifi-
cant importance, also the willingness to do some-
thing.
MICHIGAN LEGISLATION
On the home state scene, there are some points
of legislative action which we should be known
as advocating instead of opposing. It has been
shown that Michigan imports 250 graduates in
medicine each year because our own medical
schools cannot supply the demand. The Wayne
State University Medical School now could ac-
cept about fifty more students in each class, if
money for more teachers were available. Our
House of Delegates, in September, 1956, passed a
resolution urging the State to accept this obliga-
tion. We can heartily support such a bill.
THE YEAR 1956: MEDICARE
The year 1956 has been one of extremely sig-
nificant accomplishment. The most outstanding is
the action of the government in providing medical
care for the dependents of military personnel.
Such care has been available traditionally, but
only at military hospitals where the family was
stationed. With business booming as it is, it
is becoming increasingly difficult to keep the mili-
tary strength up to what is required, especially
the more experienced and necessary personnel.
The draft helps, but does not hold the older men
in service.
Another cause of difficulty is the highest per-
centage of employed persons in history, and un-
employment is no problem for the person who
wishes a job. Industry is naturally competing
with the armed forces with its higher pay ant
more prerequisites, especially in health insurance
This year, the government has provided the Med
icare program, through which the actual depend
ents of service men will get care under regulation
and considerations, but very liberal ones.
The act went into effect on December 7. Con
gress provided the machinery and appointed ai
army task force to make negotiations. Not tot
much time was available after the adjournmen
of Congress up to December 7. The Americai
Medical Association, being the representativi
of the medical profession, appointed a task fore
to accomplish an almost impossible task in th<
time limit. Their attorneys and designated offi
cials, after innumerable conferences, arrived a
a procedure. A controlling contract form wa
negotiated, through which the individual stati
medical societies would contract with the military
departments to render care for the dependent
of the armed forces personnel.
This contract form wisely provided that eacl
state medical society negotiate fees on its owi
basis and agree to administer the program itself
or designate some organization as representativi
and intermediary. Late in October, the stati
medical societies were invited to Washington t(
sign their contracts. On that trip, the terms o
the contract were first learned. Many of thi
states had designated Blue Shield as their repre
sentative; others were to administer their owi
program.
The contract provides that, regardless of thi
arrangements, each doctor who serves these de
pendents is actually in a personal contract, no
with the padent but with the United States gov
eminent. The service must be rendered for thi
agreed amount, and under no circumstances is ;
separate or additional bill to be rendered. Thi
states negotiated their fees, as provided. No on<
knows the extent and amount of medical anc
hospital, or even nursing care which will be in
volved in this new adventure in medicare, so thi
contracts are all on the cost-plus-operation ex
pense basis. The present veteran’s home-towr
care program is on a somewhat similar basis
the General Accounting Office reserving and usint
the right of visiting our offices and rechecking tht
expense claims. The government did not raist
much objection, its rule being to accept mostl)
fee schedules as presented, because under tht
(Continued on Page 130)
94
JMSM5
HOWARD B. SPRAGUE, M.D.
Heart Association
Program
Featured speaker at the Annual Dinner Meeting of the Michigan Heart
Association in the Grand Ballroom of the Sheraton-Cadillac Hotel, Detroit, at
6:30 P.M., Thursday, March 14, 1957, and Moderator of a Panel on “The Heart
Patient at Work” during the Thursday morning program of the Michigan Clinical
Institute (see below).
SCIENTIFIC SESSIONS ON HEART DISEASES
at the
MICHIGAN CLINICAL INSTITUTE
(Speakers provided by the Michigan Heart Association)
8:30-9:00 A.M.
“Rheumatic Fever”
Donald E. Cassels, M.D., Chicago, Illinois
Professor , Department of Pediatrics, University of Chicago
9:00-10:30 A.M.
Panel Discussion on “The Heart Patient at Work”
Moderator :
Howard B. Sprague, M.D.
Lecturer on Medicine , Harvard Medical School
Panel Members :
E. A. Irvin, M.D.
President, Michigan Heart Association
Medical Director , Ford Motor Company
January, 1957
M. S. Chambers, M.D.
President-Elect,
Michigan Heart Association
Marion Jocz, M.D.
Medical Director,
Chrysler Cor poration
Gordon B. Myers, M.D.
Professor of Medicine
College of Medicine
Wayne State University
John G. Bielawski, M.D.
Medical Director,
Michigan Heart Association
95
Michigan Clinical Institute
Closed Circuit Color Television Program
Elmer B. Miller,
M.D.
Nicholas Gimbel,
M.D.
William S. Carpenter,
M.D.
Charles G. Johnston,
M.D.
M. S. DeWeese,
M.D.
Russell L. Mustard,
M.D.
Wednesday
March 13, 19 57
11:15 A.M. to 12:45 P.M.
COLOR TELEVISION PROGRAM, beamed to the
Grand Ballroom, Sheraton-Cadillac Hotel through the
co-operation of the staff of The Grace Hospital, De-
troit and Smith. Kline and French Laboratories of
Philadelphia.
OPERATIVE CLINICS
A. Operating Rooms of Grace Hospital
Under supervision of Elmer B. Miller, M.D., De-
troit, Associate Attending Surgeon at Grace Hos-
pital and Instructor in Surgery, Wayne State Uni-
versity
1. “Cholecystectomy and Bile Duct Exploration”
Nicholas Gimbel, M.D., Detroit
Associate Professor of Surgery, Wayne State
University, College of Medicine
2. “Gastric Resection”
William S. Carpenter, M.D., Detroit
Harper and Mt. Carmel Hospitals and Instructor
in Surgery at Wayne State University
B. Grand Ballroom, Sheraton-Cadillac Hotel
1. Surgical Commentator and Moderator
Marion S. DeWeese, M.D., Ann Arbor
Associate Professor of Surgery, University of
Michigan ; Chief of Surgical Services, Ann Arbor
Veterans Administration Hospital
2. Panel of Discussants
Charles G. Johnston, M.D., Detroit
Professor of Surgery, Wayne State University
College of Medicine
Russell L. Mustard, M.D., Battle Creek
Past Chief of Surgery, Leila Post Montgomery
Hospital; Consultant to Percy Jones Hospi-
tal and Lecturer in Surgery, University of
Michigan
James W. Logie, M.D., Grand Rapids
Consultant to St. Mary’s and Blodgett Hos-
pitals; Counselor, Michigan Chapter, Ameri-
can College of Surgeons
JMSMS
Thursday
March 14, 1951
11:15 A.M. to 12:45 P.M.
11:15 “Management of Hypertension”
Floyd B. Levagood, M.D., Detroit
Associate Attending Physician, Grace Hospital; In-
structor in Medicine, Wayne State University
11:45 Clinic on “Endocrine Diseases”
William O. Maddock, M.D., Detroit
Associate Professor of Medicine, Wayne State Uni-
versity College of Medicine
Robert Leach, M.D., Detroit
Assistant Professor of Medicine , Wayne State Uni-
versity College of Medicine
12:15 Clinic on “Collagen Diseases”
Alfred Jay Bollet, M.D., Detroit
Assistant Professor of Medicine, Wayne State Uni-
versity College of Medicine
Friday
March 15, 195 1
11:15 A.M. to 12:45 P.M.
11:15 “Uterine Bleeding”
George S. Fisher, M.D., Detroit
E. S. Hoffman, M.D., Detroit
11:45 “Diagnosis and Management of Acute Arterial Ob-
struction”
James B. Blodgett, M.D., Detroit
Associate Attending Surgeon, Grace Hospital
12:15 “Examination of the Patient with Acute Abdominal
Pain”
Gordon B. Myers, M.D., Detroit
Professor of Medicine, Wayne State University Col-
lege of Medicine
January, 1957
Michigan’s Department of Health
Albert E. Heustis, MX)., Commissioner
MAJOR ISSUES IN PUBLIC HEALTH
Among the major issues in public health in Michigan
today that will be reflected in budget requests made to
the Legislature by the Michigan Department of Health
are polio immunization, prevention of relapse in mental
illness and air pollution control.
Polio Immunization
Michigan youngsters one through fourteen are now a
well-immunized group. This year, immunization is
being provided for children reaching one year and
booster doses for all in the one through fourteen age
range. But next year there will be approximately 200,-
000 more children reaching one year and unless vac-
cinations continue to be given widely, the immunized
group will be diluted by 200,000 unvaccinated children
each year.
There are three possible approaches in considering
polio immunization:
1. A strong, positive program of all-out public par-
ticipation might be developed to increase most rapidly
the number of people protected from paralytic polio.
2. The entire responsibility for immunization might
be placed on individuals and their own physicians.
This would make polio the only communicable disease
handled in this way. By Michigan law, the State
Health Commissioner and local health officers are re-
sponsible for assuring that protection is offered for all
children of the state against smallpox, diphtheria,
whooping cough, tetanus and, in certain situations,
typhoid fever. Polio vaccine was, of course, not avail-
able when these acts were written, but there is very
specific emphasis on the state’s interest in the wise use
of the then known vaccines for the protection of all
children.
3. The program might be planned in terms of the
legally defined responsibilities of the State Health Com-
missioner in matters involving a communicable disease.
Under such a program, opportunity for polimyelitis
vaccination would be provided for the youngsters born
each year, and for those children under 15 who move
into Michigan, developing over the years, a population
protected from paralytic polio.
Prevention of Relapse in Mental Illness
Over the years, local health department personnel,
particularly nurses, have aided families in meeting
problems in emotional and mental health as well as
in physical health. A number of basic health depart-
ment programs, such as child health conferences, have
definite preventive mental health implications.
An expansion in this field is recommended on a trial
basis to determine whether home visits and family con-
sultation by the public health nurse can help to cut
down the high rate of relapse in patients released from
the mental hospitals.
In fiscal 1955, a total of 4,305 patients were released
from Michigan mental hospitals on a convalescent
98
placement basis. Of these, 1,457 later had to re-enter
the hospital for further treatment.
In the recommended trial program which would be
carried on in co-operation with the Michigan Depart-
ment of Mental Health, six local health departments
would be provided with an additional public health nurse.
The nurse would be given certain basic training and
would work not only under supervision of the local
health officer but also under standing orders of the
mental hospital medical staff. Each nurse would, in turn,
provide training for other public health nurses on the
local health department staff in working with mentally
ill patients and their families.
Air Pollution Control
As a part of its occupational health program, the
Michigan Department of Health has worked with in-
dustries t® protect their employes from contaminated
air within the factories. Today, the state is faced with
a different and growing aspect of the same problem,
community air pollution resulting from industrial dusts
and fumes.
Industrial expansion, relocation of industries and
adoption of new processing techniques, together with
the public’s insistent demand for cleaner air all point
to the need for a well planned and carefully executed
air pollution control program. Since several counties,
or cities and counties, may have an air pollution prob-
lem stemming from a single industrial source, state reg-
ulations are needed to supplement local ordinances in
bringing about effective control.
It is recommended that legislative action be taken
to officially place community air pollution control under
jurisdiction of the Michigan Department of Health.
Health Officer Positions Open
A number of desirable openings in Michigan for di-
rectors of local health departments are on file with the
Section of Local Health Services of the State Health
Department. Physicians interested are invited to write
to the Section for information.
Externship Program for 1957
During the summer vacation period of 1957 the Mich-
igan Department of Health will again sponsor an ex-
ternship training program that will give to six selected
sophomore or junior medical students ten weeks of
work experience in local health departments.
The objectives of the program are to provide inter-
ested students with an opportunity to observe and par-
ticipate in an official public health program and, at
the same time, to furnish personnel for carrying out
useful projects. Health departments have already been
invited to submit to the State Health Department proj-
ects suitable for the ten-weeks program. The local
agency is responsible for travel expenses of the externs
and the State Health Department pays salaries. Se-
lection of students is made in co-operation with the
deans of Michigan’s medical schools.
TMSMS
DIAGNOSTIC AID
Reduced Hypermotility with Pro-Banthlne®
Improves Visualization
Posterior-anterior film: definite hyperper-
istalsis with poor duodenal visualization .*
The same anticholinergic action which
has made Pro-Banthlne (brand of pro-
pantheline bromide) the outstanding
therapeutic agent in peptic ulcer has also
proved valuable in diagnosis.
By controlling the hypermotility, Pro-
Banthlne may permit delineation of a
lesion otherwise not clearly visualized.
The technic is simple: If the first set
of films shows hypermotility but no filling
defect is demonstrable, reexamination is
Posterior-anterior film after 15 mg-, of Pro-
Banthine intramuscularly : chronic duode-
nal ulceration clearly disclosed.
done a few minutes after intramuscular
injection of 15 mg. or a half hour after
oral administration of 30 mg. of Pro-
Banthlne.
This procedure has the additional ad-
vantage of demonstrating the patient’s
response to a given dosage of the drug.
G. D. Searle & Co., Chicago 80, Illinois,
Research in the Service of Medicine.
^Roentgenograms courtesy of I. Richard Schwartz, M.D.,
Kings County Gastrointestinal Clinic, Brooklyn, N.Y.
January, 1957
Say you saw it in the Journal of the Michigan State Medical Society
99
w*1-
BAND-AID
TRADE MARK
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• ELASTIC PLASTIC
• FLESH COLORED
• STAYS CLEAN
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• GREASE RESISTANT
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TOO’s 3/4 "x 3"
In Memoriam
Paul W. Butterfield, M.D., died Friday, October 12,
1956, at the age of forty-seven. He was stricken with
a cerebral hemorrhage in Chicago where he had gone
to attend annual meetings of the College of American
Pathologists, of which he was a fellow, and the Ameri-
can Society of Clinical Pathologists.
Born April 23, 1909, Dr. Butterfield attended Bow-
doin College at Brunswick, Maine, and Boston Uni-
versity Medical School. He interned- in 1934-35 at
Salem Hospital (Massachusetts) and was a resident
pathologist in 1935-36 at Huntington Memorial Hos-
pital in Boston and at Massachusetts Memorial Hospital.
He went to Alpena with his family to take the post
of Alpena Hospital pathologist in 1953.
Dr. Butterfield was a member of the Tri-County
Medical Society, Alpha Kappa Kappa medical frater-
nity, the Michigan State Medical Society, the College
of American Pathologists, the American Society of
Clinical Pathologists, the AMA, the Michigan State
Pathological Society, and the Michigan State Blood
Bank. He was a Rotarian and a member of Hopper
Lodge No. 386, F and AM.
Surviving are Mrs. Butterfield and two sons, Paul,
nine and Stuart, seven.
CcHfiettienthf located
in (fraud Rapid*
• Hospital Equipment
• Pharmaceuticals
• Office Equipment
• Physicians’ Supplies
® Trusses
• Surgical Garments
• Physiotherapy Equipment
Medical Arts Supply Company
233 Washington S. E. Phone GL 9-8274
Grand Rapids 2. Mich.
Medical Arts Pharmacy
20-24 Sheldon S.E. Phone GL 9-8274
Grand Rapids 2. Mich.
William A. Evans, Jr., M.D., Chief of Staff of
Children’s Hospital of Michigan and chief radiologist
there for years, died at his home in Detroit, October
17, 1956, at the age of forty-nine.
Dr. Evans was widely known for his scientific work
through the numerous articles he wrote covering various
phases of roentgenology.
Dr. Evans was an active member of the Wayne
County Medical Society from 1937 until his death. He
was a Fellow of the American College of Radiology
and American Roentgen Ray Society and a member of
Nu Sigma Nu medical fraternity.
Born in Bellaire, Michigan, January 14, 1907, Dr.
Evans resided in Detroit for forty-five years and prac-
ticed his specialty there for more than twenty years.
Following graduation from Williams College in 1926,
he studied medicine at Johns Hopkins Medical School,
from which institution he obtained his M.D. degree in
1930.
Following his internship at Peter Bent Brigham Hos-
pital, Boston, Dr. Evans did postgraduate work at the
University of Wurzburg. He returned to Boston to
serve two years as assistant instructor in medicine at
Harvard University Medical School. He then came to
Detroit to enter private practice as a roentgenologist.
His wife, Charlotte, a daughter, Elizabeth, and his
mother, Mrs. William A. Evans, Sr., survive.
100
Say you saw it in the Journal of the Michigan State Medical Society
JMSMS
Hmoa9-*f NOissaaddns
INIOd 9NliasB
w%
average dosage only t.i.d.
antibiotic
synergism
The three gray lines of this graph show the
growth rate of a penicillin-sensitive strain of
Staphylococcus (Micrococcus pyogenes, var.
aureus) under 3 conditions:
1. In the absence of antibiotics
2- In the presence of subinhibitory concen-
tration of penicillin
3- In the presence of subinhibitory concen-
tration of Albamycin*
Even half these subinhibitory concentrations of
penicillin and Albamycin, when combined, (black
line) produce a dramatic bactericidal effect.
-Penicillin
(Albamycin plus penicillin) |
Compare it with \
the antibiotic you are
currently using: \
Range of effectiveness: Alba-Penicillin is
effective against the organisms that cause the
overwhelming majority of bacterial infections
(Staphylococci, Streptococci, Pneumococci,
Proteus).
Risk of resistance: Because in vitro tests
show this combination is synergistic against
even Staphylococci already resistant to ail other
antibiotics, the risk of resistance is minimized.
Risk of enterocolitis: Because it has little
or no effect on the predominant Gram-negative
intestinal bacteria, and is highly effective
against Staphylococci, there is virtually no dan-
ger of enterocolitis due toalteration in intestinal
flora, or of other side effects such as perianal
pruritus.
Convenience: Alba-Penicillin is oral therapy,
and the average adult dosage is only 1 to 2 cap-
sules t.i.d., which eliminates middle-of-the-night
medication.
It is available in bottles of 16 capsules. Each
capsule contains 250 mg. Albamycin ( as novo-
biocin sodium, crystalline) and 250,000 units
penicillin G potassium.
Upjohn
THE UPJOHN COMPANY, KALAMAZOO, MICHIGAN
10 12 14 16
Time in hours
January, 1957
Say you saw it in the Journal of the Michigan State Medical Society
101
NEWS MEDICAL
Lewis Cohen, M.D., Detroit, is the author of “Electro-
vasography— For the Rehabilitation of Patients with
Peripheral Arterial Disease,” published in the Bulletin
of Sinai Hospital, Detroit, June, 1956.
* * *
Plinn F. Morse Honored. — In recognition of more
than forty years of devoted service to Harper Hospital,
his stimulating leadership and wise counsel, the editors
of Harper Hospital Bulletin have published a special
number for September and October, honoring Plinn
F. Morse, M.D.
The papers in this collection “represent the esteem
of some of his many friends and associates and were
born from studies inspired by a teacher . . . who gave
his heart ‘to seek and search out by wisdom concerning
all things that are done under heaven.’ ”
There are some thirty papers in this special number.
Contributors include: James Milton Robb, M.D., Law-
rence Reynolds, M.D., Carl V. Weller, M.D., W. L.
Brosius, M.D., L. W. Gardner, M.D., Viola G. Brekke,
M.D., E. M. Knights, M.D., M. Hutchins, Sc.B., C.R.F.
di Profio, M.D., G. T. Bradley, M.D., J. E. Croushore,
M.D., W. H. Gordon, M.D., L. E. Holly II, M.D.,
D. J. Sandweiss, M.D., H. I. Kallet, M.D., B. R. Lutes,
M.D., T. Leucutia, M.D., B. C. Lockwood, M.D.,
H. C. Mack, M.D., F. C. Schreiber, M.D., A. Nielsen,
M.D., P. J. Huber, M.D., W. D. Mayer, M.D., M. R.
Beitman, M.D., Richard M. McKean, M.D., S. G.
Meyers, M.D., Rachel B. Keith, M.D., R. C. Moehlig,
M.D., E. A. Osius, M.D., G. C. Penberthy, M.D.,
C. D. Benson, M.D., C. R. Reiners, M.D., A. Hazen
Price, M.D., W. S. Reveno, M.D., H. Rosenbaum,
M.D., H. C. Saltzstein, M.D., L. F. Segar, M.D.,
George Sewell, M.D., R. S. Siddall, M.D., L. D. Stern,
M.D., and G. C. Thosteson, M.D.
* * *
I he Seventh International Cancer Congress will meet
in London, England, in July, 1958. It is sponsored
by the International Union Against Cancer. The
Congress will be held under the presidency of Sir
Stanford Cade, and the headquarters will be the Royal
Festival Hall.
There will be two main sessions of the Congress:
Experimental and Clinical and Cancer Control. Special
emphasis will be placed on Hormones and Cancer,
Chemotherapy, Carcinogenesis and Cancer of the Lung.
Proffered papers will be considered only if sub-
mitted with an accompanying abstract (not over 200
words) before October, 1957, and must deal with new
and unpublished work.
Registration forms and a preliminary program will
be available early in 1957 on application to The Secre-
tary General, Seventh International Cancer Congress,
45 Lincoln’s Inn Fields, London, W.C.2, England.
* * *
Schering Award Winners. — Two senior medical
students and one sophomore have won top places — and a
total of $1,500 in cash prizes — in the 1956 Schering
Award Contest. A panel of judges who are medical
authorities in their respective fields have selected the
students as first prize winners in this year’s contest,
open to all medical students in the United States and
Canada.
* * *
Plan Now for Istanbul. — It’s none too soon to make
your plans to attend the 11th General Assembly of the
World Medical Association — one of the most tangible
privileges of your U.S. Committee membership. The
forthcoming Assembly will be held in the world’s
“oldest and newest” city, Istanbul, Turkey, where
Europe and Asia meet. The dates for the meeting are
September 29 to October 5, 1957. Full information
regarding travel arrangements, hotel reservations, and
projected special tours, may be obtained by writing
Louis H. Bauer, M.D., Secretary-Treasurer, The World
Medical Association, 10 Columbus Circle, New York
19, N. Y.
* * *
A $1,000 contribution to aid Hungarian refugees in
Austria was cabled November 18, 1956, by the Interna-
tional College of Surgeons following the receipt of an
appealing letter from its Austrian chapter, with offices
in Vienna. The letter referred to a “state of turmoil
difficult to describe” and a “situation heart-rending be-
yond description.” The letter was from M. Arthur
Kline, M.D., physician to the American Embassy in
Vienna and Secretary of the American Medical Society
in Vienna.
* * *
Research in Blood. — An important award of $17,000
has been given to a Wayne State University Medical
School professor by the Commonwealth Fund of New
York for his work in blood clotting diseases.
Walter H. Seegers, Ph.D., chairman of the depart-
ment of physiology and pharmacology since 1948, re-
ceived a special creative scholarship award.
Significance of this honor was noted by Dean Gordon
H. Scott of Wayne’s College of Medicine:
“This award is newly created and designed by Com-
monwealth to allow scientists freedom from teaching
and administrative duties to spend at least a year for
uninterrupted research, study and lecturing.
( Continued on Page 104)
102
JMSMS
when you want broad spectru m antibiotic therapy with
added safety for the many common respiratory, gastro -
intestinal and u ri nary tract i nfecti o ns . . . the product
to prescribe is
MYSTECLIN
Squibb Tetracycline - Nystatin
the ONLY broad spectrum anti bi oti c preparation with
added protection against monilial superinfection
when you want specific anti biotic therapy for infections
caused by Candida albicans (m on ilia) . . . the prod uct
to prescribe is
MYCOSTATIN
Squibb Nystatin
the ON LY effective and safe antifungal antibiotic available
’MYCOSTATIN'® AND ’MYSTECLIN'® ARE SQUIBB TRADEMARKS
Squibb
e
Squibb Quality — the Priceless Ingredient
January, 1957
Say you saw it in the Journal of the Michigan State Medical Society
103
NEWS MEDICAL
for modern
control of
salt retention
edema
CUMERTIUN*
(Brand of Mercumatilin, Endo)
Tablets
• effective oral diuretic with no sig-
nificant gastrointestinal irritation1
• Suitable for long-term mainte-
nance therapy.
• eliminates need for injections ir
certain cases, lengthens interval
between injections in others
• basically different in chemical
structure, extending the therapeu-
tic choice in organic mercurials
DOSAGE: 1 to 3 tablets daily as required.
SUPPLIED: As orange tablets, in bottles
of 100 and 1000. Also available —
CUMERTILIN Sodium Injection, 1- and 2-cc.
ampuls, in boxes of 12, 25, and 100; and
10-cc. vials, individually and in boxes
of 10 and 100.
1. Pollock, B. E., and Pruitt, F. W.: Am. J. M.
Sc., 226:172, 1953.
THE G. A. INGRAM COMPANY
4444 Woodward Avenue, Detroit 1, Mich.
( Continued from Page 102)
“To be picked one of the first recipients from a
nationwide group of recognized scientists is a high
honor for Dr. Seegers and Wayne’s College of Medi-
cine.”
Dr. Seegers has spent twenty years tracing the myster-
ies of the clotting factors of blood. Late in the 1930’s
Dr. Seegers and his associates purified thrombin, a blood
derivative — important to clotting. This was the first
time any blood-clotting substance had been available
for scientists to study in purified form. Blood clots
in a few seconds when mixed with this powerful clotting
agent.
Recently, Dr. Seegers and his associates have dis-
covered derivatives of prothrombin. His blood research
laboratory — one of the best equipped in the world — is
in the process of describing the properties of these de-
rivatives and obtaining purified products from platelets.
* * *
American Board of Obstetrics and Gynecology. —
The next scheduled examinations (Part I), written,
for all candidates will be held in various cities of the
United States, Canada, and military centers outside
the Continental United States, on Friday, February 1,
1957, at 2:00 P.M.
Candidates must submit case reports to the office
of the Secretary within thirty days of being notified
of their eligibility to Part I. Cases must be prepared
in the manner described in the Bulletin of the Board
and submitted with a duplicate index list.
Requests for re-examination in Part II must be re-
ceived prior to February 1, 1957.
Current Bulletins outlining present requirements may
be obtained by writing to: Robert L. Faulkner, M.D.,
Secretary, 2105 Adelbert Road, Cleveland 6, Ohio.
* * *
The Bankers Life and Casualty Company, owners of
White Cross, have lost a suit of four years’ standing,
in which they attempted to enjoin certain groups from
selling White Cross policies in Florida and Georgia.
The judge claimed they had not shown a conspiracy.
Bankers Life was assessed all costs.
* * *
American Academy of General Practice. — It is
estimated that more than 5,000 members will attend
the next session of the American Academy of General
Practice in St. Louis, Missouri, March 25-28. 1957.
During the four-day scientific meeting, the doctors
will hear outstanding speakers discuss important sub-
jects including infertility, polio vaccination, and the
“neglected” pediatric areas, the eyes, ears, and feet.
They will visit sixty scientific and 260 technical exhibits.
The Academy’s policy-making Congress of Delegates
will convene at 2 p.m., Saturday, March 23. All
sessions of the Congress and many social functions will
be held in the Sheraton- Jefferson hotel.
Wednesday evening, March 27, following induction
ceremonies for Academy President-elect Malcolm E.
Phelps, El Reno, Oklahoma, more than 3,000 guests
will attend a President’s reception and dance honoring
J. S. DeTar, M.D., Milan, Michigan, president of the
Academy.
(Continued on Page 106)
104
Say you saw it in the Journal of the Michigan State Medical Society
TMSMS
mg./ml.
700
new
6oo sulfonamide formula
for urinary tract infections
500 —
400
300-
UNEXCELLED SOLUBILITY
optimal concentrations at site of
infection; avoids crystalluria
BROAD ANTIBACTERIAL RANGE
active against wide range of urinary
pathogens, including staphylococci,
gonococci, Escherichia coli
QUICK SYMPTOMATIC RELIEF
hyoscyamus component quickly
relieves pain and burning
FREEDOM FROM TOXIC EFFECTS
low degree of acetylation; no forcing
of fluids or alkalization needed
UronamicLe
TABLETS
SYRUP
|V\
Each tablet or 5-cc. tsp. provides
250 mg. sulfamethylthiadiazole,
250 mg. sulfacetamide, and equiv.
of 0.015 mg. alkaloids of
Hyoscyamus niger.
DOSAGE: Adults— 2 tablets or 2 tsp
q.i.d. first 2 days, thereafter.
1 tablet or 1 tsp. q.i.d.
Children — 1 cc. (16 drops) syrup
per 10 lb. body weight first 2 days,
thereafter, 0.5 cc. (8 drops) per
10 lb. SUPPLIED: Tablets,
bottles of 50 and 500. Syrup,
1-pt. and 1-gal. bottles.
T rademark
Decatur. Illi ,
h 25'
“Sulfamethyl-
thiadiazole . . .
effective chemo-
therapeutic
agent in
urinary infec-
tion... tolerated
quite well . . .
bacterial spec-
trum is com-
parable to that
of sulfadime-
tine and sulfi-
soxazole.”1
“[ Sulfaceta-
mide] . . . among
the least toxic
but one of the
most effective
of the sulfona-
mides against
urinary tract
pathogens.”2
1. Hughes, J.,
et al. : South, M. J.
4 7:1082, 1954.
2. Kerley, L., and
Headlee, C. P.:
J. Am. P.harm. A.
(Scient. Ed.)
4S:S2, 1956
Tanuary, 1957
Say you saw it in the Journal of the Michigan State Medical Society
105
NEWS MEDICAL
The Besi
"DOCTOR of DISTINCTION"
we know!
There’s little else that will perk up
your appearance as will a fine new
Fall and Winter outercoat from Kil-
gore and Hurd’s impressive collection.
— They’ll perk you up too. when you
discover their modest cost. We invite
your early inspection.
{sJlgorIwJJurd
92 Kercheval 1 W//A Washington Blvd.
Grosse Pointe Detroit
The Hidden Valley Shops
Gaylord, Mich, and Del-Ray Beach, Fla.
(Continued from Page 104)
Clifford W. Brainard, M.D., orthopedic surgeon of
Battle Creek, has been appointed Special Advisor to
the Crippled Children’s Commission. His duties will ex-
tend throughout the state.
* * *
Martha Elliott Retires. — Those members who remem-
ber the many years of medical domination, or attempts
at it, from Washington, will also remember Dr. Martha
Elliott and the Children’s Bureau which for years told
the doctors what they could and could not do. Dr.
Elliott, now of retiring age, will become Professor and
head of the Department of Maternal and Child Wel-
fare at Harvard University.
* * *
Congress on Medical Education. — The fifty-third
annual Congress on Medical Education and Licensure
will be held in Chicago’s Palmer House, February 10-
12, 1957. As in other years, the February program
will center around an important current problem: grad-
uate medical education for general practice.
Last year’s co-sponsored program with the Advisory
Board for Medical Specialties met with such success
that it was decided to conduct another such program
during the 1957 Congress.
Because of the general concern over preparation for
general practice, the AMA Council on Medical Educa-
tion and Hospitals decided to center a half-day co-
sponsored program on Sunday, February 10, around dis-
cussion of the subject, “Graduate Medical Education for
General Practice — 1957.” This program will be conducted
as a symposium, covering the concept of what can be ac-
complished during the undergraduate four years of
medical school. In addition, papers on the subject
will be read, followed by a series of short, clear-cut
statements by a group of representatives from the
various specialty areas as to “What Should Constitute
Graduate Medical Education for General Practice To-
day.” There will also be a question-and-answer dis-
cussion period.
Sunday afternoon will be devoted to business meet-
ings of the Advisory Board for Medical Specialties and
the open meeting of Federation of State Boards of the
United States.
The Monday afternoon session will be devoted to
problems of postgraduate medical education. This
will include keynote statements on the importance of
postgraduate medical education and the challenges it
presents, together with reasons for the council’s current
interest. This will be followed by a series of interest-
ing papers.
On Monday evening, the Federation of State Medi-
cal Boards will hold its annual banquet, and on Tuesday,
February 12, the conference program will be devoted
to the Federation of State Medical Boards of the
United States. Its program is centered on the theme:
“Re-evaluation of the Licensing Examination.” — AMA
Secretary’s Letter.
(Continued on Page 108)
106
Say you saw it in the Journal of the Michigan State Medical Society
JMSMS
Meat...
and the Need for Reasonable Amounts
of Fat to Maintain Good Health
Th e place of dietary fat in human nutrition is being widely dis-
cussed. Scientists who know tell us that some fat is desirable in
our everyday diet whether body weight has to be reduced or not.
Why are fats important to good health? Because they con-
tribute to the processes of growth and replacement of tissue.
Because they are an important source of calories. Because they
make foods more inviting and better tasting.
Despite great advances in nutritional knowledge the exact
role of fat in the diet is not yet fully defined. Yet it is known that
some fat is necessary in healthful day-to-day nutrition.
For good health, good nutrition, and tastier meals, be sure
there is some fat — in reasonable amounts— in your daily diet.
Meat — the most versatile of high protein and B vitamin foods—
because of its many varieties and cuts is an excellent vehicle to
provide this essential fat in any amount desired. Animal fat
products, such as lard, are not only economical, but add delight-
fully to the taste appeal of hundreds of recipes.
The nutritional statements made in this advertisement
have been reviewed by the Council on Foods and Nutri-
tion of the American Medical Association and found
consistent with current authoritative medical opinion,
American Meat Institute
Main Office, Chicago ... Members Throughout the United States
[anuary, 1957
Say you saw it in the Journal of the Michigan State Medical Society
107
NEWS MEDICAL
Dise
Monthly Clinical
Monographs on Current
Medical Problems
EXAMPLES OF FORTHCOMING
MONOGRAPHS: The Purpuras
(Harrington), Peripheral Arte-
rial Insufficiency (DeBakey),
Electrolyte Disturbances in Con-
gestive Heart Failure (Seldin),
Anxiety States (Shands), Head-
ache (Graham), etc., etc.
< EDITORIAL BOARD-- •
| Mark Aisner, M.D., Chairman
i Charles H. Burnett, M.D. i
J Maxwell Finland, M.D.
i Hugh H. Hussey, M.D. ;
[ Franz J. Ingelfinger, M.D. J
i Jack D. Meyers, M.D. i
; Myron Prinzmetal, M.D. ;
In but two years, DM has become one
of America’s most widely read medical
periodicals. Readers value its month-
after-month devotion to important
clinical problems of the day; appreciate
the top authority of editorial board and
contributors. They welcome the brevity
of style; the concentration on clinical
facts; the convenience of being able to
carry it in the pocket for comfortable
reading anywhere. Most subscribers
wish to keep DM permanently, there-
fore, sturdy and attractive binders for
filing are available.
Published Monthly. Only $9.00 a year,
postpaid. Binder $1.25, postpaid, addi-
tional.
THE YEAR BOOK PUBLISHERS, INC.
200 East Illinois Street, Chicago 11, Illinois
□ Enter my subscription to DM beginning January
1957, at annual fee of $9.00, postpaid.
□ Also send binder to hold 12 issues, $1.25, postpaid.
(Continued from Page 106)
Lloyd L. Kempe, M.D., associate professor of bac-
teriology, told a University of Michigan “Atom Day”
gathering November 16, 1956, that the use of radiation
does not involve uncertain steps into an “eerie, intang-
ible, mysterious unknown world” as many people be-
lieve. Most of the ideas being worked on now in
research are extensions of original ideas and theories
published twenty to thirty years ago.
Dr. Kempe cited as an example of much practical
experience in the use of radiation, and the exposure
of individuals to it, the use and development of the
x-ray. “X-radiation is very similar to gamma radiation
which we are getting out of fission. This type of radia-
tion has been dealt with for many years. It is nothing
new,” said Dr. Kempe.
He stated also that although much progress has been
made in developing irradiation of foods and other sub-
stances for preservation, researchers are being painstak-
ingly cautious to answer every possible question and
overcome every potential danger before letting such
processes get to the public. Food processed by radiation
should not be offered to the public yet.
There is a basic difference between heat sterilization
and sterilization by irradiation. The first method re-
quires high temperatures to kill the putrefactive organ-
isms, while other toxin-producing organisms are killed
immediately at moderately hot temperatures.
* * *
Malaria Eradication Program in Mexico. — Approxi-
mately 3,000,000 houses in the malarious areas of
Mexico will be sprayed starting January 1, 1957, in
the largest undertaking of its kind ever attempted in
this hemisphere. This enormous enterprise is aimed
at wiping out the mosquitoes which transmit malaria,
thus effecting the eradication of this disease in Mexico.
* * *
A sharp increase in the number of
cattle infected with tuberculosis in re-
cent years is attributed mainly to com-
placency according to the Department
of Agriculture. The infection rate is
currently about 0.8 per cent. Three
years ago it was almost 0.4 per cent
and for many years the rate was as
low as 0.2 per cent. The same could
happen with human TB if case finding
is relaxed. Dr. Herbert R. Edwards,
professor of public health and medicine at Yale Uni-
versity, in the 1956 Baker Lecture at the University of
Michigan said, “It is not only complacency in the
general public we must be concerned with, but the
fact that a large number of professional workers, in-
cluding some in the field of public health, are appar-
ently not fully awake to the continued seriousness of
the disease (tuberculosis).”
Michigan Tuberculosis Association
* * *
Name
Street
City Zone State
4-1-7
Mortality is not the real yardstick to measure the
importance or judge the control of a disease. Even
if there were drugs capable of preventing the sudden
(Continued on Page 110)
108
Say you saw it in the Journal of the Michigan State Medical Society
JMSMS
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[anuary, 1957
Say you saw it in the Journal of the Michigan State Medical Society
109
NEWS MEDICAL
(Continued from Page 108)
deaths resulting from hypertension and arteriosclerosis,
these conditions would remain a tremendous medical
and social problem. Similarly, adults do not commonly
die of mental disorders, arthritis, or peptic ulcers. Yet,
no one would claim that these afflictions have been con-
quered. Neither has tuberculosis been conquered. In-
stead, the forces which have been at work during the
past century have slowly converted it from a killing to
a chronic disease. — Rene J. Dubos, Ph.D., National
Tuberculosis Association Transactions, May, 1954.
* * *
J. Earl McIntyre, M.D., of Lansing, was elected
President of the Association of Surgeons of the Chesa-
peake and Ohio Railway System at the November an-
nual meeting held at White Sulphur Springs, W. Va.
* * *
Paul H. Engle, M.D., of Olivet, has departed for
Pakistan, India, under State Department appointment
for two years at the American Embassy to serve the
nationals of the area.
* * *
Courses in “Surgery in Acute Trauma” are being
conducted by the American Army Medical Services
at Army Hospitals in Washington, D. C., Denver, Col-
orado, San Francisco, California, Phoenixville, Penn-
sylvania, Fort Bliss, Texas, and Tacoma, Washington,
April 1-3, 1957 and at Fort Sam Houston, Texas, May
6-8, 1957. For program and full information, write
E. Roy Wells, Director of Technical Advisory Office,
Federal Civil Defense Administration, Region 4, Battle
Creek, Michigan.
* * *
The ACS Chicago Regional Committee on Trauma is
sponsoring an intensive course on fractures and other
trauma at the John B. Murphy Auditorium, 50 E. Erie
Street, Chicago, April 10-13, 1957. For information
and program, write John J. Fahey, M.D., 1791 W.
Howard Street, Chicago, Illinois.
* * *
O. T. Mallery, Jr., M.D., has been appointed to
the newly created position of Medical Director for
Employers Mutuals of Wausau, Wisconsin. Dr. Mallery
was a member of the University of Michigan faculty
for ten years.
* * *
The Seventh International Cancer Congress will be
held in London, July 6-12, 1958. Further information
and travel details may be procured from the Secretary
General, 45 Lincoln’s Inn Fields, London, W.C. 2,
England.
* * *
Cancer News is available to all doctors of medicine
who are members of the Michigan State Medical So-
ciety, through the courtesy and generosity of the two
Divisions in Michigan of the American Cancer Society
(the Southeastern Michigan Division covering the
(Continued on Page 112)
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Ianuary, 1957
Say you saw it in the journal of the Michigan State Medical Society
111
NEWS MEDICAL
(Continued from Page 110)
counties of Wayne, Oakland and Macomb, and the
Michigan Division covering the balance of the state).
It is suggested this publication be placed in the
waiting rooms of every doctor of medicine, as it con-
tains excellent information for patients and others.
If you wish to be placed on the mailing list of either
one of the ACS Divisions to receive Cancer News month-
ly, write to either one of the Divisions, in which area
you are located — Michigan Division, Helmer Building,
Grand Rapids, and Southeastern Michigan Division,
4811 John R. Street, Detroit, Michigan.
* * *
E. M. Vardon, M.D.. Detroit, recently contributed
a valuable Verifax (photographic copying) machine
to the Michigan State Medical Society, for use in its
Executive Offices at 606 Townsend, Lansing.
The Council expressed gratitude to Dr. Vardon by
placing a vote of thanks to him on its minutes at the
meeting of November 14.
* * *
Supplying necessary rehabilitative services emphasizes
more than any other instance the combined role of the
physician, hospital, and health department in meeting
community needs. — L. E. Burney, M.D.. California
Medicine, January, 1956.
John P. Caffey, M.D., Professor of Radiology at
Columbia University Medical School, New York, will
deliver the annual Hickey Memorial Lecture at Wayne
University College of Medicine Auditorium, 645 Mullett
St., Detroit, on Thursday, March 14, 1957, at 8:30 p.m.
The Hickey Lecture is given under the auspices of the
Detroit Roentgen Ray and Radium Society, the Wayne
County Medical Society, and Wayne University College
of Medicine.
Dr. Caffey’s subject will be “The Skeleton in Cooley’s
Anemia.”
This interesting lecture will be held coincident with
the Michigan Clinical Institute at an hour when no
MCI lectures or program are scheduled. All MSMS
members are cordially invited to attend.
* * *
Next to knowing when to seize an opportunity, the most
important thing in life is to know when to forego an
advantage.
* * *
M.D. LOCATIONS — (Through December 1, 1956)
Placed by Michigan Health Council
Name Opened Practice in
Gerald S. Buchanan, M.D. Ithaca
Paul A. Dosch, M.D. Grayling
Assisted by Michigan Health Council
John L. Barrett, M.D. Royal Oak
MEDICAL TELEVISION SHOWS
Produced by Michigan Health Council
Date
Station
Subject
Guests
Nov.
4
WJBK-TV
Detroit
The Story Behind Your Doctor’s
Prescription Food and Soil
Film
Film
Nov.
8
WKAR-TV
East Lansing
Orthodontics
Edward A. Cheney, D.D.S., Lansing
Harlow Shehan, D.D.S., Jackson
Christine Lancaster, St. Johns
Christie Wiard, Lansing
Nov.
11
WJBK-TV
Detroit
M.D. Placement
(A Citizen Participates)
Film
Nov.
18
WJBK-TV
Detroit
Multiple Sclerosis
Gabriel Steiner, M.D., Detroit
A. H. Lindley, Detroit
Abraham Brickner, Detroit
Nov.
25
WJBK-TV
Detroit
A Life to Save
Film
The HAVEN SANITARIUM, Inc.
Rochester, Michigan
In operation since 1932
M. O. WOLFE, M.D.
Director of Psychotherapy
RALPH S. GREEN, M.D.
Clinical Director
GRAHAM SHINNICK
Manager
Telephone: OLive 1-9441
A hospital for the treatment of mental
and emotional illness.
Member of American Hospital Associa-
tion and Michigan Hospital Association.
112
tC)»ioos ivoipgfy 3}V)S uvStyotpy ai/j fo \vumo[ ai/? ui }i mvs noil iivg
TMSMS
how bioflavonoids
with ascorbic acid
help in threatened
and habitual abortion...
Frequent nosebleeds, gum bleeding and easy bruising were observed in
a high percentage of women who had repeated abortions,
according to one study. l
Another investigator reported abnormal capillary fragility
in 80% of habitual aborters.
Bioflavonoids with ascorbic acid help to diminish abnormal capillary
permeability and fragility by acting to maintain the integrity of the
“cement” substance of capillary walls. Thus, C.V. P. may be a helpful
adjunct in the management of threatened and habitual abortion.
C.V.P. provides the capillary-protectant factors of whole citrus
bioflavonoid compound (sometimes referred to as “vitamin P complex”)
combined with ascorbic acid. C.V. P. is water-soluble and believed to
be more readily absorbed than relatively insoluble rutin.
Each C.V. P. capsule or each teaspoonful (5 cc.)
of syrup provides:
Citrus Flavonoid Compound . . . 100 mg.
Ascorbic Acid (Vitamin C) . . . . 100 mg.
Bottles of 50, 100, 500 and 1000 capsules; 4 oz., 16 oz. and gallon syrup.
1. Science News Letter, March 1954
2. Greenblatt, R. B.: Obstet. & Gyn. 2:530, 1953
samples and literature from U. S. Vitamill COrpOratiOH
(Arlington-Funk Laboratories, division)
250 East 43rd Street, New York 17, N.Y.
January, 1957
Say you saw it in the journal of the Michigan State Medical Society
113
1956-57 RADIO SERIES
Date
No.
Subject
Speaker
October
10- 5-56
1
The Childless Couple
Samuel J. Behrman, M.D.
10-12-56
2
The Importance of Prenatal Care
Tommy N. Evans, M.D.
10-19-56
3
Preparing the Family for the New Baby
Ernest H. Watson, M.D.
10-26-56
4
What is the Meaning of Vomiting in the Baby?
Robert Heavenrich, M.D.
November
11- 2-56
5
What is the Meaning of Diarrhea in the Baby?
William Stewart, Jr., M.D.
11- 9-56
6
Why does Your Baby Need “Shots”?
George Lowrey, M.D.
11-16-56
7
Muscular Dystrophy
Russell Dejong, M.D.
11-23-56
8
The Menopause
F. W. Tamblyn, M.D.
1 1-30-56
9
Health Investments for Advancing Years
Seward E. Miller, M.D.
December
12- 7-56
10
Why You Need an Annual Health Examination
John R. Rodger, M.D.
12-14-56
11
Rheumatism
William Mikkelsen, M.D.
12-21-56
12
Advances in the Treatment of Arthritis
William Caster, M.D.
12-28-56
13
Backache
Charles H. Frantz, M.D.
January
1- 4-57
14
Research and the March of Dimes
James L. Wilson, M.D.
1-11-57
15
What is being done for the Polio Patient Today?
David G. Dickinson, M.D.
1-18-57
16
Body Functions and the Endocrine Glands
Jerome W. Conn, M.D.
1-25-57
17
The Thyroid Gland
William Bierwaltes, M.D.
February
2- 1-57
18
Trends in the Treatment of Diabetes
Steven Fajans, M.D.
2- 8-57
19
Coronary Heart Disease
Park Willis, M.D.
2-15-57
20
Rheumatic Heart Disease
Aaron Stem, M.D.
2-22-57
21
How to Live with Your Heart Disease
Franklin Johnston, M.D.
March
3- 1-57
22
High Blood Pressure
Sibley W. Hoobler, M.D.
3- 8-57
23
What can You do for the Victim of an Automobile Accident?
C. Thomas Flotte, M.D.
3-15-57
24
What can You do for the Burned Victim?
Robert E. L. Berry, M.D.
3-22-57
25
What can You do for the Person Who Swallows Poison?
Craig Booher, M.D.
3-29-57
26
What can You do to Prevent Accidents in the Home?
Robert H. Trimby, M.D.
April
4- 5-57
27
Early Warning Signs of Cancer of the Female Generative Organs
Tommy N. Evans, M.D.
4-12-57
28
Breast Cancer
Burgess Vial, M.D.
4-19-57
29
Cancer of the Blood
Frank Bethell, M.D.
4-26-57
30
Cancer Research
Howard Latourette, M.D.
May
5- 3-57
31
What is Cerebral Palsy?
Martha Westerberg, M.D.
5-10-57
32
What is Being Done for the Cerebral Palsied?
Richard Allen, M.D.
5-17-57
33
The Problem of Sex Education
Stuart Finch, M.D.
5-24-57
34
The Emotional Aspects of Epilepsy
H. Waldo Bird, M.D.
5-31-57
35
What can be Done for the Hard of Hearing?
James H. Maxwell, M.D.
June
6- 7-57
36
Recent Advances in the Treatment of Tuberculosis
W. N. Davey, M.D.
6-14-57
37
The Medical Aspects of Cough
Nancy Furstenberg, M.D.
Marion DeWeese, M.D.
6-21-57
38
Appendicitis
6-28-57
39
Hay Fever
Robert Lovell, M.D.
July
7- 5-57
40
Summer Itch
Richard Harrell, M.D.
PlatHitell
Sanitarium
PL AIN WELL, MICHIGAN
Member American Hospital Association
EDWIN M. WILLIAMSON, M.D.
Psychiatrist-in-Chief
Professional care for the nervous
and mentally ill.
Telephone MUrray 5-8441
Restful Six-acre Estate Overlooking the Kalamazoo River
.TMSMS
114
Say you saw it in the Journal of the Michigan State Medical Society
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Remember how much you enjoyed it?
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Instant Sanka booth.
And how right you are, Doctor. Instant Sanka
is not a coffee substitute. It’s 100% pure coffee
— rich and full-bodied. Only the caffein has been
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you to enjoy.
Why not introduce your patients to satisfying
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January, 1957
Say you saw it in the Journal of the Michigan State Medical Society
117
Legal Opinions
Mr. William J. Burns
Executive Director
Michigan State Medical Society
Dear Mr. Burns:
In answer to inquiry as to the legality of consult-
ing surgeons from out state who have no Michigan li-
cense but who are qualified men in their specialties:
I believe the answer is to be found in the statutes
relating to the practice of medicine and surgery in
Michigan. Section 7 of the Act (14.537 M.S.A.) makes
it unlawful for any person to practice medicine or sur-
gery in this state who is not the lawful possessor of a
certificate of registration or license issued under and
pursuant to the Michigan Registration Act. However,
Section 8 of the Act (14.538 M.S.A.) provides in part
as follows: “This Act shall not apply to the commis-
sioned surgeons of the United States Army, Navy or
Marine hospital service, in actual performance of their
official duties, nor to regularly licensed physicians and
surgeons from out of this state, in actual consultation
with physicians and surgeons of this state.”
It is my opinion that the foregoing exception covers
the situation outlined in the inquiry and that a regularly
licensed physician and surgeon from out of the state
and who is qualified may properly consult with physi-
cians and surgeons in this state.
Very truly yours,
Lester P. Dodd, Legal Counsel
Dear Mr. Burns:
You recently referred to me for opinion an inquiry
with respect to so-called “privileged communications.”
Specifically, the doctor inquires as to the propriety
(1) of giving information with respect to injuries sus-
tained by a patient to a newspaper for publication
therein, and,
(2) of giving information pertaining to the diagnosis
and prognosis to a Red Cross Worker for the pur-
pose of informing or obtaining leave for a Service-
man relative.
These inquiries present interrelated questions of law
and ethics. The Michigan Statutes deal with the gen-
eral subject of privileged or confidential communica-
tions in two ways. Section 27.911 M.S.A. provides in
part as follows:
“No person duly authorized to practice medicine or
surgery shall be allowed to disclose any information
which he may have acquired in attending any patient
in his professional character, and which information
was necessary to enable him to prescribe for such
patient as a physician, or to do any act for him as
a surgeon.”
This Section is a part of the Judicature Act and per-
tains primarily to court procedures. It is essentially
a rule of evidence and is involked only in relation to
determining what a physician or surgeon may or may
not be permitted to testify to on the witness stand.
The privilege is that of the patient and not of the
doctor and may be waived either expressly or impliedly
by the patient. Moreover, the privilege applies only
to such matters as are given to the physician in con-
fidence and does not apply to many items of informa-
tion gained by the physician from observation. This
statute is not a penal one and, as observed above, is
intended primarily to apply to a physician’s disclosures
while a witness in court.
(Continued on Page 120)
Annual Clinical Conference
CHICAGO MEDICAL SOCIETY
March 5, 6, 7 and 8, 1957
Palmer House • Chicago
Daily Half-Hour Lectures by Outstanding Teachers and Speakers
on subjects of interest to both general practitioner and specialist
Panels on Timely Topics Daily Teaching Demonstrations
Medical Color Telecasts
Scientific Exhibits worthy of real study and helpful and time-saving
Technical Exhibits
The Chicago Medical Society Annual Clinical Conference should
be a MUST on the calendar of every physician. Plan now to at-
tend and make your reservation at the Palmer House.
118
TMSMS
for “This Wormy World
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brand
PIPERAZINE
SYRUP - TABLETS • WAFERS
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ROUNDWORMS IN ONE OR TWO DAYS
PALATABLE • DEPENDABLE • ECONOMICAL
‘ANTEPAR’ SYRUP - Piperazine Citrate, 100 mg. per cc.
‘ANTEPAR’ TABLETS -Piperazine Citrate, ,250 or 500 mg., scored
‘ANTEPAR’ WAFERS - Piperazine Phosphate, 500 mg.
Literature available on request
BURROUGHS WELLCOME & CO. (U.S.A.) INC., Tuckahoe, N, Y.
January, 1957
Say you saw it in the Journal of the Michigan State Medical Society
119
LEGAL OPINIONS
(Continued from Page 118)
Another section of the Michigan Statutes (14.533
M.S.A.) makes it a ground for refusal of registration,
revocation or suspension of registration, or conviction
of a misdemeanor for a physician to “willfully betray
a professional secret.”
The Statute does not define what constitutes the will-
ful betrayal of a professional secret and has never been
before our courts for construction so that its interpre-
tation is a matter of first impression. In my opinion,
however, it relates solely to the keeping in confidence
of such matters as are disclosed to the physician by the
patient while in professional attendance upon the pa-
tient and which are given in confidence and with the
intention that they be kept secret.
From a strict legal point of view, it is my opinion
that neither of the questions posed would involve vio-
lation of the so-called “privileged communication” stat-
ute above quoted since court action is not involved.
As to whether giving out information under either
set of circumstances outlined by the doctor would in-
volve betrayal of a professional secret would depend
wholly upon the specific information disclosed. If it did
not include or depend upon information conveyed by
the patient in confidence and with the intention that
it be kept secret, it would not, in my opinion, be a
violation.
I feel, however, that the questions here raised in-
volve such inter-related questions of law and profes-
sional ethics as to warrant some discussion of the
latter aspect of the matter. Assuming that in most
cases it would not be unlawful to disclose information
under either set of circumstances outlined by the doc-
tor, the propriety of so doing, particularly the giving
of information to newspapers, may be open to question.
Section 5 of Chapter I of the Principles of Medical
Ethics of the American Medical Association, having
to do with the physician’s relationship to the media of
public information, states that “an ethical physician
* * * may reveal information regarding a patient’s
physical condition if the patient gives his permission.”
While not stated in the converse, this language rather
strongly implies that it would not be regarded as ethical
to disclose such information without the patient’s per-
mission. I am quite willing to assume that there may
be circumstances where such permission may be implied
but in the absence of either express or implied permis-
sion, I am of the opinion that a physician may not,
with propriety, give information about his patient’s in-
juries to a newspaper for publication.
With respect to the propriety of giving information
to a Red Gross Worker under the circumstances out-
lined by the doctor, I reach a somewhat different con-
clusion. Here the physician cannot be charged with
advertising or self-aggrandizement as he might in the
case of giving information to a newspaper. Section 3
of Chapter II of the Principles of Medical Ethics of
the American Medical Association provides: “the physi-
cian should neither exaggerate nor minimize the gravity
of a patient’s condition. He should assure himself that
the patient, his relatives or his responsible friends
have such knowledge of the patient’s condition as will
serve the best interests of the patient and the family.”
I am of the opinion, therefore, that subject always
to the necessity of making sure that he does not dis-
close information given to him by his patient in con-
fidence, the physician may, in the exercise of his judg-
ment of what is in the best interest of his patient, law-
fully and with propriety, give information to a Red
Cross Worker under the circumstances outlined in the
doctor’s second question.
Very truly yours,
Lester P. Dodd, Legal Counsel
120
Say you saw it in the Journal of the Michigan State Medical Society
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NUARY, 1957
Say you saw it in the Journal of the Michigan State Medical Society
121
CORRESPONDENCE
Correspondence
It has been brought to my attention that some of the
persons with whom we have negotiated contracts under
the Dependents’ Medical Care Act are of the opinion
that the Program is not one of full service coverage. This
concept may have arisen because the Act itself is not
specific regarding this matter. It may also have arisen
either because certain fees are stipulated to be paid by
the patient or because the contract allows for unusual or
difficult case an additional fee payable by the Govern-
ment to the physician if he makes proper request under
a special report.
Upon inquiry, I have been assured that members of
negotiating teams have not indicated the contract is oth-
er than for full coverage. Further, no instance has been
found where any member of the negotiating teams has.
in any way, intimated that the Dependents’ Medical
Care Program is not one of full coverage.
In order to clarify this matter and to avoid any im-
proper interpretation of the Dependents' Medical Care
Act with regard to payments to physicians under a
Schedule of Allowances as provided in our contracts,
the position of the Department of Defense as is being
carried out by my office is submitted for your guidance:
(a) It is intended that civilian medical care author-
ized under Public Law 569. 84th Congress, will be on a
basis comparable to that provided in uniformed services
medical facilities. Except for specified amounts to be
paid by the patient, the services which are provided
under the law will be furnished by physicians partici-
pating in the program who will receive payment in full
from the Government in accordance with the published
Schedule of Allowances or under a special report as the
case may be. In most instances, this means that the
physician participating in the program will receive pay-
ment for his usual charge or the amount established in
the local schedule of allowances, whichever is less.
(b) Section 5, paragraph 507b, of the Joint Directive
promulgated by the Secretary of Defense and the Secre-
tary of Health, Education, and Welfare provides as fol-
lows: “The Executive Agent (Secretary of the Army)
shall be responsible within the continental United States,
Alaska, Hawaii, and Puerto Rico for the following:
( 1 ) Preparation of the terms and placement of the
contract or contracts to be established to include
but not limited to:
(a) Local schedules of allowances to be used in
full payment of bills presented by physicians
and surgeons.” (Underscoring added.)
A copy of this Joint Directive is an integral part of
every contract and there is no question that the contract
provides for full service coverage.
(c) There may be unusual instances in which the
physician will believe that an allowance greater than
that prescribed in the local schedule of allowances is
justified. In such cases, the physician should look to the
Government for additional payment, and not to the
patient. Provision is made for the physician to submit
a special report to his state medical society and in turn
to the Government as a request for additional payment.
Such additional payment will be made upon approval by
the medical society’s review board and by the Gov-
ernment’s contracting officer.
Your assistance in providing physicians in your state
with this information will be helpful to all concerned.
We believe that a clear understanding of this matter
before the Dependent's Medical Care Program goes into
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Say you saw it in the Journal of the Michigan State Medical Society
CORRESPONDENCE
Tect is essential and will help to prevent problems or
iticisms which otherwise might result from a lack of
nderstanding on the part of physicians participating in
le program.
Your co-operation and assistance in implementing the
ependents’ Medical Care Program is most gratifying
id with your continued help I believe the program
ill be most successful.
Sincerely,
Paul I. Robinson
Major General , M.C.
Executive Director
Office for De pendents’ Medical Care
epartment of the Army
ffice of the Surgeon General
'ashington, D. C.
1 November 1956
LOOD TRANSFUSIONS
nimals Used 300 Years Ago
Blood transfusion as a means of preserving life reached
> indispensable place in today’s medicine only after
nturies of trial and error.
The first authentic record of a blood transfusion
lows that 300 years ago an Italian physician, Fran-
■sco Folli experimented with animal transfusions, al-
lough during the fifteenth century unsuccessful trans-
isions were performed through a hollow quill.
England was the scene of several experiments in 1666,
me of which were witnessed by Pepys and recorded in
s Diary. But, during this period the operation created
ifavorable public reaction since blood used in trans-
ision to humans was usually that from a lamb or a
ilf.
No further attempts were recorded until the 1800’s,
hen it was discovered that removal of the fibrin from
e blood eliminated coagulation during transfusion.
Again, however, the record shows little advance until
1907 when Dr. George W. Crile, Cleveland surgeon,
;rformed a successful direct transfusion, suturing the
ood donor’s artery to the patient’s vein in the wrist,
t this time the brother of the patient was used, since
was felt his blood would be most suitable.
* * *
Money is such an elusive thing — not only to get and
■ep, but even to keep track of. New reports say that
mericans owe more than ever before, some 700 billion
>llars in public and private debt — up a whopping 294
llion since World War II ended. But along with this,
e reports say also that Americans are richer than
er before — they own, in public and private wealth,
me \x/i trillion dollars’ worth of property, and this
ar their income will be 340 billion dollars. But still
lother report says that all this doesn’t mean what it
ems to mean; that rising taxes and inflation since
>39 have made $6,122 now equal actually to only
1,000 then. However you slice it, money, it seems, is
11 purely relative. — B. C. Enquirer , Oct. 24, 1956.
* * *
Postgraduate course in Diabetes and Basic Metabolic
oblems will be held January 30, 31 and February 1,
'57, at Columbus, Ohio, University Health Center.
>r further information and registration forms, write:
nerican Diabetes Association, 1 East 45th Street, New
>rk 17.
* * *
The Frank E. Bunts Educational Institute of the
eveland Clinic Foundation will present a course on
leneral Practice” February 6-7, 1957, “Otolaryngology”
February 27-28, 1957, and “Medical Progress and its
dationship to Deintistry” on March 13-14, 1957. For
ditional information and registration forms write:
■gistrar, 2020 East 93rd Street, Cleveland 6, Ohio.
nuary, 1957
EVERY WOMAN
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5645
Say you saw it in the Journal of the Michigan State Medical Society
123
THE DOCTOR’S LIBRARY
THE DOCTOR’S LIBRARY
Acknowledgment of all books received will be made in this column,
and this will be deemed by us as full compensation to those
sending them. A selection will be made for review, as expedient.
BOOKS RECEIVED
AIRCRAFT IN DISTRESS. A Study of the broad
field of aircraft assistant and distress operations, fly-
ing safety, aircraft emergencies and evacuation, rescue
aircraft interception procedures, aircraft emergency
landing and ditching procedures, and first-aid and
survival. Harry D. Kysor, Captain, Eastern Air Lines,
Inc. New York; Aviation Consultant to the Aviation
Bureau, Loss Prevention Department, Liberty Mutual
Insurance Company, Boston, Massachusetts. Phila-
delphia: Chilton Company, Inc., 1956.
MYSTERIOUS WATERS TO GUARD. (Essays and
Addresses on Anesthesia). By Wesley Bourne. Spring-
field, Illinois: Charles C Thomas, 1955. Price $8.50.
DISEASES OF THE LIVER. Edited by Leon Schiff,
M.D., Ph.D., Professor of Clinical Medicine, Univer-
sity of Cincinnati, College of Medicine; Director,
Gastric Laboratory, Cincinnati General Hospital. With
A Foreward by Cecil J. Watson, M.D., Ph.D., Phila-
delphia and Montreal: J. B. Lippincott Company,
1956. Price $16.00.
BELLEVUE IS MY HOME. By Salvatore R. Cutolo,
M.D., with Arthur and Barbara Gelb. Garden City,
New York: Doubleday & Company, Inc., 1956. Price
$4.00.
CLINICAL ELECTROCARDIOGRAPHY. Fart I. The
Arrhythmias With An Atlas Of Electrocardiograms
By Louis N. Katz, A.B., M.A., M.D., F.A.C.P. Direc-
tor, Cardiovascular Department, Michael Reese Hos-
pital, Chicago, Illinois; Professional Lecturer in
Physiology, University of Chicago, Chicago, Illinois.
And Alfred Pick, M.D., Physician-In-Charge of Heart
Station and Research Associate, Cardiovascular De-
partment, Michael Reese Hospital, Chicago, Illinois.
Illustrated With 415 Engravings. Philadelphia: Lea
& Febiger, 1956. Price $17.50.
THE OFFICE ASSISTANT in Medical or Dental Prac-
tice. By Portia M. Frederick, Instructor, Medical
Office Assisting, Long Beach City College, and Carol
Towner, Executive Assistant, Department of Public
Relations, American Medical Association. Philadelphia
and London: W. B. Saunders Company, 1956.
DISTURBANCES OF BODY FLUIDS. Clinical Recog-
nition and Management. By John H. Bland, M.D.,
Associate Professor of Medicine, University of Ver-
mont College of Medicine. Second edition. Phila-
delphia and London: W. B. Saunders Company, 1956.
TEXTBOOK OF MEDICAL PHYSIOLOGY. By Ar-
thur C. Guyton, M.D. Professor and Chairman of
the Department of Physiology and Biophysics, Uni-
versity of Mississippi School of Medicine. Illustrated.
Philadelphia and London: W. B. Saunders, 1956.
IN THE DOCTOR’S OFFICE. The Art of the Medi-
cal Assistant. By Esther Jane Parsons, formerly Re-
search Technician, Department of Biochemistry, Col-
lege of Physicians and Surgeons, Columbia University;
formerly Instructor in Medical Office Procedures,
(Continued on Page 126)
124
Say you saw it in the Journal of the Michigan State Medical Society
JMSMS
Outguessing your "Second Ouessers"
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ST. JOSEPH’S RETREAT
Member: American Hospital Association
Catholic Hospital Association
National Association of Private
Mental Hospitals
The Central Neuro-Psychiatric
Hospital Association
Under the direction of the
Daughters of Charity of St. Vincent de Paul
Serving Metropolitan Detroit
and Michigan almost a century
Martin H. Hoffmann, M.D.
Medical Director
23200 West Michigan Avenue
Dearborn
Logan 1-1400
January. 1957
Say you saw it in the Journal of the Michigan State Medical Society
125
THE DOCTOR’S LIBRARY
(Continued from Page 124)
Paine Hall School for Medical Assistants, New York
City. Illustrations by Jean McConnell. Second edition.
Philadelphia and Montreal: J. B. Lippincott Com-
pany, 1956. Price $3.95.
THE NEUROSES IN CLINICAL PRACTICE. By
Henry P. Laughlin, M.D., Assistant Clinical Profes-
sor of Psychiatry, George Washington University
School of Medicine; Head, Psychiatry and Neurology
Division, Suburban Hospital, Bethesda, Maryland;
Consultant in Psychiatry, Walter Reed Army Medical
Center. Philadelphia, London: W. B. Saunders Com-
pany, 1956. Price $12.50.
YOUR BLOOD PRESSURE and How to Live With It.
By William A. Brams, M.D. Illustrations by Hertha
Furth. Philadelphia and New York: J. B. Lippincott
Company, 1956. Price $2.95.
DICTIONARY OF POISONS. By Ibert Mellan and
Eleanor Mellan. New York: Philosophical Library.
Price $4.75.
This book is printed in large type and easily read.
Each poison is listed in alphabetical order and there
is a full history or description of the poison, its uses
and forms, the scientific and common names and the
antidote to be given. Usually there is a list of three
things to do, and on many in capital letters there
is a warning CALL A PHYSICIAN. Sometimes the
word IMMEDIATELY is added! We notice one item
that is repeated many times, “give a universal anti-
dote,” but we are unable to find such a formula in
the book. There is a recognized universal antidote
consisting of charcoal, or burnt toast, strong tea or tanic
acid, with magnesium sulfate in a mixture.
SLEEP. By Marie Carmichael Stopes, D.Sc., London;
Ph.D., Munich; Fellow of the Royal Society of Lit-
erature. New York: Philosophical Library. Price
$3.00.
Sleep is the primitive and profound pleasure of all
mankind. It is enjoyed when past. Many people sleep
badly and to some inducing sleep is an effort. The
amount of sleep needed varies from one person to an-
other but fairly constant for individuals. Short periods
of daytime sleep often give proportionately more refresh-
ment than the long sleep at night. “It is a crime of
the first magnitude to wake anyone, save in an emer-
gency.”
Chapters are devoted to Beds and Bed Clothes, What
Is Sleep, Sleep in Animals, Insomnia, Do’s and Don’ts
and Feeling versus Thought. It is readable.
TREATMENT OF HEART DISEASE. A Clinical
Physiologic Approach. By Harry Gross, M.D., F.A.
C.P., Attending Physician, the Montefiore Hospital;
Assistant Clinical Professor of Medicine, Columbia
University College of Physicians and Surgeons, and
Abraham Jezer, M.D., Attending Physician, The
Montefiore Hospital ; Assistant Clinical Professor of
Medicine, Columbia University College of Phyiscians
and Surgeons. Philadelphia and London: W. B.
Saunders Company, 1956.
In no other text on heart disease has the reviewer
noted a more concise yet complete interpretation of
clinical cardiology and therapeutics based upon the
(Continued on Page 128)
126 TMSMS
Say you saw it in the Journal of the Michigan State Medical Society
SAMMOND PLEASANT LODGE
Oilers to the elderly and chronically ill
Peace and quiet. Freedom oi a large and richly
furnished home and acres of lawns and wooded
rolling grounds, scientifically prepared tasty
meals, congenial companionship. A real
"Home away from Home"
Approved by the American Medical Association
and Michigan State Department of Social Wel-
fare— Highly recommended by members of the
Medical Profession who have had patients at
the Lodge.
For further information write to:
SAMMOND PLEASANT LODGE
124 West Gates Street
Romeo. Michigan
"The Doctor and the Law"
prepared by our Law Department
keeps policyholders informed
on reducing malpractice expense.
SfreccaCcfed Service
aun, cCoct&i
THEJ
Medic ae ,BRQTEjGrTi>yEf GjpMPAwyc
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Professional Protection Exclusively
since 1899
DETROIT Office
George A. Triplett and Richard K. Wind
Representatives
2405 West McNichols Road
Telephone University 2-8064
mm i garni
IF YOUR PATIENT WANTS TO DRINK
THAT’S HIS BUSINESS
IF HE WANTS TO QUIT that’s our BUSINESS
BRIGHTON HOSPITAL, now in opera-
tion for more than three years, wishes to
thank the physicians of Michigan and On-
tario for the good reception and the confi-
dence given to us.
We know that today’s physician recognizes
the many-sided nature of the disease — Al-
coholism. Beyond the physical, which re-
quires expert treatment in itself, the alco-
holic’s physician is plagued, we know, with
the equally vital aspects, which make de-
mands on his time and attention, of the
emotional, spiritual and mental sickness he
notes in his patient.
We believe that Brighton Hospital offers the
answer. Physicians can now send their alco-
holic patients to Brighton with the certain
assurance that they will find expert medical
and nursing attention AND that, if they so
desire, patients will be thoroughly indoctrin-
ated with the program of Alcoholics Anony-
mous.
BRIGHTON HOSPITAL is NOT interest-
ed in the patient who merely wishes to be
dried out in order to resume drinking. We
ARE interested in those patients who really,
fervently, seek complete rehabilitation and a
way of life FREED from alcohol.
BRIGHTON HOSPITAL is owned and
operated by MICHIGAN ALCOHOLIC
REHABILITATION FOUNDATION, a
non-profit organization devoted to the best
possible hospitalization of the alcoholic who
seeks to stop drinking.
DOCTORS, we are here to serve you. We
are here to serve your patients.
BRIGHTON HOSPITAL
12851 East Grand River Avenue Brighton, Michigan Phone: Brighton Academy 7-1211
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The Sandura Case is molded in reinforced
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tire case can be washed or sterilized with
alcohol.
THE MEDICAL SUPPLY CORPORATION
3502 Woodward Avenue
OF DETROIT
TEmple 1-4588
Detroit 1, Michigan
.NUARY, 1957
Say you saw it in the Journal of the Michigan State Medical Society
127
THE DOCTOR S LIBRARY
PATENTED ARCH SUPPORT CONSTRUC-
TION — WIDE STEEL SHANK IMBEDDED
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• Insole extension and wedge at inner corner ©f
heel where support is most needed.
• The patented arch support construction is guaran-
teed not to break down.
• Innersoles guaranteed not to crack or collapse.
• Foot-so-Port lasts designed and the shoe construc-
tion engineered with orthopedic advice.
• Conductive Shoes for surgical and operating room
personnel. N.B.F.U. specifications.
• We are also the manufacturer of the Gear-Action
Shoe designed by noted orthopedic surgeon.
• We make more shoes for polio, club feet and dis-
abled feet than any other shoe manufacturer.
Send for free booklet, “The Preservation of the Function of the
Foot Balancing and Synchronizing the Shoe with the Foot."
Write for details or contact your local FOOT-SO-PORT
Shoe Agency. Refer to your Classified Directory
Foot-so-Port Shoe Company, Oconomowoc, Wis.
A Division of Musebeck Shoe Company i
V
All important laboratory exam-
inations; including —
Tissue Diagnosis
The Wassermann and Kahn Tests
Blood Chemistry
Bacteriology and Clinical Pathology
Basal Metabolism
Aschheim-Zondek Pregnancy Test
Intravenous Therapy with rest rooms for
Patients
Electrocardiograms
Central Laboratory
Oliver W. Lohr, M.D., Director
537 Millard St.
Saginaw
Phone. Dial 2-4100 — 2-4109
The pathologist in direction is recognized
by the Council on Medical Education
and Hospitals of the A.M.A.
128
(Continued from Page 126)
now voluminous theoretical and experimental work on
the subject. The reader is not overwhelmed with a
never-ending detail of experimental statistics; instead
theoretical and experimental topics are well indexed
for those in search of greater detail, while the average
reader finds facts sufficient to draw logical conclusions.
The authors have achieved their objective very well,
“to reach the general physician who, imbued with the
physiological point of view, may more readily under-
stand the symptoms and clinical course of his patients.”
The volume is divided into seven parts, the first of
which consists of an excellent summary of cardiac physio-
logy. Digitalis and Quinidine are discussed thoroughly
in succeeding chapters, followed by an excellent chapter
on the arrhythmias. Congestive heart failure is dealt
with in the light of present knowledge of chemistry
and physiology. In the chapter on The Diet and
Heart Disease, the factors of nutrition in heart disease
are described. Sample diets and menus, including nu-
merous recipes, are listed in detail in the appendix, com-
posing one of the practical features of the book. Part
II is concerned with the discussion of Hypertension,
Hypertensive Heart Disease and Arteriosclerotic Heart
Disease. Part III presents diseases of the heart secondary
to inflammation, including Rheumatic Fever, Subacute
Bacterial Endocarditis, Luetic Heart Disease, Cor Pul-
monale, Non-specific Myocarditis and Pericarditis. In
light of the marked advances in the diagnosis and
treatment of congenital heart disease, part IV is well
written to bring the busy physician an awareness of
congenital heart disease and its management. The fifth
section of the book. Surgery in the Cardiac Patient,
contains chapters on anesthesia, preoperative and post-
operative care, and pregnancy in the cardiac patient.
Part VI, Disease of the Heart Secondary to Metabolic
Disorders, Hyper and Hypothyroidism, is adequately
discussed along with Beriberi Heart Disease. In the
opinion of the reviewer, the closing chapter is one of
the best features of the book. It discusses adequately
the psychosomatic aspects of heart disease, how to live
with a sick heart, and the rehabilitation of the cardiac
patient.
G.A.Z.
PHYSICAL DIAGNOSIS. By Ralph H. Major, M.D.
Professor of Medicine and of the History of Medi-
cine, The University of Kansas, and Mahlon H.
Delp, M.D., Professor of Medicine, The University
of Kansas. Fifth Edition, Illustrated. Philadelphia
and London: W. B. Saunders Co., 1956. Price $7.00.
Major’s Diagnosis, in its fifth edition, has an added
author and is almost an entirely new book. Much has
been rewritten, and the arrangement of chapters and
sequence is changed for the better. It is well printed
on non-gloss paper, in large clear type, and is easily
readable. The illustrations are profuse and well se-
lected to illustrate the text.
CLINICAL EXAMINATIONS IN NEUROLOGY. By
Members of the Section of Neurology and Section of
Physiology, Mayo Clinic and Mayo Foundation for
Medical Education and Research, Graduate School,
JMSMS
Say you saw it in the Journal of the Michigan State Medical Society
THE DOCTOR S LIBRARY
GINGER ALE
Developed by Michigan’s First Registered Pharmacist
Recommended by Eminent Michigan Physicians
FLAVOR MELLOWED 4 YEARS IN WOOD
A PREFERRED BEVERAGE FOR HOME AND HOSPITAL
University of Minnesota, Rochester, Minnesota:
James A. Barston, M.D.; Reginald G. Bickford, M.B. ;
Joe R. Brown, M.D.; Edward C. Clark, M.D.; Ken-
dall B. Corbin, M.D.; David D. Daly, M.D.; Lee
M. Eaton, M.D.; Norman P. Goldstein, M.D.; Ed-
ward H. Lambert, M.D.; Clark H. Millikan, M.D.;
Donald W. Mulder, M.D.; Harry L. Parker, M.D.;
E. Douglas Rooke, M.D.; Joseph G. Rushton, M.D.;
Robert G. Siekert, M.D.; Jack P. Whisnant, M.D.
Philadelphia and London: W. B. Saunders Company,
1956.
This outline of the clinical neurologic examination
vas written by members of the Section of Neurology
tnd Section of Physiology of the Mayo Clinic. As it
vas intended as a guide to the Fellows of the Mayo
■oundation, it includes a chapter on the forms and
aethods used in recording the results of the neurologic
xamination. A series of these forms is included.
There are chapters on The Neurologic History, Gen-
ral Observations and Order of Procedure, The Cranial
lerves. Motor Function, Reflexes, The Sensory Ex-
mination. Mental Function, Language and Motor
peech, Autonomic Function, Clinical Examinations in
■elected Problems of Pain, Electroencephalography,
llectromyography and Electric Stimulation of Periph-
ral Nerves and Muscle, Biochemical and Pharmaco-
)gic Aids in Neurologic Diagnosis, Examinations of
lerebrospinal Fluid by Lumbar and Cisternal Puncture.
The book is well organized, well written, and liter-
Uy packed with practical information. Though it is
ifficult to select any specific portion for comment,
le anatomic diagrams in the chapter on Motor Func-
on are unusually good and should be of help in
this most important but often tedious portion of the
neurologic examination. The Table of Contents, the
Index and the general organization of the book make
it easy to use as a reference and it is recommended
not only to the neurologist but also to anyone in the
active practice of medicine.
F.O.M.
INTERNATIONAL MEDICAL FILM PROGRAM
The international medical film program, new feature
of the American Medical Association’s 1957 annual
meeting, is creating considerable interest abroad, ac-
cording to Ralph P. Creer, AMA Director of Motion
Pictures and Medical Television.
The aim of the film program is to bring before the
doctors attending the meeting outstanding motion pic-
tures produced abroad dealing with many aspects of
medical science. This feature is in support of the
People-to-People Program which President Eisenhower
launched this summer and in which the medicine and
health professions are co-operating under the chairman-
ship of Dr. Louis H. Bauer, Secretary-General of the
World Medical Association.
In connection with this film program, which is to be
held at the Barbizon Plaza Hotel in New York City,
June 3-7, 1957, a discussion is planned on the problems
of a freer international medical film exchange. All
country representatives interested in dissemination of
medical knowledge by the film medium are invited.
Special social events will also provide an opportunity
for the participants to meet informally and discuss
problems of mutual interest.
Applications for the program and further information
can be obtained from the American Medical Association,
Motion Pictures and Medical Television, 535 North
Dearborn Street, Chicago 10, Illinois.
anuary, 1957
Say you saw it in the Journal of the Michigan State Medical Society
129
e
Protection against loss of income from
accident and sickness as well as hospital
expense benefits for you and all your
eligible dependents.
PHYSICIANS CASUALTY & HEALTH
ASSOCIATIONS
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90th Year of
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Ideal for Executives. Rest combined with med-
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Diagnostic and therapeutic service. Special De-
partments in Physical Therapy including Hydro
and Mechanotherapy, Electrotherapy, Helio-
therapy, Radiotherapy and Massage.
Well suited for treatment of metabolic disorders,
hypertension, obesity, arthritis and degenerative
diseases generally. All Sanitarium care is under
the immediate guidance of qualified physicians.
For rates and further information,
address Box 40
THE BATTLE CREEK SANITARIUM
Battle Creek, Michigan
Not affiliated with any other Sanitarium
Classified Advertising
$2.50 per insertion of fifty words or less, with an
additional five cents per word in excess of fifty.
PHYSICIAN for opening in industrial medicine. This
is to work in a well-established and staffed medical
department in downtown Detroit. It offers a five-
day-week. Salary $10,000, with many outside benefits.
Davis Smith Agency, 1914 Dime Building, Detroit.
WOodward 1-4567.
WANTED: Middle-aged physician for full-time duty,
out-patient department of small hospital. Some house
calls. Also, desire internist. Salary and commission
open. Reply Box 8. 606 Townsend Street. Lansing
15, Michigan.
POSITION VACANCY : General practice residency,
two years, Stanislaus County Hospital, Modesto, Cali-
fornia. 400 beds, hospital fully approved by the Joint
Commission of Accreditation; Salary — $500.00 per
month. Address communications to Dr. Allan A.
Craig, M.D., Stanislaus County Hospital, Modesto,
California.
OFFICE SPACE: Rent or lease. Newly remodeled,
excellent location with established dentist. Available
at once. Contact: O. S. McElmurry, D.D.S., 607
W. Ottawa Street, Lansing, Michigan. Telephone
IVanhoe 4-0329.
THE YEAR 1956: MEDICARE
(Continued from Page 94)
terms of the law these are to be renegotiated be-
fore July 1, 1957.
When Michigan sent to Washington, D. Bruce
Wiley, M.D., Chairman of the Council, MSMS,
Jay C. Ketchum, Executive Vice President of
Michigan Medical Service and the attorney, they
found the proffered contract could not be signed
on account of fine points of understanding and
extended services implied. Negotiations were ex-
tended nearly three weeks before questions were
resolved. The contract was signed November
15, 1956. More than ten years of administering
the veterans’ program pointed out features to be
avoided.
We believe the trial time until July 1, 1957.
will prove the Michigan concept of medicare
warrants continuing. Seven state medical societies
have signed to operate their own program, one
has designated a commercial insurance company,
and to date thirty-three have named Blue Shield.
130
Say you saw it in the Journal of the Michigan State Medical Society
JMSMS
THE JOURNAL
of the Michigan State Medical Society
OLUME 56 FEBRUARY, 1957 NUMBER 2
Contributors to This Issue
M. W. Alcorn, M.D.
S. Bardvvell, M.D.
J. DeWitt Fox, M.D.
J. M. Hammer, M.D.
Maurice Levine, M.D.
B. Levine, M.D.
R. J. Lilly, M.D.
F. Yonkman, M.D
Table of Contents
Cancer Day in Genesee County
II. B. Elliott, M.D 181
Dystrophia Myotonica
Stanley Bar die ell, M.D 185
The Modern Treatment of Uremia
Marshall W. Alcorn, M.D 190
Sterilization of Ureteral Catheters
John M. Hammer, M.D., M. J. Hickman, M.D.,
and R. J. Hubbel, M.D 194
Abdominal Pregnancy
Bernard Levine, M.D., and Max Blaine, M.D. 196
Esophageal Hiatus Hernia
Julian M. Guidot, M.D., Hugh F. Kerrin, M.D.,
and I. Donald Fagin, M.D., F.A.C.P 200
What’s New in Drugs?
Frederick F. Yonkman, M.D 203
Lung Function in Asthma and Emphysema
William Appel, M.D 213
Narcotic Addiction Among Physicians
J. DeWitt Fox, M.D 214
The Evolution of Psychiatry as an Integral Part of
Medical Practice
Maurice Levine, M.D 218
New Drugs in Psychiatry
Richard ]. Lilly, M.D 223
Detroit Surgical Association:
Meetings of September 24, 1956 and October
22, 1956 225
President’s Message:
Operation Armor 227
Editorial 228
Michigan Clinical Institute 234
Technical Exhibits 235
Michigan’s Department of Health 240
Legal Opinions..... 242
In Memoriam 246
News Medical 250
The Doctor’s Library 269
You and Your Business 140
AMA Washington Letter 152
AMA News Notes 154
Report of House of Delegates, AMA Tenth Clinical
Meeting 156
J. R. Bruce, Journal of MSMS Publisher, Dies 164
PR Report 168
Rheumatic Fever Co-ordinator Leon DeVel Resigns 170
Editorial Opinion 172
© 1957 by Michigan State Medical Society
5BRUARV, 1957
135
THE JOURNAL
of the Michigan State Medical Society
=VOLUME 56 FEBRUARY, 1957 NUMBER 2=
PUBLICATION COMMITTEE
G. B. SALTONSTALL, M.D., Chairman Charlevoix
WILLIAM BROMME, M.D Detroit
B. M. HARRIS, M.D Ypsilanti
O. B. McGILLICUDDY, M.D Lansing
W. S. STINSON, M.D Bay City
T. P. WICKLIFFE, M.D Calumet
Office of Publication
2642 University Avenue
Saint Paul 14, Minnesota
Editor
WILFRID HAUGHEY, M.D.
610 Post Bldg., Battle Creek, Michigan
Secretary and Business Manager of THE JOURNAL
L. FERNALD FOSTER, M.D.
Thorne Bldg., 919 Washington Ave.
Bay City, Michigan
Executive Director
WM. J. BURNS, LL.B.
606 Townsend Street, Lansing 15, Michigan
All communications relative to exchanges, books for review, manu-
scripts, should be addressed to Wilfrid Haughey, M.D., 610 Post
Bldg,, Battle Creek, Michigan.
All communications regarding advertising and subscription should
be addressed to Wm. J. Burns, 2642 University Avenue, Saint
Paul 14, Minnesota, or 606 Townsend Street, Lansing 15, Michigan.
Telephone Ivanhoe 57125.
© 1957, by Michigan State Medical Society.
Published monthly by the Michigan State Medical Society as its
official journal at 2642 University Avenue, Saint Paul 14, Minnesota.
Entered at the post office at Saint Paul, Minnesota, as second
class matter. May 7, 1930, under the Act of March 3, 1879.
Acceptance for mailing at special rate of postage provided for
in Section 1103 Act of October 3, 1917, authorized August 7, 1918.
Yearly subscription rate, $6.00; single copies, 60 cents. Additional
postage; Canada, $1.00 per year; Pan-American Union, $2.50 per
year; Foreign, $2.50 per year.
PRINTED IN U.S.A.
OFFICERS OF THE SOCIETY
President
President-Elect
Secretary
Treasurer
Speaker
Vice Speaker...
Editor
1956-1957
ARCH WALLS, M.D
G. W. SLAGLE M.D
L. FERNALD FOSTER, M.D.
W. A. HYLAND. M.D
K. H. JOHNSON, M.D
J. J. LIGHTBODY, M.D
...WILFRID HAUGHEY, M.D..
Detroit
Battle Creek
Bay City
Grand Rapids
Lansing
Detroit
Battle Creek
THE COUNCIL
D. BRUCE WILEY, M.D., Chairman, Utica
W. B. HARM, M.D., Vice Chairman, Detroit
L FERNALD FOSTER, M.D.. Secretary, Bay City
Term
District Expires
A. E. SCHILLER, M.D 1st Detroit 1961
O. B. McGILLICUDDY, M.D 2nd Lansing 1960
H. J. MEIER, M.D 3rd Coldwater 1960
RALPH W. SHOOK, M.D 4th Kalamazoo 1961
C. ALLEN PAYNE, M.D 5th Grand Rapids 1961
H. H. HISCOCK, M.D 6th Flint 1961
H. B. ZEMMER, M.D 7th Lapeer 1957
L. C. HARVIE, M.D 8th Saginaw 1957
G. B. SALTONSTALL, M.D 9th Charlevoix 1957
W. S. STINSON, M.D 10th Bay City 1957
W. M. LeFEVRE. M.D 11th Muskegon 1958
B. T. MONTGOMERY, M.D 12th Sault Ste. Marie .1958
T. P. WICKLIFFE, M.D 13th Calumet 1959
B. M. HARRIS, M.D 14th Ypsilanti 1959
D. BRUCE WILEY, M.D 15th Utica 1960
G. THOMAS McKEAN. M.D 16th Detroit 1960
W. B. HARM, M.D 17th Detroit 1958
WILLIAM BROMME, M.D 18th Detroit 1959
ARCH WALLS, M.D President Detroit
G. W. SLAGLE, M.D President-Elect Battle Creek
K. H. JOHNSON, M.D Speaker ....Lansing
J. J. LIGHTBODY, M.D Vice Speaker Detroit
L. FERNALD FOSTER, M.D Secretary Bay City
W. A. HYLAND, M.D Treasurer Grand Rapids
W. S. JONES, M.D Past President Menominee
EXECUTIVE COMMITTEE OF THE COUNCIL
D. BRUCE WILEY, M.D Chairman
W. B. HARM. M.D Vice Chairman
W. M. LeFEVRE, M.D Chairman. County Societies Committee
G. B. SALTONSTALL, M.D Chairman, Publication Committee
RALPH W. SHOOK, M.D Chairman, Finance Committee
K. H JOHNSON, M.D. Speaker, House of Delegates
J. J. LIGHTBODY, M.D Vice Speaker, House of Delegates
ARCH WALLS, M.D President
G. W. SLAGLE. M.D President-Elect
L. FERNALD FOSTER, M.D Secretary
W. A. HYLAND. M.D Treasurer
Dermatology and Syphilology
Wm. T. Kruse, M.D Grand Rapids
Chairman
Coleman Mopper, M.D Detroit
Secretary
Gastroenterology and Proctology
N. D. Nigro, M.D.. Detroit 1
Chairman
E. J. Tallant, M.D Detroit
Secretary
General Practice
F. P. Rhoades, M.D Detroit 2
Chairman
F. C. Brace, M.D Grand Rapids
Secretary
Gynecology and Obstetrics
J. H. Beaton, M.D Grand Rapids
Chairman
R. W. McClure, M.D Detroit 26
Secretary
Medicine
J. M. Kaufman, M.D Detroit 26
Chairman
J. W. Hall, M.D Traverse City
Sec retary
SECTION OFFICERS
Nervous and Mental Diseases
W. R. Slenger, M.D Ann Arbor
Chairman
S. C. Mason, M.D Ann Arbor
Secretary
Occupational Health
O. J. Johnson, M.D Bay City
Chairman
P. B. Rastello, M.D Detroit 9
Secretary
Ophthalmology and Otolaryngology
B. C. Wildgen, M.D Muskegon
Chairman ( Ophth .)
W. K. Locklin, M.D Kalamazoo
Co-Chairman ( Oto.)
H. A. Dunlap, M.D Detroit 14
Secretary (Ophth.)
H. L. LeVett, M.D Lansing
Co-Secretary ( Oto.)
Pediatrics
C. E. Booher, M.D Grand Rapids
Chairman
A. M. Hill, M.D. Grand Rapids
Secretary
Public Health and Preventive
Medicine
J. D. Monroe, M.D Pontiac
Chairman
J. K. Altland, M.D Lansing 4
Secretary
Radiology, Pathology, Anesthesiology
R. B. Sweet. M.D Ann Arbor
Chairman (Anes.)
E. R. Jennings, M.D Detroit
Vice-Chairman (Path.)
E. O. Pearson. M.D Kalamazoo
Secretary (Rad.)
Surgery
E. T. Thieme, M.D Ann Arbor
Chairman
H. M. Bishop, M.D Saginaw
Secretary
Urology
R. P. Lytle, M.D Detroit i
Chairman
J. F. Harrold, M.D Lansing
Secretary
Delegates DELEGATES
W. A. Hyland, M.D.. Grand Rapids, Chairman 1957
J. S. DeTar, M.D., Milan 1957
C. I. Owen, M.D.. Detroit 1957
W. D. Barrett, M.D., Detroit 1958
W. H. Huron. M.D.. Iron Mountain 1958
R. L. Novy, M.D., Detroit 1958
Section
G. C. Penberthy, M.D. (Surgical
TO A. M. A. Alternates
W. W. Babcock, M.D., Detroit
E. F. Sladek, M.D., Traverse City
O. J. Johnson, M.D., Bay City
William Bromme, M.D.. Detroit
J. R. Rodger, M.D., Bellaire
G. W. Slagle, M.D., Battle Creek
Delegate
Section) Detroit
1957
1957
1957
1958
1958
1958
136
TMSMS
The subway is taking him home today. But,
sometime soon, the depression and anxiety
you can see may lead him to irresponsible
behavior, impaired mental and emotional
health, or even to physical illness.
If he comes to your office, you’ll find that
Dexamyl* can help you to relieve his
depressed sense of “being unable to do any-
thing right.” ‘Dexamyl’ (a combination of
dextro-amphetamine sulfate, S.K.F., and
amobarbital) is smooth and subtle in action,
helps to restore a sense of well-being.
In three dosage forms: tablets, elixir,
Spansule+ capsules.
Smith, Kline & French Laboratories,
Philadelphia
*T.M. Reg. U.S. Pat. Off.
tT.M. Reg. U.S. Pat. Off. for sustained release capsules, S.K.F.
this man
February, 1957
Say you saw it in the Journal of the Michigan State Medical Society
137
COUNTY MEDICAL SOCIETY OFFICERS
COUNTY
PRESIDENT
SECRETARY
ALLEGAN
ALPENA-ALCONA-PRESQUE ISLE
BARRY
BAY-ARENAC-IOSCO
BERRIEN
BRANCH
CALHOUN
CASS
CHIPPEWA-MACKINAC
CLINTON
DELTA-SC'HOOLCRAFT
DICKINSON-IRON
EATON
GENESEE
GOGEBIC
GRAND TRAVERSE-LEELANAU-
BENZIE
GRATIOT-ISABELLA-CLARE
HILLSDALE
HOUGHTON-BARAGA-KEWEENAW
HURON
INGHAM
IONIA-MONTCALM
JACKSON
KALAMAZOO
KENT
LAPEER
LENAWEE
LIVINGSTON
LUCE
MACOMB
MANISTEE
MARQUETTE-ALGER
MASON
MECOSTA-OSCEOLA-LAKE
MENOMINEE
MIDLAND
MONROE
MUSKEGON
NEWAYGO
NORTH CENTRAL
NORTHERN MICHIGAN
Bert Van Der Kolk, M.D., Hopkins
R. G. Ries, M.D., Rogers City
R. B. Pryor, M.D., Hastings
J. N. Asline, M.D., Bay City
F. H. Lindenfeld, M.D., Niles
C. A. Coates, M.D., Quincy
Leland P. Shipp, M.D., Battle Creek
J. K. Hickman, M.D., Dowagiac
Donald D. Finlayson, M.D..
Saulte Ste. Marie
James M. Grost, M.D., St. Johns
Robert E. Ryde, M.D., Escanaba
R. E. Carlson, M.D., Iron Mountain
Fred L. Arner, M.D.. Bellevue
O. J. Preston, M.D., Flint
J. E. McEnroe, M.D., Ironwood
John G. Milliken, M.D., Traverse City
R. F. Hall, M.D., Mt. Pleasant
H. F. Mattson, M.D., Hillsdale
T. P. Wickliffe, M.D., Calumet
T. L. Bash, M.D., Kinde
G. A. Sherman, M.D., Lansing
John F. Tannheimer, M.D., Ionia
L. F. Thalner, M.D., Jackson
John V. Fopeano, M.D., Kalamazoo
D. B. Hagerman, M.D., Grand Rapids
Thomas Buchanan, M.D., Imlay City
George C. Wilson, M.D., Clinton
E. G. Walker, M.D., Lakeland
T. W. Thompson, M.D., Newberry
Edward G. Siegfried, M.D.,
Mt. Clemens
E. C. Hansen, M.D., Manistee
A. S. Narotzky, M.D., Ishpeming
J. R. Carney, M.D., Ludington
Jacob Bruggema, M.D., Evart
F. J. DeWane, M.D., Menominee
Leonard Poznak, M.D., Midland
J. P. Flanders, M.D., Monroe
E. J. Lauretti, M.D., Muskegon
Robert E. Paxton, M.D., Fremont
George L. Schaiberger, M.D..
West Branch
Victor Mateskon, M.D., Petoskey
J. E. Mahan, M.D., 402 Trowbridge St., Allegan
Harold Kessler, M.D., 312 E. Chisholm, Alpena
E. L. Phelps, M.D., 118 E. Walnut St., Hastings
H. T. Knobloch, M.D., 1102 Columbus Ave., Bay City
R. L. Landgraf, M.D., P.O. Box 222, Niles
J. C. Heffelfinger, M.D., 292 E. Chicago St., Coldwater
Keith Wemmer, M.D., 1501 W. Michigan Ave., Battle
Creek
G. E. Loupee, M.D., 110 W. Division, Dowagiac
T. B. Mackie, M.D., 300 Court St., Sault Ste. Marie
B. C. Cook, M.D., Westphalia
Norman L. Lindquist, M.D., 205 S. 10th St., Escanaba
D. T. Anderson, M.D., 400 Woodward Ave., Iron
Mountain
Joseph Riley, M.D., 201 V2 S. Cochran, Charlotte
J. B. Rowe. M.D., 202 Paterson Bldg., Flint
W. H. Wacek, M.D., Grand View Hospital, Ironwood
Bernard Sweeney, M.D., 227I/2 Grandview Parkway,
Traverse City
J. M. Wood, M.D., 815 E. Maple St., Mt. Pleasant
M. P. Bates, M.D., 108 S. Manning, Hillsdale
F. W. Larson, M.D., 1400 E. Houghton, Houghton
C. F. Wible. M.D., Sebewaing
R. H. Trimby, M.D., 122 W. Hillsdale, Lansing
J. A. Van Loo, M.D., 103 E. Washington, Belding
H. W. Porter, M.D., 505 Wildwood Ave., Jackson
E. O. Pearson, M.D.. 458 W. South St., Kalamazoo
G. A. Mulder, M.D., 26 Sheldon Ave. S.E., Grand
Rapids
James Doty, M.D.. 315 Clay St., Lapeer
A. J. Phelan, M.D., 102 S. Pearl St., Tecumseh
R. M. Duffy, M.D., 250 E. Main St., Pinckney
R. P. Hicks, M.D., 210 W. John St., Newberry
Dan Zavela, M.D., 22644 Gratiot, East Detroit
Ruth E. Lalime, M.D., 12395 Lynn, Bear Lake
J. R. Acocks, M.D., Morgan Heights Sanatarium,
Marquette
A. F. Boon, M.D., 203 N. Ferry, Ludington
J. A. White, M.D., 121 S. Michigan Ave., Big Rapids
L. G. Glickman, M.D., 958 First St., Menominee
Benjamin B. Holder, M.D., Dow Medical Department,
Midland
W. A. Meier, M.D., 105 E. Front St., Monroe
H. C. Tellman, M.D., 706 Hackley Bank Bldg.,
Muskegon
J. Paul Klein, M.D., 16 West Sheridan, Fremont
Charles Oppy, M.D., Roscommon
E. F. Crippen, M.D., 12654 State St., Mancelona
OAKLAND
OCEANA
ONTONAGON
OTTAWA
SAGINAW
ST. CLAIR
ST. JOSEPH
SANILAC
SHIAWASSEE
TUSCOLA
VAN BUREN
WASHTENAW
WAYNE
WEXFORD-MISSAUKEE
Hazen L. Miller, M.D., Royal Oak
W. G. Robinson, M.D., Hart
H. B. Hogue, M.D., Ewen
John Winters, M.D., Grand Haven
J. E. Manning, M.D., Saginaw
Charles N. Hoyt, M.D., Port Huron
Raymond D. Zimont, M.D.,
Constantine
John W. McCrea, M.D., Marlette
Walter D. Buzzard, M.D., Chesaning
R. R. Howlett. M.D., Caro
R. I. McFadden, M.D., Bloomingdale
Frank H. Bethell, M.D., Ann Arbor
L. R. Leader, M.D., Detroit
W. W. Moon, M.D., Cadillac
G. N. Petroff, M.D., 1301 Pontiac St. Bank Bldg.,
Pontiac
W. G. Robinson, M.D . 219 State St., Hart
W. F. Strong, M.D.. Ontonagon
William Westrate, Jr., M.D., 17 W. 10th St., Holland
C. G. Kramer, M.D., 3900 Holland Road, Saginaw
C. D. Selby, M.D., 1916 Military, Port Huron
C1. G. Porter, M.D., 226 East St., Three Rivers
E. W. Blanchard, M.D., Deckerville
Norman F. Bach, M.D., 113 E. Williams, Owosso
E. N. Elmendorf, M.D., Vassar
Arthur E. Parks, M.D., Lawton
B. C. Payne, M.D., 202 Michigan Theatre Bldg., Ann
Arbor
R. R. Cooper, M.D., 4421 Woodward Ave., Detroit 1
D. W. Seger, M.D.. Lake City
138
TMSMS
contributing to ... a world-wide acceptance unmatched
in modern intravenous anesthesia
Twenty years of use, over 2500 published reports— seldom
in the history of medicine has a single drug enjoyed the
acceptance accorded Pentothal Sodium. This modern
intravenous anesthetic is more than just thiopental sodium.
It is thiopental sodium plus the most exacting controls
. . . plus adaptability to widely varying practices . . . plus
the most thoughtfully planned dosage forms. Priceless pluses,
these, making Pentothal Sodium an agent of
choice the world over in intravenous anesthesia. CIMrtVtt
PENTOTHAL® Sodium
(Thiopental Sodium for Injection. Abbott) 7oics6
EBRUARY, 1957
Say you saw it in the Journal of the Michigan State Medical Society
You and Your Business
PROFESSOR COLLER TO MODERATE
AT MCI
The hour 5:00 to 6:00 p.m.
on Wednesday, March 13,
1957, will be an interesting,
instructive and stimulating
period at the Michigan Clini-
cal Institute. Frederick A.
Coller, M.D., Profesor of Sur-
gery and Head of the Depart-
ment, University of Michigan,
Ann Arbor, will hold forth
during that sixty minutes as
Moderator of a panel compris-
ing all the seven speakers on the Wednesday pro-
gram.
In order of appearance, the March 13 guest
lecturers and their topics are:
1. John H. Garlock, M.D., New York City —
“Present Day Approach to the Surgical Therapy
of Non-specific Ulcerative Colitis.”
2. John H. Gibbon, Jr., M.D., Philadelphia —
“Pulmonary Ventilation During Surgical Opera-
tions.”
3. L. Henry Garland, M.D., San Francisco —
“The Pursuit of the Unorthodox.”
4. Charles B. Huggins, M.D., Chicago —
“Control of Human Cancers by Endocrinologic
Methods.”
5. Frank H. Mayfield, M.D., Cincinnati-
“Whip Lash Injuries.”
6-7. Ralph C. Moore, M.D., Omaha, and
Charles L. Marsh, M.D., Valley, Nebraska —
“The Medical Aspects of Highway Accidents.”
A provocative period can be prophesied for
the panel discussion of Wednesday, March 14.
during the 1957 Michigan Clinical Institute—
with F. A. Coller, M.D., in the “driver’s seat!”
NEW INTERNATIONAL PRIZES FOR
FAMILY PHYSICIANS
A new series of prizes for family physicians of
any country has been announced in London by
B. D. Thornley, managing director of Benger
Laboratories, British pharmaceutical firm. The
prizes total 500 pounds in value and will be
known as the “Benger Prizes for Original Obser-
vations in General Practice.” Entries will be
judged by the awards committee of the British
College of General Practitioners.
The ideas or hunches or subject matter may be
concerned with the causation, diagnosis, treat-
ment or prevention of any disease. All entries
will be published and the book will be available
to physicians everywhere. Physicians’ ideas may
prove a stimulus to medical research workers
everywhere, whether in hospitals, special institu-
tions or pharmaceutical companies. Among the
obscure and unassuming family doctors of the
world there may be another Jenner or another
Lind.
Manuscripts or correspondence should be ad-
dressed to Benger Laboratories, Ltd., Holmes
Chapel, Cheshire, England.
THE GENESEE COUNTY MEDICAL
SOCIETY
Cordially Invites Every Member Of The
Michigan State Medical Society To Attend
THE TWELFTH ANNUAL CANCER DAY
Wednesday, April 17, 1957
Merliss Brown Auditorium — Hurley Hospital
Flint
9:30 A.M.
Morning Session
Address of Welcome
Otto J. Preston, M.D., President, Genesee County
Medical Society, Flint
Presiding — Arch Walls, M.D., President, Mich-
igan State Medical Society, Detroit
“Cancer of the Breast” — Grantley W. Taylor,
M.D., Department of Surgery. Harvard Uni-
versity and Massachusetts General Hospital,
Boston
“Cobalt-60 Radiotherapy for Cancer” — Isadore
Lampe, M.D., Department of Radiology, Uni-
versity of Michigan Hospital. Ann Arbor
“Progress in the Control and Therapy of Cancer”
— Sidney Farber. M.D., Professor of Pathology,
Harvard Medical School: Director, Children’s
Cancer Research Foundation, Boston
Afternoon Session
Presiding — Charles S. Kennedy, M.D., Detroit,
Member, Board of Regents, University of Mich-
igan
“Cancer of the Colon” — Warren H. Cole, M.D.,
Professor of Surgery, University of Illinois Col-
lege of Medicine, Chicago
“Cancer of the Prostate” — Perry B. Hudson,
M.D., Department of Urology, Columbia Uni-
versity; Chief, Urological Service, Frances Del-
afield Hospital, New York City
“General Considerations in Cancer Management”
— Carl A. Moyer, M.D., Bixby Professor of
Surgery, Washington University, St. Louis.
( Continued on Page 144)
IMSMS 1
140
Many of your patients, Doctor, are among
the millions of people who have seen this
newest Parke- Davis advertisement on the
cost of today’s more effective medical
care. We believe that this sensible-talking ad
—the latest in a continuing P-D series appear-
ing in LIFE, TIME, SATURDAY EVENING POST and
today’s health— dramatically confirms our year-
long public service message to your patients:
“prompt and proper medical care may well turn out to
be one of the biggest bargains of your life
You may be assured that Parke-Davis national adver-
tising will continue to be in our mutual best interests . . . designed to give your
patients a better understanding of costs and a clearer appreciation of the effec-
tiveness of modern medical care. PARKE, DAVIS & COMPANY, Detroit 32, Michigan.
The Salurdav Evening
EBRUARY, 1957
Say you saw it in the Journal of the Michigan State Medical Society
143
YOU AND YOUR BUSINESS
(Continued from Page 142)
WAYNE COUNTY MEDICAL SOCIETY
BREAKS GROUND FOR NEW BUILDING
Two silver spades helped to rearrange some im-
portant dirt at the formal groundbreaking cere-
mony of the new David Whitney House, soon
to be headquarters for the Wayne County Medi-
cal Society on the campus of Wayne State Uni-
versity, Detroit. Wielders of the dirt pushers
at the December 19 ceremony were WCMS Presi-
dent Luther R. Leader, M.D., Lawrence Reynolds.
M.D. and Milton A. Darling, M.D.
This medical milestone in Wayne County was
recognized by the press through a heart-warming
editorial in the Detroit Times of December 23
which read :
A Great Profession
We were pleased when the Wayne County Medical
Society broke ground the other day for its new head-
quarters building that there was considerable emphasis
by the doctors on the importance of good deeds rather
than fancy words.
There was more emphasis on the part that physicians
do and must play in training of new doctors.
There even was a reference to a fact well known
to doctors but overlooked by most of the public, that
our doctors in Michigan, contrary to popular belief,
have been urging for years that more doctors be trained
in the schools, and that Wayne State University be
expanded for that purpose.
We wish the doctors good fortune with their new
building.
We wish also to express our respect to the profession
for its genuine service and genuine public spirit in
trying to provide still more doctors to serve us.
The medical profession, often criticized, remains a
great one, and one with a real spirit of good citizenship.
Congratulations, Wayne County Medical, So-
ciety, on your great day of progress. Significant
is the increasing rapport with Wayne State Uni-
versity in this new “good neighbor” activity.
HIGHLIGHTS OF EXECUTIVE
COMMITTEE OF THE COUNCIL
Meeting of December 12, 1956
• Medicare Program: It was reported that recom-
mended changes in the Medicare Program, in-
cluding fee schedule, should be submitted before
July 1, 1957.
• Practice of Psychotherapy: Attorney General’s
reply in answer to criticism made before 1956
MSMS House of Delegates re AGO No. 2359
(ruling that the practice of social work includ-
ing psychiatric social work and the practice of
psychology are not violative of the Medical
Practice Act) was read; the Executive Com-
mittee instructed that copies be sent to all
parties in interest.
• Officers Night Banquet, 1957: Arrangements
for this dinner, to be held in the Pantlind Ho-
tel, Grand Rapids, were approved.
• “Community Health Association”: Dr. Walls
stated that he as an individual had been in-
vited to attend the January 11 meeting of this
group which will consider formation of a pre-
paid hospital-medical care plan under union
et al auspices.
• Appointments: O. K. Engelke, M.D. of Battle
Creek, to represent MSMS at AMA Rural
Health Conference, March 7-9, Louisville,
Kentucky; J. R. Rodger, M.D., Bellaire, to rep-
resent MSMS at public hearings before U. S.
House of Representatives on traffic safety.
• Reports: O. B. McGillicuddy, M.D., reported
on November 17 Conference on Teacher Cer4
tification Code, East Lansing; Secretary Foster
reported on contents of booklet entitled “Private
Practice of Medical School Faculty Members.”
• Beaumont Memorial: Chairman Otto O. Beck,
M.D., reported that 450 MSMS members had
contributed (to December 11) the sum of $5,-
095 to underwrite the deficit. A vote of thanks
to these generous donors was placed on the
Executive Committee minutes.
• 1956 MSMS Annual Session Attendance was
reported, with a breakdown as to Michigan
communities and medical specialties represent-
ed.
• Plaque Presented by the Michigan State
Pharmaceutical Association to the MSMS
Executive Office staff for cooperative work dur-
ing 1956 was displayed.
• Committee on Llniform Fee Schedule for Gov-
ernmental Agencies was appointed by Council
Chairman D. Bruce Wiley, M.D.: T. H. Hunt
M.D., Detroit, Chairman; R. J. Armstrong
M.D., Kalamazoo; James D. Fryfogle, M.D.
Detroit; C K. Hasley, M.D., Detroit; D. H
Kaump, .M.D., Detroit; R. F. Kernkamp, M.D.
Detroit; O. M. Randall, M.D., Lansing; D. C
Somers, M.D., Royal Oak; C. E. Toshach
M.D., Saginaw; George Van Rhee, M.D., Por
Huron; Frank Van Schoick, M.D., Jackson
and F. P. Walsh, M.D., Detroit.
• Committee on Use of the Word “Clinic,” as pe:
resolution No. 19 of 1956 House of Delegates
Council Chairman Wiley appointed the follow
ing committee: J. E. Livesay, M.D., Flint
Chairman; Robert E. Rice, M.D., Greenville
and A. E. Schiller, M.D., Detroit.
• Committee on Michigan Medical Service
Council Chairman Wiley appointed the follow
ing committee: G. W. Slagle, M.D., Battle
Creek, Chairman; J. F. Beer, M.D., St. Clair I
E. F. Sladek, M.D., Traverse City; D. W
Thorup, M.D., Benton Harbor; Arch Walls
M.D., Detroit; and Wilfrid Haughey. M.D.
(Continued on Page 146)
144
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electrolyte metabolism; no mental fogging
or major toxicity in ataractic action.
FOR UNMATCHED RESPONSE AND
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AS IN OTHER COLLAGEN DISEASES, BRONCHIAL
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Supplied: Each green, scored
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PFIZER LABORATORIES
Division, Chas. Pfizer & Co., Inc.
Brooklyn 6, New York
YOU AND YOUR BUSINESS
HIGHLIGHTS OF THE COUNCIL
(Continued from Page 144)
Battle Creek, and L. Fernald Foster, M.D., Bay
City, as Advisors.
• Committee to Study Comprehensive Pre-Paid
Medical Care Insurance Plans (as per resolu-
tions No. 1-32 of 1956 MSMS House of Dele-
gates) : Speaker K. H. Johnson, M.D., appoint-
ed the following committee: C. I. Owen, M.D.,
Detroit, Chairman; J. F. Beer, M.D., St. Clair;
K. E. Fellows, M.D., Grand Rapids; J. E.
Hauser, M.D., Detroit; H. C. Hill, M.D., How-
ell; E. G. M. Krieg, M.D., Detroit; M. L.
Lichter, M.D., Detroit, and K. H. Johnson,
M.D., Lansing (Ex Officio).
• Report on AMA Delegates Meeting, Seattle,
November, 1956, was reported by Chairman
William A. Hyland, M.D., Grand Rapids.
• A Councilor’s letter, published periodically in
the Muskegon County Medical Society Bulle-
tin, by William M. LeFevre, M.D., Councilor
of the Eleventh District, was given commenda-
tion and referred to JMSMS Editor Haughey
for publication.
• Leon DeVel, M.D., Grand Rapids, for eight
years MSMS Rheumatic Fever Control Co-
ordinator, presented his resignation which was
accepted with sincere regret. A vote of appre-
ciation for Dr. DeVel’s valuable services in
this pioneering work was placed on the Exec-
utive Committee minutes.
• Public Relations Counsel’s report included in-
formation on legislation; “Be Safe at Home”
pamphlet; Diabetes Detection Week activities;
Michigan Rural Health Conference program;
documentation of Wayne County Medical So-
ciety’s new building groundbreaking ceremony.
• Committee reports: The following were re-
viewed: (a) Arbitration Committee, meetings
of November 9 and 23; (b) Maternal Health
Committee, November 14; (c) Committee on
Scientific Work, November 16; (d) Liaison
Committee with the University of Michigan,
November 19; (e) Liaison Committee with
Labor, November 21; (f) Mental Health Com-
mittee, meeting of December 5; (g) Commit-
tee on “Big Look,” December 11; (h) Meeting
to arrange conference for residents, interns, sen-
ior medical students, December 5; (i) Rheu-
matic Fever Control Committee, December 5;
and (j) Committee on Prevention of Highway
Accidents, December 6.
• Matters of mutual interest were discussed with
State Health Commissioner A. E. Heustis, M.D.,
including poliomyelitis vaccine and diphtheria
incidence in Detroit. (On these subjects, the
motion of the Executive Committee was: “That
the MSMS communicate with each county
medical society urging that their members get
behind the poliomyelitis and diphtheria im-
munization programs by personal participation,
television, bulletins, office cards and through
every other means of publicity and communi-
cation.”) Also discussed were recommendations
of the Governor’s Public Health Study Com-
mission and nursing home licensure. Dr. Heustis
was thanked for his excellent report and for
his hospitality to the members of the Executive
Committee on this occasion.
DETROIT LEABtS IN 1956 ANNUAL
SESSION ATTENDANCE
At the September, 1956, Michigan State Medi-
cal Society Annual Session in Detroit, 1101 De-
troit physicians were registered out of a total
of 2,564 in attendance. Flint came in second with
126 and Lansing third with seventy-two. Pontiac
sent seventy M.D. representatives; Saginaw sixty-
eight; Ann Arbor sixty, and Grand Rapids fifty-
eight.
Ninety-nine M.D.’s came from without Michi-
gan— with twenty-nine from varied points in On-
tario.
Two hundred and thirteen separate communi-
ties in Michigan were represented at the annual
session. Monroe County sent the greatest per-
centage of its membership to the annual session:
63 per cent.
Sixteen specialties were represented with the
generalists leading with a registration of 705.
Surgery had a total of 307 M.D..’s present with
Medicine coming in third with 228.
Other sections were represented as follows:
Pediatrics, 104; Obstetrics and Gynecology 101;
Ophthalmology and Otolaryngology, 106; Urol-
ogy, 54 ; Pathology, 5 1 ; Public Health, 45 ; Radi-
ology, 43; Anesthesiology, 34; Gastroenterology-
Proctology, 33; Occupational Health, 32; Der-
matology-Syphilology, 31.
Residents and interns chalked up a total of 338.
CAMP FOR DIABETIC CHILDREN
Report of the Camp Committee,
Michigan Diabetes Association
In August, 1955, the Michigan Diabetes As-
sociation sponsored for the first time a camp for
diabetic children. The venture was so success-
ful that it was repeated in 1956.
From August 12 to August 25 of this year, fifty
diabetic children were able to enjoy camping ex-
perience with no medical mishaps. They were
supervised by two doctors, three nurses and two
dieticians, as well as twelve counselors. The camp
was held at the Tau Beta Camp in Columbiaville,
Michigan. There are available at that site one
hundred acres of land, a lake and multiple camp
crafts and activities.
With fifty campers there were only two illness
(Continued on Page 148)
146
JMSMS
(Prednisolone ferfiory-butylocetote. Merck!
for relief that lasts -longer
Osteoarthritis
Acute gouty arthritis
Bursitis
Tendinitis
Trigger finger
Peritendinitis
Trigger points
Tennis elbow
Lumbosacral strain
jg Capsulitis
5 Rheumatoid arthritis
IgjL Frozen shoulder
Coccydynia
' Rheumatoid nodules
Fibrositis
Tensor fascia lata
in MYOSITIS
relieves
pain and
disability a
Anti-inflammatory
effect lasts longer
than that provided
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steroid ester
(13.2 days— 20 mg.)
o i a 9 4 0 • 9 a 9 to it 12 n i4 is days
Dosage: the usual intra-articular,
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ranges from 20 to 30 mg. depend-
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Supplied: Suspension ‘hydeltra’-
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MERCK SHARP 0k DOHME
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PHILADELPHIA 1 . PA.
/. Hollander, J. L., Paper read at conference in New York Cityy May 31 and June /, 1955
February, 1957
Say you saw it in the Journal of the Michigan State Medical Society
YOU AND YOUR BUSINESS
CAMP FOR DIABETIC CHILDREN
(Continued from Page 146)
cases. One was that of a girl who presented a
problem not because of her diabetes but because
of the complication of epilepsy. The other case
was that of a girl who was in acidosis on admis-
sion and had to be treated with intravenous fluids,
but was able to stay throughout the whole season.
The medical management of these children was
simply but efficiently arranged. Each child as
well as each of two adult diabetics who were
present had a number. Their meal trays, urines,
dining room seats and activities all bore the same
number. When the meals were served, the dieti-
cian had a card with all the numbers and the
number of servings of the different food groups
for each of these numbers. In this manner, the
meals could be served rapidly and easily. Each
counselor was responsible for a limited number
of campers and always picked up their trays at
meal time from a serving table where each tray
was placed upon an area bearing its number. A
master book was also kept with a daily record of
each child v/ith his number, a list of any reactions,
the urine sugars, and the insulin dose for that
day. At the end of the day, Doctor Shulman,
the medical director. Doctor Cantor, his assistant,
the camp director, the nurses, the counselors and
the dieticians meet to discuss and to decide upon
the activities for the following day and the insulin
dose for each child. Supplementary feedings were
routinely given to all children after strenuous
activities, and rounds were made at intervals dur-
ing the evening and at night to detect and treat
any insulin reaction.
Last year, a Christmas reunion party was held
for the children who had attended the camp.
Another party will be given again this year.
The Michigan Diabetes Association is planning
on continuing the Diabetic Camp for children
each year. Applications for the camp may be
directed to the Secretary of the Society, Miss Mary
Harrington, Michigan Diabetes Association, 3825
Brush Street, Detroit 1, Michigan.
GRANTS FOR EDUCATION
Within the month two outstanding announce-
ments have been made with reference to further-
ing education in Michigan. The Ford Founda-
tion and the Ford Motor Company gave to the
University of Michigan the Fair Haven estate
of the senior Henry Ford at Dearborn, and con-
siderations estimated to be of about $6,500,000,
to establish a branch of the University of Michi-
gan in Dearborn. Especial emphasis is made on
education in engineering in addition the regular
collegiate subjects. No gift for education ever
made has been of more tremendous scope and
size.
The first week of January, 1957, Mrs. Wilson,
148
the widow of the late John F. Dodge, creator
of the Dodge automobile, made a donation to the
Michigan State University. She gave her Mea-
dowbrook estate in Oakland County and a cash
stipend to accomplish her intent of establishing
in Oakland County a branch of the Michigan
State University. Her interest is also in engineer-
ing. The total amount is estimated to be about
ten million dollars. The University has an-
nounced the probable opening of this school in
1958. Mrs. Wilson formerly served on the Michi-
gan Agricultural Board and the Administrative
Board of Michigan State University.
MORE RESOLUTIONS
APPROVED BY THE 1956 MSMS
HOUSE OF DELEGATES
1. RESOLUTION RE ESTABLISHMENT OF
DEPARTMENTS OF GENERAL PRACTICE
IN MEDICAL SCHOOLS
Whereas, there has been a declining proportion of
medical graduates going into general practice, and
Whereas, the medical student is not now exposed to
the various requirements of general practice because of
the fact that all his instructors are those limiting their
practice to the various specialties, and
Whereas, the modern generalist requires training in
the art of medicine as well as the scientific approach,
more knowledge of preventive medicine, physiotherapy,
family counseling, medical and social economics and
public relations in general, and
Whereas, the House of Delegates of the American
Medical Association has passed a resolution requesting
that medical schools add a Department of General
Practice to their curriculum; therefore be it
RESOLVED, That the House of Delegates of the
Michigan State Medical Society request the University
of Michigan and the Wayne State University Medical
College to add a Department of General Practice to
their curriculum.
* * *
2. RESOLUTION RE EQUAL HEALTH
OPPORTUNITIES FOR ALL
Whereas, the health opportunities of the community
are our basic concern, and
Whereas, restriction or denial of health services and
facilities because of race, creed or color violates the
spirit of our ethical code; therefore be it
RESOLVED, That the Michigan State Medical So-
ciety record itself as favoring equal health opportunities
3. RESOLUTION RE COMMITTEE TO STUDY
USE OF WORD “CLINIC”
Whereas, during the last decade we have seen many
changes in medical practice, such as the growth of
groups, partnerships, clinics and medical centers, and
Whereas, this growth and grouping of medical re-
sources is natural and good, and in most instances re-
sults in better medical service for the public, and
(Continued on Page 164)
TMSMS
Immediate antirheumatic therapy is to be encouraged
in the treatment of tenosynovitis, as it should be in
the majority of other common rheumatic disorders,
to alleviate pain and prevent progression of the dis-
turbance to a point of irreversible damage.
SlGMAGEN provides doubly protective corticoid-sali-
cylate therapy— a combination of Meticorten® (pred-
nisone) and acetylsalicylic acid giving additive anti-
rheumatic benefit as well as rapid analgesic effect.
These benefits are supported by aluminum hydroxide
to counteract excess gastric acidity and by ascorbic
acid, the vitamin closely linked to adrenocortical func-
tion, to help meet the increased need for this vitamin
during stress situations.
protective corticoid-salicylate therapy
SIGMAG6N
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corticoid-analgesic compound
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The pain Dad feels now is the beginning of tenosyno-
vitis. With adequate early treatment he’ll be able to
stay on his job. Delaying therapy might result in the
development of effusion and, later, calcification of
ligaments or even periarthritis with severe pain and
serious restriction of movement.
AM A Washington Letter
THE MONTH IN WASHINGTON
The broad issue of federal construction grants
for medical schools pending before the 85th Con-
gress raises again a major question: To what
extent is there a physician shortage in the United
States?
The administration, through Secretary Folsom,
maintains that the need for more doctors and
research scientists is increasing rapidly as the
population rises, as medical science grows more
complex and as research programs are greatly-
expanded. And. he adds, the need undoubtedly
will continue to increase in the years ahead.
Many of these schools already are in a critical
financial plight, Mr. Folsom argues, and they need
increased private and public funds “just to meet
regular operating expenses.'’ Under these cir-
cumstances, without further aid, “many schools
face almost impossible obstacles in raising funds
for construction of new classrooms, laboratories
and other facilities.” The Secretary then sounds
this warning:
“Unless effective action is taken now toward
providing these facilities, the shortage of medical
scientists will grow much more acute in the years
ahead, and the health of the American people
will be retarded.”
To solve this problem, the administration wants
to broaden the program enacted last year for $30
million a year for three years to help build and
equip laboratories doing research in various
diseases. It asked the last Congress for $50 mil-
lion a year for five years for both research labs
and teaching facilities. The legislators only granted
the $30-miliion-a-year part. That, says the ad-
ministration. is not enough.
And to bolster that contention. Mr. Folsom
cites the record on the laboratory facilities act:
within three months after authorization, requests
totalling well over $100 million were received by
the Public Health Service.
But when the committees of Congress — in all
hkckhood starting with the House Interstate and
Foreign Commerce group — launch their hearings,
members will want to know just how short the
country is of doctors and whether reoorts of
shortages take into account the increased produc-
tivity of each physician in the light of new tech-
niques and other medical advances.
On the opening day of the 85th Congress, health
legislation emerged as a popular subject. Of the
approximately 2,000 bills, resolutions and private
measures introduced that day. seventy were
marked for study by the Washington Office of
152
the American Medical Association. Experienc'
has shown that about 3 per cent of all measures
are of medical importance.
Many of the bills were duplicates of those in
the last Congress, while others were revised ver-
sions of old favorites. In the latter category were
the Jenkins-Keogh bills (again bearing the num-
bers (H.R. 9 and H.R. 10) which would provide
tax deferment on money paid in annuity plans,
and the Bricker Amendment for keeping interna-
tional treaties from affecting internal laws of the
United States.
The tax deferment proposal was changed in
several respects, the most important being a pro-
vision for withdrawal of money from plans in
advance of age sixty-five, upon payment of a tax
penalty. The key section in the proposed con-
stitutional amendment sponsored by the Ohio
Senator states that “A provision of a treaty or
other international agreement not made in pursu-
ance of this Constitution shall have no force or
effect.”
One of the few' surprises in the opening day
rush to the bill hoppers was a bill by Rep. Poage
(D., Tex.) to authorize the Secretary of HEW
to make long-term, 3 per cent interest loans to
nonprofit hospitals for construction and expan-
sion of facilities, including nurses homes. Cer-
tain sectarian groups have been pressing for just
such a plan in lieu of taking federal grant money
under the Hill-Burton program.
Moving to fill two major spots in the Depart-
ment of HEW, President Eisenhower has named
as Assistant Secretary, thirty-six-year-old Elliot L.
Richardson, a Boston lawyer and son of the late
Dr. Edward P. Richardson of Massachusetts Gen-
eral Hospital and Harvard Medical School. Mr.
Richardson served at one time as law clerk to
Judge Learned Hand and Tustice Felix Frank-
1 inter, as assistant to Senator Saltonstall and as
consultant to former Governor Christian Herter,
now Under-Secretary of State.
To succeed Dr. Lowell T. Coggeshall as special
assistant for health and medical affairs, the Presi-
dent appointed Dr. Aims C. McGuinness. a Phila-
delphia pediatrician, who was last in Washington
as a clinical consultant to the United Mine Work-
ers’ Welfare and Retirement Fund. He was re-
sponsible for the medical staffing of the Fund’s
ten memorial hospitals in three mining states. Dr.
McGuinness was dean of the University of Penn-
sylvania Graduate School of Medicine and one-
time director of Children’s Hospital of Phila-
delphia.
JMSMS
in treatment
of respiratory
infections
new multi-spectrum synergistically strengthened antibiotic formulation
Sigmamycin adds certainty in antibiotic therapy, particularly for the 90% of patients
treated at home or in the office where sensitivity testing may not be practical, and provides :
a new maximum in therapeutic effectiveness, a new maximum in protection against resist-
ance, a new maximum in safety and toleration.
Supply: Capsules, 250 mg. (oleandomycin 83 mg., tetracycline 167 mg.). Bottles of 16
and 100.
. . , and for a new maximum in palatdbility
New mint-flavored Sigmamycin for Oral Suspension, 1.5 Gm. in 2 oz. bottle; each 5 cc. tea-
spoonful contains 125 mg. (oleandomycin 42 mg., tetracycline 83 mg.). ‘Trademark
Pfizer Laboratories, Division, Chas. Pfizer & Co., Inc., Brooklyn 6, N. Y.
World leader in antibiotic development and production
"... effective., .in the treatment of
a variety of infections seen regu-
larly by the practicing clinician . .
including pharyngitis, bronchitis and
other respiratory infections
and "... often useful in the treat-
ment of infections due to staphylo-
cocci resistant to one or several of
the regularly used antibiotics"
"side effects . . . [are] notable by
their absence"1
1. Carter, C. H.. and Maley, M. C. : Antibi-
otics Annual 1956-1957, New York, Medical
Encyclopedia, Inc., 1967, p. 51.
February, 1957
Say you saw it in the Journal of the Michigan State Medical Society
AM A News Notes
AMA RURAL HEALTH DERBY”
MARCH 7-9
The Blue Grass country of Louisville, Ken-
tucky, will be the scene of the American Medical
Association’s rural health “derby” March 7-9.
Sponsored by the Council on Rural Health, this
Twelfth National Conference on Rural Health
will be held at the Brown Hotel. It will feature
discussions on various problems of rural health and
medical care. Built around the theme of “To-
gether We Build,” the Conference will open
with greetings from the Honorable A. B. Chand-
ler, governor of Kentucky, the Honorable J. An-
drew Broaddus, mayor of Louisville, and Dr.
George F. Lull, AMA secretary-general manager.
Also scheduled to speak Thursday morning.
March 7, are Dr. F. S. Crockett, Council chair-
man; Dr. Austin Smith, AMA Journal editor, and
Dr. Julius Michaelson. chairman, Alabama State
Medical Association committee on medical service
and public relations.
Problems of medical education will be outlined
during the afternoon session by Dr. Edward Turn-
er, secretary, AMA Council on Medical Educa-
tion; Dr. J. Murray Kinsman, dean of medicine
at the University of Louisville; Dr. Charles Bush,
resident physician planning to enter rural prac-
tice in Kirkland, Ind., and Dr. W. Wyan Wash-
burn, chairman, North Carolina State Medical
Society committee on rural health and education.
The Friday program will cover the economics
of agriculture and medical and hospital care costs
and health and medical care problems of farm
laborers and migrant workers. Speakers include
Carroll Bottom, Purdue University economist;
Mary Schabinger, Detwiler Memorial Hospital,
Wauseon, Ohio, and Dr. Carll S. Mundy, Coun-
cil vice-chairman. Principal speaker at the Fri-
day evening banquet will be Dr. Leroy Burney,
surgeon general, U. S. Public Health Service,
Washington, D. C.
Other highlights of the Conference include dis-
cussions on rural-urban problems and rural aspects
of the problems of the aging. At the final session
on Saturday morning, Joseph Ackerman, man-
aging director, Farm Foundation, will give a
brief resume on the Conference, and Mrs. Charles
W. Sewell, Council advisory committee member,
will give an inspirational talk entitled “And Away
We Go.”
AMA TO SURVEY COUNTY
MEDICAL SOCIETIES
Questionnaires to determine the scope of ac-
tivity in various areas- including public educa-
tion, community service, society projects, meetings,
personnel, and finances — will be distributed early
this year by the American Medical Association to
all county medical societies. This fifth biennial
survey of county medical society activities is being
undertaken by the Council on Medical Service
and the Department of Public Relations with the
assistance of other AMA departments. More than
1,200 county societies supplied information for
the 1955 survey, and it is hoped that an even
larger number will complete the 1957 question-
naire.
AMA STUDIES MEDICAL CARE
PAYMENTS FOR INDIGENTS
A number of amendments which provide a new
method of financing medical care for indigent per-
sons receiving state public assistance aid were
passed by the 1956 Congress. The AMA Council
on Medical Service’s Committee on Indigent Care
has studied the changes these amendments make
in state and local indigent care plans and pre-
pared a question-and-answer survey for distribu-
tion to state medical societies. The Committee’s
“guides” for indigent care plans also have been
brought up to date for state society use.
After July 1, 1957, the federal government will
reimburse the states on a 50-50 basis for medical
care expenditures. The federal Bureau of Public
Assistance pays half the amount expended in any
program which meets its standards, up to an av-
erage of six dollars per month for adults and three
dollars per month for children. The Bureau is
attempting to encourage expansion of the medical
care benefits available after July 1, when the new
system of financing takes effect.
The program involved in this new plan in-
clude the federally-aided Aid to the Blind, Aid
to Dependent Children, Old Age Assistance, and
Aid to the Permanently and Totally Disabled.
These public assistance programs are organized
and administered by the states — the federal gov-
ernment participates only in the financing.
Any questions regarding the new plan should
be referred to John F. Burton, M.D., committee
chairman, at AMA Headquarters, Chicago.
AMA PUBLISHES NEW GUIDEBOOK ON
MATERNAL DEATH STUDIES
A new “Guide for Maternal Death Studies”
will be made available through the American
Medical Association’s Council on Medical Serv-
ice for distribution to state and county medical
societies interested in developing similar studies.
The publication will include — in addition to the
guides — a description of seven maternal death
study committees now in operation, sample forms,
material showing how the results of these studies
are being used in postgraduate education, and a
(Continued on Page 199)
154
JMSMS
PROTEIN PREVIEWS
utritional Problem
Knox “Food Exchange” Diet Enlists the Cooperation
of Your DIABETIC Patients for Dietotherapy
1. This Knox booklet is based on nutritionally-tested Food
Exchanges1 and demonstrates that variety is possible for
diabetic diets.
2. The easy-to-understand Food Exchanges simplify dietary
control for the diabetic by eliminating calorie counting.
3. Diets promote accurate adjustment of caloric levels to
the special needs of the patient, yet allow each individual
considerable latitude in the choice of foods.
4. Each booklet presents in addition 16 pages of appetizing,
kitchen-tested recipes.
1. The Food Exchange Lists referred to are based on material in
“Meal Planning with Exchange Lists” prepared by Committees of
the American Diabetes Association, Inc., and The American Dietetic
Association in cooperation with the Chronic Disease Program, Public
Health Service, Department of Health, Education and Welfare.
Cha9. B. Knox Gelatine Co., Inc.
Professional Service Dept. SJ-22
Johnstown, N. Y.
Please send me dozen copies
of the Knox diabetic brochure describ-
ing the use of Food Exchange Lists.
Your Name and Address
u
February. 1957
Say you saw it in the Journal of the Michigan State Medical Society
155
American Medical Association
Report of the House of Delegates
TENTH CLINICAL MEETING
November 27-30, 1956, Seattle, Washington
By Wm. A. Hyland, M.D.,
Grand Rapids, Michigan
Chairman of Michigan Delegation
\
Medical ethics, veterans’ medical care, radio-
active isotopes, continuance of the American
Medical Association interim session, hospitaliza-
tion for patients with alcoholism and a report of
the Committee on Medical Practices were among
the wide variety of subjects acted upon by the
House of Delegates at the American Medical
Association’s Tenth Clinical Meeting held No-
vember 27-30 in Seattle.
Dr. Edward M. Gans of Harlowton, Montana,
was announced at the opening session Tuesday as
the 1956 General Practitioner of the Year. Dr.
Gans, who is eighty years old, has practiced
medicine for fifty-one years and has been in the
Harlowton area for the past forty-four years.
Strongly condemning government intervention
in medicine, Dr. Dwight H. Murray of Napa,
California, American Medical Association Presi-
dent, told the opening session that “the medical
profession, along with business and industry, is
caught between those who desire even more in-
tensely to perpetuate party politics. Unfortunate-
ly, in recent years a benevolent federal government
appears more attractive to the voting public than
the preservation of individual freedoms. Medicine
must do its utmost to reverse this trend.”
Total registration at the end of the meeting,
was 6,282 including 2,813 practicing physicians
and 3,813 residents, interns, medical students,
nurses and guests.
Medical Ethics
Subject of greatest interest at Seattle was the
proposed, ten-section revision of the Principles of
Medical Ethics originally submitted at the .June,
1956, Annual Meeting in Chicago, where final
action was deferred until the Seattle session. The
proposed short version of the Principles was re-
submitted with some changes based on sugges-
tions received since last June by the Council on
Constitution and By-Laws. The House of Dele-
gates, however, decided to refer the matter back
to the Council on Constitution and By-Laws for
further study and consideration. The reference
committee report adopted by the House included
the following statements:
Careful consideration was given to the Preamble and
the ten sections of the proposed Principles. The Pre-
amble and seven of the ten sections appear to be ac-
ceptable in their present form.
Sections 6 and 7 were not acceptable as presented
either to the group which appeared at the hearing or to
your reference committee.
Out of the general discussion the reference committee
received the crystallized opinion that at least four areas
needed more specific attention in Sections 6 and 7 .
These are: 1) Division of fees; 2) the dispensing of
drugs and appliances; 3) the corporate practice of
medicine; and 4) greater emphasis concerning the re-
lationship between physicians and patients.
In addition, the reference committee felt that the
wording in Section 10 could be improved if amended to
read as follows:
“the responsibilities of the physician extend not only
to the individual but also to society and deserve his
interest and participation in activities which have as
their objective the improvement of the health and
welfare of the individual and the community.”
In view of the above your reference committee be-
lieves that the proposed Principles of Medical Ethics
should be referred back to the Council on Constitution
and By-Laws for further study and consideration of the
above stated principles.
In the short space of time at our disposal and in view
of the importance of the subject, your reference commit-
tee did not deem it wise to attempt to properly phrase
these concepts.
We would also recommend that if possible this study
be completed at least six weeks prior to the June session
and that the new version be published in The Journal
in order that all interested physicians might have an op-
portunity to comment thereon.”
Veterans’ Medical Care
The House revised American Medical Associa-
tion policy on veterans’ medical care by endorsing
in principle the following paragraph suggested by
the Council on Medical Service:
With respect to the provision of Medical care and
hospitalization benefits for veterans in Veterans Ad-
ministration and other federal hospitals that new legis-
lation be enacted limiting such care to veterans with
peacetime or wartime service whose disabilities or dis-
eases are service-incurred or aggravated.
( Continued on Page 158)
156
JMSMS
for the average
patient in
erergdap practice
H well suited for prolonged therapy
0 well tolerated, nonaddictive, essentially nontoxic
no blood dyscrasias, liver toxicity, Parkinson-like syndrome
or nasal stuffiness
.. chemically unrelated to chlorpromazine or reserpine
f; does not produce significant depression
i orally effective within 30 minutes for a period of 6 hours
Indications' anxiety and tension states, muscle spasm.
Tranquilizer with muscle-relaxant action
DISCOVERED AND INTRODUCED
BY ^WALLACE LABORATORIES, New Brunswick, N.J.
| 2-methyl-2-n-propyl-l, 3-propanediol dicarbamate — V- S. Patent 2,721,720
SUPPLIED: 100 mg. scored tablets. Usual dose: 1 or 2 tablets t.i.d.
Literature and Samples Available on Request
CM-3706-R2
February, 1957
Say you saw it in the Journal of the Michigan State Medical Society
157
AMA TENTH CLINICAL MEETING
(Continued from Page 156)
This action eliminates the temporary exceptions
which were made in the June, 1953, policy re-
garding wartime veterans who are unable to de-
fray the expenses of necessary hospitalization for
non-service-connected cases of tuberculosis or
psychiatric or neurological disorders. In making
the policy change, the House approved this sup-
plementary statement:
We recognize the laws and administrative extensions
of the law that are now in operation. We feel that
under the circumstances it will be to the best interests
of the public in general, and veterans in particular, if
medical societies, county and state as well as national,
develop committees to assist in guaranteeing VA hos-
pital admission to service-connected cases. While the
present law exists, we should help assure that veterans
whose illness constitutes economic disaster will not be
displaced by those suffering short-term remediable ills
which, at the worst, constitute financial inconvenience.
In another action concerning veterans, the
House passed two resolutions condemning as un-
lawful the practice of Veterans Administration
hospitals which admit patients who are covered
by workman’s compensation insurance or bv pri-
vate health insurance and which render bills for
the cost of their care. Both resolutions requested
the American Medical Association to take action
to bring about a discontinuance of such prac-
tices by VA Hospitals, and one of them instructed
the Association Secretary to obtain from each
state testimony or records of each known case that
violates VA Reg. 6047-D1.
Military Dependents (Medicare)
The House recognized the assistance that the
American Medical Association has given to the
government and state societies in negotiating con-
tracts for medical care of the military dependents
and urged that this guidance be continued in the
future. It was also emphasized that the medical
profession must make every effort to carry out
successfully this liberal program, for it will be
used as a yardstick in future plans that may come
up before Congress.
Social Security
Attention was called to Public Law 880, which
provides cash benefits for total and permanently
disabled persons. Since administrative regulations
have not yet been developed, the House asked
the Board of Trustees to consider the establish-
ment of a regulation to provide that the findings
of the physician making the original examination
be forwarded to a rotating committee of Dhysi-
cians appointed by county society for review and
final report.
Attention was also called to another amend-
158
ment to the Social Security act which provides for
federal funds on a matching basis for medical
care for groups in the welfare program; it was
recommended that state societies develop ma-
chinery for handling this program.
Radioactive Isotopes
The House rescinded the June, 1951, action,
which limited the hospital use of radium and
radioactive isotopes to board-certified radiologists,
by approving a new policy statement which says:
1. In any hospital in which a patient is to receive
radium or the products of radium or artificially pro-
duced isotopes, there should be a duly appointed Com-
mittee on Radium and Artificially Produced Radioiso-
topes of the hospital professional staff. This committee
should include, but not necessarily be limited to, the
following qualified physicians: a radiologist, a surgeon,
an internist, a gynecologist, a urologist and a pathologist.
This committee should have available such competent
consultation of other physicians and scientific personnel
as may be required by it. Where this is not practicable,
the Hospital staff should consult the nearest Committee
on Radium and Artificially Produced Radioisotopes.
2. In any hospital, the use of radium or its products
and artificially produced radioactive isotopes for diag-
nostic or therapeutic purposes shall be restricted to
qualified physicians so judged by the Committee on
Radium and Artificially Produced Radioisotopes of the
professional staff to be adequately trained and com-
petent in their particular use.
3. It is recommended that procurement, storage,
dosimetry control and inventory of all radioactive iso-
topes for the use of the hospital staff and radiological
safety control be centralized, and. where ? ministrative-
ly possible, centralization be located in the Department
of Radiology.
4. It is recommended that the Board of Trustees as-
sign to the appropriate council or committee the con-
tinuous study of the problems of radiological safety con-
trol in the use of radium and its products and artificial-
ly produced radioactive isotope for diagnostic or thera-
peutic purposes.
Civil Service Employes
view of the continued expansion in the fielc
of tedical care, as evidenced by the above new
laws, the report on medical care for Civil Service
Employees was referred back for further stud'
and report. The report had expressed the opinioi
that no action was needed for this problem.
Guides
The House approved the “Guides for Medica
Societies in Developing Plans for Tax-Supportei
Personal Health Services for the Needy.” Becaus !
of the new Social Security amendments, it was be
lieved these Guides would be helpful to the stat
societies.
(Continued on Page 160)
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Effective in 93-98% of cases
The original Azo-Sulfa Formula*
Antibacterial • Analgesic
LOCALIZED MUCOSAL ANALGESIA
Phenylazo-diamino-pyridine HCI — acts solely ori the urogenitaO
mucosa; provides prompt relief from burning, pain and frequency.
LOCALIZED ANTIBACTERIAL ACTIVITY
Sulfacetamide— eliminates mixed infections rapidly because of its
unusual solubility in acid urine common to bacterial invasion of the
urinary tract. No renal damage, concretions or anuria.
...and when Spasmolysis is essential
sulfid B-A
Antibacterial • Analgesic • Antispasmodic
—the dual activity of SULFID with the well-known antispasmodic
effect of natural belladonna alkaloids.
FORMULAE:
SULFID B-A-Each coated
tablet contains the SULFID
formula with natural belladonna
alkaloids, 0.065 mg., in bottles of
100 tablets.
COLUMBUS
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contains: Phenylazo-diamino-
pyridine HCI, 50 mg. and Sulfa-
cetamide, 250 mg., in bottles of
100 tablets.
ACAL COMPANY — Columbus 16, Ohio
’Introduced— luly, 1954
February, 1957
Say you saw it in the Journal of the Michigan State Medical Society
159
AMA TENTH CLINICAL MEETING
(Continued from Page 158)
Medical Education and Hospital
Apparently the Council on Medical Education
and Hospitals and the Joint Commission on Ac-
creditation of Hospitals have carried out success-
fully the programs and mandates of the House of
Delegates, for there were few resolutions and no
controversy about the many subjects in this field.
Council on Medical Educational and Hospitals:
The House reviewed and approved the report
of the Council and urged each member to fa-
miliarize himself with the work of the Council
on Medical Education on the undergraduate level,
with specialty groups, and in graduate medical
education. It noted with favor the increased in-
terest in postgraduate education for the practic-
ing physician. Approval was also given to the re-
visions to the Essentials of Approved Residencies
and Fellowships, which involve preventive medi-
cine and radiology.
Committee on Medical Practices: The delegates
accepted the report from this special committee,
which contained several recommendations:
1. That work be deferred on the relative value scale.
2. That the American Medical Association Public Re-
lations Department continue its present educational pro-
gram to increase appreciation of non-surgical work.
3. That a study committee be appointed to analyze
the best background preparation today for general prac-
tice.
4. That the previous directive be revised to read :
“The American Medical Association representatives of
the Joint Commission of Hospital Accreditation be in-
structed to stimulate action by that body leading to the
warning, provisional accreditation, or removal of ac-
creditation of community or general hospitals which ex-
clude or arbitrarily restrict hospital privileges for gen-
eralists as a class regardless of their individual profes-
sional competence where such policies adversely affect
the quality of patient care rendered. Any action taken
should be only after appeal to the Commission by the
county medical society concerned.”
The report also deplores that “segments of the med-
ical profession make sweeping and inaccurate statements
for public consumption without prior consultation with
other interested and informed groups.”
Clinical Meetings
Rejecting a resolution which recommended dis-
continuance of the interim sessions, or clinical
meetings, the House adopted a reference commit-
tee report which said:
We believe that the interim sessions should be con-
tinued because of the public relations value of these
meetings to the Association and the educational value
to physicians and the general public in the various geo-
graphical areas involved.
It is the suggestion of the reference committee that
maximum attention be given to these potential benefits
in selecting for the interim meeting.
It is our further recommendation that the Board of
Trustees consider the advisability of holding an Interim
Scientific Session in November or December of each
year in different parts of the United States. The refer-
ence committee suggests that the views of the Board of
Trustees in this regard be reported to the House of
Delegates next June.
Hospitals
The House took the following action on sub-
jects pertaining to hospitals. They endorsed the
activities initiated by the American Hospital As-
sociation and American Institute of Architects to
carry on a research project financed by a gov-
ernmental grant on hospital design and construc-
tion and recommended that the American Medi-
cal Association join in the proposed study.
Hospitalization for Alcoholics
To implement educational approaches to the
problem of alcoholism, the House approved a
statement submitted through the Board of Trus-
tees by the Council on Mental Health and its
Committee on Alcoholism. The House also rec-
ommended that the statement be brought to the
attention of the Council on Medical Education
and Hospitals, the Joint Commission on Accredita-
tion of Hospitals and the American Hospital As-
sociation. It includes the following:
The Council on Mental Health urges hospital admin-
istrators and the staffs of hospitals to look upon alco-
holism as a medical problem and to admit patients who
are alcoholics to their hospitals for treatment, such ad-
mission to be made after due examination, investigatior
and consideration of the individual patient. Chronic
alcoholism should not be considered as an illness which
bars admission to a hospital, but rather as qualification
for admission when the patient requests such admission
and is co-operative, and the attending physician’s opinion
and that of hospital personnel should be considered
The chronic alcoholic in an acute phase can be, anc
often is, a medical emergency.
Committee on Medical Practices
In approving a progress report of the Commit-
tee on Medical Practices, the House amended one
of its directives to read as follows in order to re-
move any legal objections:
The American Medical Association representatives on
the Joint Commission on Accreditation of Hospitals be
instructed to stimulate action by that body leading to
the warning, provisional accreditation, or removal of
accreditation of community or general hospitals which
exclude or arbitrarily restrict hospital privileges for
generalists as a class regardless of their individual pro-
fessional competence where such policies adversely affect
(Continued on Page 162)
ISO
JMSMS
Mr,BAcra
^''tSag&S
an effective adjunct to therapy
of common dermatoses
prolonged antibacterial action — emollient effect
no irritation — french-mi I led — noncrumbling
AMA TENTH CLINICAL MEETING
(Continued from Page 160)
the quality of patient care rendered. Any action taken
should be only after appeal to the Commission by the
county medical society concerned.
The House also approved a recommendation
by the Committee on Medical Practices that a
study group be formed to consider the best back-
ground preparations for general practice, and it
urged that such action be implemented as soon
as practicable.
Miscellaneous Actions
Among many other actions on a wide variety
of subjects, the House of Delegates also:
Urged the widest possible publication and dis-
tribution of Dr. Murray’s presidential address at
the opening session;
Pledged the full support of the Association’s
initiative and energy to President Eisenhower’s
people-to-people program as a means of promot-
ing understanding, peace and progress;
Directed the Board of Trustees to continue its
investigation of the practicability of developing a
statement of American Medical Association poli-
cies and to arrange for the periodic publication
of revised versions of such a policy statement;
Commended the objectives of the American
Association of Medical Assistants and its sincere
desire to work closely with the medical profes-
sion in improving medical service and medical
public relations;
Noted with pride the good work being done by
the 75,000 members of the Woman’s Auxiliary;
Directed the Councils on Pharmacy and Chem-
istry and on Foods and Nutrition to conduct a
joint study of all presently available information
concerning the fluoridation of public water sup-
plies and to present a documented report of find-
ings and recommendations at the December, 1957,
meeting;
Urged all physicians to participate actively in
the formulation of medical policy for prepaid
medical care plans which are under physician
direction or sponsorship;
Changed the By-laws to extend service mem-
bership to reserve officers on extended active duty
with the defense forces and the U. S. Public
Health Service;
Changed the By-laws relating to transfer of
membership so that an active or associate mem-
ber of the Association who moves his practice to
another jurisdiction may continue his American
Medical Association membership by applying for
membership in the constituent association in his
new jurisdiction, subject to a two-year limit on
approval of his application;
Changed the By-laws so that the election of
officers may take place at any time on the fourth
day of the annual session, instead of being re-
stricted to the afternoon of that day;
Passed a resolution calling for the American
Medical Association to join with the American
Hospital Association and the American Institute
of Architects in their proposed study of hospital
design and construction;
Approved the principle of voluntary reduction
in the self-assigned quota of interns as printed in
the 1956 handbook of the National Intern Match-
ing Program, and;
Instructed the Board of Trustees to accentuate
cooperation between the American Medical As-
sociation and the American Bar Association to
the end that a bill of the Jenkins-Keogh type be
enacted at the next session of Congress.
Scientific Exhibits
Several groups from Michigan had worthy ex-
hibits at this meeting: “Oral Phenoxymenthyl
Penicillin in the Treatment of Bacterial Endo-
carditis,” by E. L. Quinn, J. L. Colville, Frank
Cox, Jr., and Joseph Truant, Henry Ford Hos-
pital, Detroit; “Diagnosis and Treatment of Non-
Otosclerotic Middle Ear Deafness,” by H. G.
Kobrak, Geraldine Purcell and Eduard Domeier,
Detroit; “Current Status of Intravenous Chole-
cystography and Cholangiography,” by J. Edward
Berk, Howard Feigelson Sinai Hospital and Wayne
State University, Detroit; “Hemorrhage and Hypo-
fibrinogenemia : Clinical and Experimental
Studies,” by C. Paul Hodgkinson, Paul W. Pifer,
Melvin A. Block and Donald G. Remp, Henry
Ford Hospital, Detroit; “Ectylurea, A New Calma-
tive for the Relief of Anxiety and Tension States,”
by John T. Ferguson and Frank V. Z. Linn,
Traverse City State Hospital, Traverse City.
MEDICAL MEETINGS AND CLINIC DAYS
A list of known medical meetings and clinic days, sponsored by county medical societies and
other physician groups in Michigan, follows:
1957
March 13-15
Spring
April 17
May 5-10
Michigan Clinical Institute, Sheraton-Cadillac Hotel
MSMS Postgraduate Extramural Courses
Genesee County Medical Society, Twelfth Annual Cancer Day
Sixth International Congress of Otolaryngology
Detroit
Statewide
Flint
Washington, D. C.
162
TMSMS
Tastiest way to dissolve sore throat symptoms
(hydrocortisone-bacitracin-tyrothricin-
NEOMYC1N-BENZOCAINE TROCHES)
Adult or juvenile, your patients with sore throats
will welcome a course of HYDROZETS. These
newest Merck Sharp & Dohme troches offer anti-
inflammatory, anti-infective and analgesic proper-
ties that promptly alleviate distressing mouth or
throat irritation whether caused by infection,
mechanical injury or allergic reaction. And
HYDROZETS taste so good, it’s hard to believe
they’re medicine.
Formula: Each HYDROZETS Troche contains —
2.5 mg. ‘H YDROCORTONE’ to reduce pain, heat
and swelling; 50 units Zinc Bacitracin, 1 mg.
Tyrothricin and 5 mg. Neomycin Sulfate to com-
bat gram-positive and gram-negative bacteria; and
5 mg. Benzocaine for rapid soothing analgesia.
Other indications: As adjunct therapy in aphthous
ulcers, acute and chronic gingivitis and Vincent's
infection.
Supplied: Vials of 12 troches.
MERCK SHARP & DOHME
DIVISION OF MERCK & CO . INC.. PHILADELPHIA 1. PA
February, 1957
Say you saw it in the Journal of the Michigan State Medical Society
163
J. R. BRUCE, JOURNAL OF MSMS
PUBLISHER, DIES
J. R. Bruce, 81,
of St. Paul, found-
er and chairman
of the Board of
the Bruce Publish-
ing Company —
long-time publish-
er of The Jour-
nal of the Michi-
gan State Medi-
cal Society — died
in late December.
Mr. Bruce
founded his pub-
lishing and adver-
tising company in 1912 with the Northwestern
Druggist as his first publication. At the time of
his death his company had fifty-two publications
on its list, including the Journal of the Mich-
igan State Medical Society.
Mr. Bruce was born in Freedom, Kentucky,
and came to St. Paul in 1903. He lived there
continuously since. He retired as president of
Bruce Publishing Company in 1946 to become
Chairman of the Board.
Mr. Bruce is survived by his wife, Anna H.
Rowan Bruce, one daughter, Mrs. W. G. Shep-
herd, and one son. J. Robert Bruce, Jr., (associ-
ated with Bruce Publishing Company) and six
grandchildren.
The sympathy of the Editor and members of
the Publication Committee of JMSMS have been
extended to the wife and family of Mr. Bruce
— a man who during more than a quarter of a
century aided The Journal of the Michigan
State Medical Society with constant advice,
understanding, good will and outstanding service.
3. RESOLUTION RE COMMITTEE TO STUDY
USE OF WORD “CLINIC”
(Continued from Page 148 )
Whereas, the word “clinic” implies resources and
facilities not usually found in a private physician’s office,
and
Whereas, there are rapidly becoming too many one-
and two-physician clinics, which are unethical, mislead-
ing, false advertising, therefore be it
RESOLVED, That this House of Delegates of the
Michigan State Medical Society request The Council
to appoint a committee to study this situation and make
recommendations to the House of Delegates for proper
action.
- TRANSACTION IS EVER CON-
Kin SIDERED COMPLETE AT KILGORE
and HURD UNTIL YOU ARE
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TO OUR SUCCESS IN MAKING THIS SO.
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92 Kercheval
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Detroit
164
Say you saw it in the Journal of the Michigan State Medical Society
JMSMS
//
In one investigation, 75 adult patients with bacterial pneumonia
were treated with erythromycin. In his summary, the clinician re-
ported: “It is concluded that erythromycin is highly effective in the
treatment of pneumonia due to gram-positive bacteria.”2 *
This, of course, is only one of many reports showing the effective-
ness of Erythrocin against coccic infections. You’ll get the same
good results (nearly 100% in common, bacterial res-
piratory infections) when you prescribe Erythrocin
. QMrott
f'lmtab6 1
Erythrocin
(Erythromycin, Abbott)
STEARATE
' AJo S>tAMno$ S>u£e, OecuAAzdiS'
After a study of 171 patients treated with erythromycin, the investi-
gator wrote: “No serious side effects occurred with prolonged therapy
or with doses up to 8 Gm. per day in the severe infections.”1
Actually, Erythrocin stands on a remarkable record of safety.
After four years, there’s not a single report of a severe or fatal reac-
tion attributable to erythromycin. In addition, you’ll find allergic
manifestations rarely occur. Filmtab Erythrocin r\ f) fl , ,
Stearate (100 and 250 mg.), in bottles of 25 and 100. (JJjvTMX
® Filmtab — Film-Sealed tablets, Abbott; pat. applied for.
1. Romansky, M.J., et al.. Antibiotics Annual 1955-1956, p. 48,
2. Waddington, W. S., Maple, F. C., and Kirby, W. M. M.,
A.M.A. Archives of Internal Medicine, 1954, p. 556.
701051
PR REPORT
DR. PAYNE MOVES UP:
DR. TEED TAKES OVER
R. W. Teed, M.D., took up
the reins of the MSMS Pub-
lic Relations Committee at the
January 25 meeting in De-
troit. Doctor Teed was ap-
pointed committee chairman
in September to succeed C.
Allen Payne, M.D., who was
elected Councilor of the Fifth
District by the 1956 House of
Delegates.
Doctor Teed, an Ann Arbor ophthalmologist,
has a consuming interest in medical public rela-
tions which began in 1947, his first year as a
member of the newly created PR Committee.
Since 1954 he has served as vice-chairman.
A believer in “preventive medicine,” Doctor
Teed felt that this could well be a new ap-
proach to public relations and thus he became
a prime mover in the continuing program to
insert the socio-economic “facts of life” in the
training of medical students.
The experience which Doctor Teed brings to
the committee stems from his service record on
MSMS committees through the years, including:
Medication (eight years), Scientific Radio, and
Legislative Study.
C. Allen Payne, M.D., for
the past four years chairman
of the MSMS Public Relations
Committee, also devoted a full
ten years of service to improv-
ing the doctors’ relations with
their public. In his present ca-
pacity as Councilor, Doctor
Payne may well draw upon his
PR knowledge in matters of
decision. A broad background
in many areas of medical or-
ganization gives Doctor Payne an enviable scope
of understanding. His decade of service to MSMS
includes contribution to these committees: Can-
cer Control, Legislative Study, Michigan Cancer-
Coordinating, and Advisor to Woman’s Auxiliary
to MSMS and the State Medical Assistants So-
ciety.
BUSY DAYS are the rule in the MSMS these
winter months as committees and staff swing into
the crucial portion of the year’s work.
The policies of the House of Delegates take
168
form in programs developed by dozens of com-
mittees and executed by The Council.
An active legislature considers budgets and proj-
ects of state health agencies and considers the
policies of hundreds of organizations as they affect
the welfare of the people. Material from legis-
lative hearings flows to doctors on a hundred and
one health matters. Liaison meetings with related
organizations tumble over one another seeking a
place on the crowded calendar of events. Con-
ferences, big and small, are arranged, reported
and their findings acted upon.
Work is evaluated and programs are revised to
meet changing situations. A flood of communica-
tions to large groups and small — often on an emer-
gency basis — tax the facilities and personnel avail-
able to MSMS.
Yes, these are busy days. But occasionally,
through the fog of routine, things happen that
deserve special cognizance. This month The
Journal presents two films and two doctors that
are important to the MSMS PR program.
“Something Called Epilepsy.” — After nearly two
years in the making, “Something Called Epilepsy,”
a new 16 mm. motion picture film in sound and
color, will be ready for its premiere by the time
you read this.
Produced by MSMS, this film departs from the
strictly documentary approach used in most of
the previous MSMS pictures. Instead, it in-
corporates a story line that will have appeal par-
ticularly to teen-agers and their parents.
Services of the Michigan Epilepsy Center were
used in the filming, and the team approach to
diagnosis advocated by the Center is effectively
utilized in the story.
The basic theme of the picture is that epileptics
can live in society happily if they — and the pub-
lic at large — understand that “Something Called
Epilepsy” is not a thing to be ashamed of, that
cures can be effected, and that there is promise
for a brighter future.
New Film Document. — A documentary motion
picture, recording the transition of the Wayne
County Medical Society from its present quarters
to the New David Whitney House, was approved
in December by the Executive Committee of The
Council for presentation to Wayne doctors.
Shooting began on December 19 at ground-
breaking ceremonies opposite the Medical Science
Building on the College of Medicine campus of
Wayne State University.
The complete film will have a running time of
(Continued on Page 170)
TMSMS
SYMPTOMATIC
RELIEF... PLUS!
ACHROCIDIN
TETRACYCLINE-ANTIHISTAMINE-ANALGESIC COMPOUND
Tablets
and
Syrup
Achrocidin is particularly valuable in treating acute
respiratory infections during epidemics or when ques-
tionable middle car, pulmonary, nephritic, or rheumatic
signs are present.
Achrocidin offers early, potent therapy against such
disabling complications as otitis media, sinusitis, bron-
chitis to which the patient may be highly vulnerable at
this time.
Included in the comprehensive achrocidin formulation
are the analgesic components recommended for prompt
relief of common cold symptoms.
Adult dosage for achrocidin Tablets and new, caffeine-
free achrocidin Syrup is two tablets or teaspoonfuls of
syrup three or four times daily. Dosage for children ac-
cording to weight and age.
Available on Prescription Only
Each tablet contains:
Achromycin® Caffeine 30 mg.
Tetracycline 125 mg. Salicylamide 150 mg.
Phenacetin 120 mg. Chlorothen Citrate 25 mg.
LEDERLE LABORATORIES DIVISION, AMERICAN CYANAMID COMPANY, PEARL RIVER. NEW YORK
^Trademark
February, 1957
Say you saw it in the Journal of the Michigan State Medical Society
169
BAND-AID
TRADE MARK
Plastic Strips
*00 ADHfSiyr
3 ' v « BANDACt
• ELASTIC PLASTIC
band-aid
• FLESH COLORED
Plastic
• STAYS CLEAN
strips
• THIN, SMOOTH PLASTIC
• GREASE RESISTANT
• WON'T WASH OFF
1 OO’s 1 "x 3"
100’s 3/4 "x 3"
CtHieueHtlif /located
in (fraud Rapid*
• Hospital Equipment
• Pharmaceuticals
• Office Equipment
• Physicians’ Supplies
• Trusses
• Surgical Garments
• Physiotherapy Equipment
Medical Arts Supply Company
233 Washington S. E. Phone GL 9-8274
Grand Rapids 2, Mich.
Medical Arts Pharmacy
20-24 Sheldon S.E. Phone GL 9-8274
Grand Rapids 2. Mich.
RHEUMATIC FEVER CO-ORDINATOR
LEON DEVEL RESIGNS
After eight years of arduous
and pioneering work in or-
ganizing and helping maintain
the thirty rheumatic fever cen-
ters of the Michigan State
Medical Society, Rheumatic
Fever Control Coordinator
Leon DeVel, M.D., of Grand
Rapids resigned as of Febru-
ary 1, 1957, to assume a posi-
tion with the Michigan Crip-
pled Children Commission.
The excellent record established by Dr. DeVel
was recognized by the MSMS Executive Com-
mitee of The Council which, at its December 12
meeting in Detroit, accepted the DeVel resigna-
tion “with very sincere regret.” A note of appre-
ciation was placed on the Executive Committee
minutes for the the valuable service Dr. DeVel
rendered during his eight years with the Society.
The Executive Committee of The Council called
Dr. DeVel’s program “a most unique and pro-
gressive activity that has gained stimulation, mo-
mentum and nationwide attention through your
good efforts. We all shall . miss you and your
effective work.”
Good luck. Dr. DeVel, and all success in your
new undertaking in behalf of rheumatic fever
patients.
PR REPORT
(Continued from Page 168)
approximately ten minutes and its premiere is
planned during the dedication celebration some
eighteen months hence.
D. Bruce Wiley, M.D., Chairman, The Council,
announced the film plans to civic and medical so-
ciety dignitaries at the WCMS Groundbreaking
Luncheon in December.
W. B. Harm, M.D., was appointed Chairman
of a Special Project Film Committee to supervise
and aid production of the motion picture. Other
Wayne doctors invited to serve are: Louis Bailey,
M.D., President-Elect; Luther Leader, M.D.,
President; A. E. Schiller, M.D., MSMS Coun-
cilor and Chairman, MSMS Sub-Committee on
Radio, TV and Motion Pictures; and Warren
Babcock, M.D., Ex officio Chairman, WCMS
Building Committee.
170
Say you saw it in the Journal of the Michigan State Medical Society
TMSMS
Proper formula for treating “Rheumatism'* patients
Multiple Compressed Tablets
TEMPOGEN
With TEMPOGEN, many patients obtain adequate
relief from immobilizing “rheumatic” pain with
lower hormone dosages than are ordinarily
required, because of the enhanced antirheumatic
effect provided by the prednisolone-salicylate
combination. In addition, the likelihood of the
occurrence of gastric distress or adrenal ascor-
bic acid depletion is minimized.
INDICATIONS: Early rheumatoid arthritis, rheu-
matoid spondylitis, osteoarthritis, Still’s disease,
psoriatic arthritis, bursitis, synovitis, tenosynovi-
tis, myositis, fibrositis, and neuritis.
Supplied: TEMPOGEN® and TEMPOGEN® Forte-in bottles of 100 Multiple Com-
pressed Tablets. (TEMPOGEN Forte provides 2 mg. ot prednisolone.) TEMPOGEN
and TEMPOGEN Forte are trademarks of Merck & Co., Inc.
* present as 60 mg. sodium ascorbate
MERCK SHARP & DOHME
DIVISION OF MERCK & CO.. INC. PHILADELPHIA 1, PA.
February, 1957
Say you saw it in the Journal of the Michigan State Medical Society
Editorial Opinion
A SUGGESTION FOR MD’S
An innovation in the field of doctoring has been
brought to our attention. We think so highly
of the new procedure that we want to pass it on
to our own doctors with the thought that the
idea may be catching. It is, the applause from
Mr. and Mrs. Citizen will resound.
In several cities here in the United States
doctors are aware that the public must be served
around the clock. This is an “old-fashioned”
idea that went out the wandow for too many
doctors of our generation. With exceptions, doc-
tors today call it quits with sundown.
It is not the purpose of this editorial to argue
the right or wrong of this practice. That there is
an answer to the problem is our concern. We
know that sickness does not wait upon the clock.
It strikes at any hour — and at any hour we may
need a doctor.
This perplexing problem is being solved in
some cities today by establishing physicians ex-
panding their organization to include one or more
young doctors, perhaps just starting out in pri-
vate practice. The office then publicly announces
“Open twenty-four hours a day,” with the young
doctors holding down the office throughout the
night.
Wherever this is being tried, public accept-
ance has been almost instant. Many of the older
physicians in other offices have been only too
happy to refer their night calls to the young
doctors who are on duty all night.
If you have ever needed a doctor in the
night for yourself or your family you will recog-
nize the importance of knowing that someone
is available. You may even want to suggest to
your own family doctor that he investigate the
merits of such a plan as we have described to
be initiated in our own Downriver area. We are
confident the public will voice wholehearted ap-
proval.— Wyandotte News-Herald , December 14
1956.
TACTLESS HOSPITALS
Hospitals, including those in Michigan, prob-
ably have as poor public relations as any known
group outside the Iron Curtain.
Why this should be so is not altogether clear
to us, but it IS so.
It may be, as some hospital people have argued
in the past, that being sick is one luxury nobody
likes to pay for. When you are sick and need to
go to the hospital you (and your relatives) are
vociferous in demanding the best and “we don’t
care about the cost — give us the best.”
After you are well, and the bill remains, your
172
wail rises to the unresponsive heavens, “Why does
it cost so much?”
Since the advent of Blue Cross, the hospital
bill no longer remains as a frightening shadow in
the background. How to prepay the doctor’s bill
is a problem not wholly solved, but Blue Cross
has made the hospital bill stop scaring us to death.
Yet hospital public relations remain bad. Even
though Blue Cross is a nonprofit organization,
certain groups grumble skilfully that Blue Cross
shouldn’t raise its rates — even though everybody
else does.
The hospitals are given a free-hand walloping
at any opportunity. We complain about the food,
the service, the cost, the visiting hours, and about
everything.
Since the hospitals, when you get right down
to it, are doing a magnificent job of getting sick
people well, the criticism isn’t altogether war-
ranted.
*5f "Jr
However, we do think the attitude of some
hospital employes, and doubtless of some hospital
executives, is haywire. The idea still seems to
prevail that, when you are in the hospital, you’d
better do as the rules say.
It’s not yours to question why. Not yours to
express a preference. Not yours to criticize any-
thing. You do as you’re told!
Some hospitals are beginning to break into a
new kind of thinking. They are beginning to
realize that we don’t always like things that are
good for us, especially if shoved down our throats.
They are beginning to realize that patients are
customers, and that they will react like any other
customer if they are treated as such.
In short a little salesmanship, as practiced by
the automobile salesman, the drug store clerk and
any salesperson with the wit to say please and
thank you, and cater a bit to our whims and egos,
will do a lot to restore the hospitals to the public
esteem and affection which, at bottom, they merit.
In other words, you hospitals, why don’t you
develop a dabble of tact?
(As to this editorial, may we add to the hos-
pitals this further advice: Don’t do as we DO;
do as we SAY.) — Detroit Times, Dec. 26, 1956.
In rural areas, cancer of the skin may comprise 40 to
50 per cent of all cancers seen.
* * *
Basal cell carcinomas are seldom found on the hands
or the temporal or cervical areas.
* * *
Complete removal and microscopic examination is the
most satisfactory treatment for early, questionable
lesions.
TMSMS
HT-te JOU R N A L
of the Michigan State Medical Society
Issued Monthly Under the Direction of The Council
VOLUME 56 FEBRUARY, 1957 NUMBER 2
Cancer Day in Genesee County
By H. B. Elliott, M.D.
Flint, Michigan
T^ARLY in 1946 the Cancer Education Commit-
tee of the Genesee County Medical Society,
under the chairmanship of Dr. George J. Curry,
voluntarily assumed increased responsibility and
promulgated the idea of presenting an educational
program for the advancement of the study of can-
cer on a statewide basis. On March 20, 1946, it
presented the first Cancer Day Program. This and
the ensuing annual programs were made possible
through the voluntary generosity of Mr. Donald
E. Johnson, publisher of the Flint News-Adver-
tiser. All the programs have consisted of five or
six presentations on timely topics directly con-
cerned with cancer problems by outstanding au-
thorities in various cancer fields.
The presentations for the 1946 program were:
“Cutaneous Malignancy”
Paul A. O’Leary, M.D. — Director, Division of
Dermatology, Mayo Clinic, Rochester, Minnesota
“Cancer of the Uterus”
Louis E. Phaneuf, M.D. — Professor of Gynecology,
Tufts Medical School, Boston, Massachusetts
“Cancer of the Stomach”
Frederick A. Coller, M.D. — Professor of Surgery,
University of Michigan Medical School. Ann Arbor,
Michigan
“Cancer of the Genito-Urinary Tract”
Charles B. Huggins, M.D. — Professor of Surgery,
Department of Urology, University of Chicago
School of Medicine, Chicago, Illinois
“Cancer of the Breast”
Frank E. Adair, M.D. — Clinical Director of Surgery,
Memorial Hospital, New York, N. Y. ( President
of the American Cancer Society)
This first meeting was attended by 210 physi-
cians; 109 from Genesee County, 100 from other
Michigan counties, and one from outside the
State of Michigan.
The second program as presented on March
19, 1947, was:
“Cancer of the Upper Respiratory Tract”
A. C. Furstenberg, M.D. — Dean and Professor of
Otolaryngology, University of Michigan Medical
School, Ann Arbor, Michigan
“Cancer Diagnosis — Laboratory Methods”
George N. Papanicolaou, M.D. — Associate Professor
of Anatomy, Cornell University Medical School,
New York, N. Y.
“Cancer of the Colon and Rectum — The Modern Con-
cept of Management”
G. Gavin Miller, M.D. — Professor of Surgery, Mc-
Gill University Medical School. Montreal, Quebec
“Cancer Research”
Mr. Charles F. Kettering — Chief, Research Divi-
sion, General Motors Corporation, Detroit, Michi-
gan
“Hormone Studies in Cancer”
Cornelius P. Rhoads, M.D. — Medical Director, Me-
morial Hospital, New York, N. Y.
This program was attended by 172 physicians;
111 from Genesee County, fifty-nine from other
Michigan counties, and two from outside the
State of Michigan.
On March 31, 1948, the substance of the third
program was:
“Cancer of the Osseous System”
Charles F. Branch, M.D. — Former Professor of
Pathology, Boston University Medical School,
Boston, Massachusetts; Assistant Director of Ameri-
can College of Surgeons, Chicago, Illinois
“Cancer of the Lung”
Richard H. Overholt, M.D. — Clinical Professor of
Surgery, Tufts University Medical School, Boston,
Massachusetts
“The General Principles of Cancer Management”
Allen O. Whipple, M.D. — Emeritus Valentine Mott
Professor of Surgery, College of Physicians and
Surgeons of Columbia University, and Director of
Surgery, Presbyterian Hospital, Director of Surgery,
Memorial Hospital, New York, N. Y.
February, 1957
181
CANCER DAY IN GENESEE COUNTY— ELLIOTT
“Extensive Surgical Procedures for Cancer”
Alexander Brunschwig, M. D. — Former Professor of
Surgery, University of Chicago; Attending Surgeon,
Memorial Hospital, New York, N. Y.
“The Role of Radiotherapy in the Management of Can-
cer”
Manuel M. Garcia, M.D. — Associate Professor of
Radiology, Tulane University Medical School, New
Orleans, Louisiana
This program was attended by 212 physicians.
Of these, 122 were from Genesee County, eighty-
five from other Michigan counties, and five from
outside of the state.
The fourth program as presented on April 13,
1949, was:
“Cancer in Children”
Harold W. Dargeon, M.D. — Attending Pediatrician,
Memorial Hospital, New York, N. Y.
“The Role of the Surgical Pathologist in Respect to the
Cancer Problem”
Arthur Purdy Stout, M.D. — Professor of Surgery,
College of Physicians and Surgeons, Columbia Uni-
versity, New York, N. Y.
“Cancer of the Lower Bowel — Present Status of Man-
agement”
Thomas E. Jones, M.D. — Chief of Surgical Staff.
Cleveland Clinic Foundation Hospital, Cleveland,
Ohio
“The Management of Uterine Cancer”
Norman F. Miller, M.D. — Professor of Obstetrics
and Gynecology, University of Michigan Medical
School, Ann Arbor, Michigan
“The Basic Principles in Cancer Management”
Alton Ochsner, M.D. — The William Henderson
Professor and Director of Surgery, Tulane Univer-
sity Medical School, New Orleans, Louisiana
This program was attended by 244 physicians.
Of these, 117 were from Genesee County, 127
from other Michigan counties and outside the
state.
The Fifth Annual Cancer Day Program was
held Wednesday, April 12, 1950.
“Sarcoma”
Herbert M. Elder, M.D., F.R.C.S. (C) — Associate
Professor of Surgery, McGill University, Montreal,
Quebec
“The Hopeful Aspects of Malignant Lymphomas”
Lloyd F. Craver, M.D. — Attending Physician, Me-
morial Hospital, New York, N. Y.
“The Management of Cancer of the Mammary Gland”
Cushman D. Haagensen, M.D. — Associate Profes-
sor of Surgery, College of Physicians and Surgeons,
Columbia University, New York, N. Y.
“The Management of Regional Lymph Node Metastasis”
Grantley W. Taylor, M.D. — Assistant Professor of
Clinical Surgery, Harvard University Medical
School, Boston, Massachusetts
“Early Signs and Symptoms of Intracranial Tumors”
Paul C. Bucy, M.D. — Professor of Neurology and
Neurological Surgery, University of Illinois College
of Medicine, Chicago, Illinois
This program was attended by 226 physicians.
Of these, 142 were from Genesee County, seventy-
eight from other counties in the State of Mich-
igan, and six from outside the state.
182
Those in attendance accepted this program
with such enthusiasm that the benefactor an-
nounced that it could be looked upon as a per-
manent annual enterprise. The committee re-
solved that it would be a policy to pursue every
effort to maintain the highest of standards for
the presentation of this annual program.
The Sixth Annual Cancer Day program pre-
sented April 18, 1951, was as follows:
“The Diagnosis and Treatment of Bone Tumors”
Bradley L. Coley, M.D. — Attending Surgeon, Me-
morial Hospital ; Associate Professor of Clinical
Surgery, Cornell University Medical School, New
York, N. Y.
“Radioactive Isotopes”
Robert Reid Newell, M.D. — Director, Departments
of Radiology and Radio-Biology, Stanford Univer-
sity Medical School. San Francisco, California
“Cancer of the Thyroid”
George M. Curtis, M.D. — Chairman and Professor
of Surgical Research, Medical Department, Ohio
State University and Starling-Loving University
Hospital, Columbus, Ohio
“The General Aspects of the Cancer Problem”
Arthur W. Allen, M.D. — Chief, East Surgical Serv-
ice, Massachusetts General Hospital ; Lecturer in
Surgery, Harvard Medical School, Boston, Massa-
chusetts
“Genito-Urinary Cancer”
Reed M. Nesbit, M.D. — Professor of Surgery, Med-
ical Department, University of Michigan; Chief of
Urological Service, University Hospital, Ann Arbor,
Michigan
This program was attended by a total of 248
physicians.
The Seventh Annual Cancer Day Program pre-
sented April 9, 1952. was as follows:
“The Leukemic States: Their Malignant and Non-
Malignant Aspects in Relation to Prognosis and
Treatment”
Charles A. Doan, M.D. — Dean and Director of In-
ternal Medicine, College of Medicine, Ohio State
University, Columbus, Ohio
“Biochemical Specificity of Cells in Cancer Chemother-
apy”
Cornelius P. Rhoads, M.D. — Director, Sloan-Ketter-
ing Institute and Memorial Hospital, New York,
N. Y.
“Cutaneous Malignancies”
Paul A. O’Leary, M.D. — Chief, Section on Derma-
tology, Mayo Clinic, Rochester, Minnesota
“The Spread of Tumors”
William J. Boyd, M.D. — Professor of Pathology,
University of British Columbia, Vancouver, British
Columbia
One-Hour Tumor Conference, moderated by:
R. Arnold Griswold, M.D. — Professor of Surgery,
University of Louisville, Louisville, Kentucky
Panel Members :
Traian Leucutia. M.D., Director of Radiotherapy,
Harper Hospital, Detroit — and Doctors Doan,
Rhoads, O'Leary and Boyd
This program was attended by a total of 264
physicians.
In view of the fact that a great number of those
TMSMS
CANCER DAY IN GENESEE COUNTY— ELLIOTT
attending the program have a special interest in
the various fields pertaining to neoplasms, it is
a policy to arrange for the arrival of some of the
speakers in Flint on the afternoon before the pro-
grams. This has enabled local and state specialty
organizations to meet with the speakers the eve-
ning before the regular program when it is deemed
appropriate.
Most members of the Genesee County Medical
Society seem to feel that there is a steady increase
in enthusiasm for the Cancer Day Program. They
credit this to the fact that the best speakers
available for the presentation of timely topics on
cancer are obtained, and feel that a large meas-
ure of their success is due to the persistent efforts
of a generous sponsor who has served without the
knowledge of the general public.
The Eighth Annual Program put on at the
Merliss Brown Auditorium at Hurley Hospital,
Wednesday, April 8, 1953, was as follows:
“Cancer of the Pancreas and Biliary Tract”
Richard B. Cattell, M.D. — Surgeon, Lahey Clinic,
New England Deaconess and New England Baptist
Hospitals, Boston, Massachusetts
“Differential Diagnosis and Treatment of Cancer of the
Ovary”
Emil Novak, M.D. — Assistant Professor Emeritus of
Gynecology, Johns Hopkins University; Gynecolo-
gist-in-Chief, St. Agnes and Bon Secours Hospitals,
Baltimore, Maryland
“Leukemia, Hodgkin’s Disease and Allied Disorders”
Cyrus C. Sturgis, M.D. — Professor and Director of
Internal Medicine, University of Michigan Medical
School and Hospital; Director of The Thomas
Henry Simpson Memorial Institute of Medical Re-
search, Ann Arbor, Michigan
“The Management of Pain Problems Related to Cancer”
Frank H. Mayfield, M.D. — Assistant Professor of
Surgery, University of Cincinnati; Neuro-Surgeon,
Cincinnati General Hospital, Cincinnati, Ohio
“The Use of Radioactive Isotopes in the Clinical As-
pects of Cancer”
Richard H. Chamberlain, M.D. — Professor of Ra-
diology, University of Pennsylvania School of Medi-
cine and Graduate School of Medicine; Radiologist,
Hospital of the University of Pennsylvania, Phila-
delphia, Pennsylvania
Panel Discussion: “Palliation and Terminal Care of
Cancer Patients”
Moderator: Charles S. Kennedy, M.D. — Emeritus Pro-
fessor of Surgery, Wayne University Medical
School; Emeritus Chief of Staff and Chief of Sur-
gery, Consulting Surgeon, Grace Hospital, Detroit,
Michigan
Panel Members:
Drs. Cattell, Novak, Sturgis, Mayfield and Cham-
berlain
The primary objective of this program was to
encourage refinement and improvement in the
care of the patient who stood little or no chance
to be separated from his cancer. The scientific
program was terminated with a panel discussion
on palliation and terminal care. We are not
aware of the presentation of any other panel dis-
cussion on this topic. The panel was made up
of the speakers and moderated by Dr. Charles
Kennedy. All of the participants were quite en-
thusiastic about giving this difficult subject its
due consideration. A large number of those in
attendance expressed their appreciation of the
efforts to give terminal care more consideration
and felt that more can be done to improve ter-
minal care.
The Ninth Annual Cancer Day Program was
presented Wednesday, April 14, 1954, with 266
physicians in attendance.
“Cancer Detection in Everyday Practice”
Emerson M. Day, M.D. — Memorial Center, New
York, N. Y.
“Early Diagnosis of Cancer of the Lung”
Eugene P. Pendergrass, M.D. — Director of Radiol-
ogy. University of Pennsylvania
“Progress Report on the Cancer Problem”
Frederick A. Coller, M.D. — Director of the Depart-
ment of Surgery, University of Michigan, Ann Ar-
bor, Michigan
“Early Cancer from a Pathologist’s Viewpoint”
Osborne A. Brines, M.D. — Professor of Pathology,
Wayne University, Detroit, Michigan
“Early Diagnosis of Cancer of the Uterus”
Howard C. Taylor, M.D. — Director of the Sloane
Hospital for Women, Columbia-Presbyterian Medi-
cal Center, New York, N. Y.
Dr. Day emphasized the need of cancer detec-
tion in the offices of all practicing physicians
rather than in so-called cancer detection clinics,
experience with cancer detection clinics in the
past few years having indicated that these clinics
should be reserved for teaching hospitals and hos-
pitals especially devoted to the management of
cancer and related diseases. These clinics will only
cover a small fraction of our population and the
vast majority of the population must be cared for
in the physician’s office.
Dr. Pendergrass emphasized the need of further
study by means of high voltage radiography.
Dr. Coller’s topic covered what has been ac-
complished in cancer management, and empha-
sized the need of more early detection and earlier
treatment.
Dr. Brines discussed his topic and gave a prac-
tical demonstration of early and transitional le-
sions.
Dr. Taylor also projected Dr. Brines’ presenta-
tion as it pertained to the uterus.
The scientific program was concluded by a
panel discussion on concerted efforts for the pre-
vention and early diagnosis of cancer. The pro-
gram terminated with a dinner meeting at the
February, 1957
183
CANCER DAY IN GENESEE COUNTY— ELLIOTT
Durant Hotel with Leonard A. Scheele, M.D.,
Surgeon General U.S.P.H.S., Washington, D. C.
Dr. Scheele rendered a report from the U. S.
Public Health Service emphasizing the public
health aspects of cancer as it pertained to the
nation as a whole.
The Tenth Annual Cancer Day Program was
presented Wednesday, April 13, 1955, and was
specifically designed to discuss prevailing current
cancer problems.
“The Prognosis of Cancer from the Viewpoint of the
Surgical Pathologist”
Lauren V. Ackerman, M.D. — Professor of Surgical
Pathology and Pathology, Washington University
School of Medicine, St. Louis, Missouri
“The Outstanding Indications and Possibilities of Radio-
therapy in the Treatment of Cancer”
Juari A. del Regato, M.D. — Director, Penrose Can-
cer Hospital, Colorado Springs; Associate Professor
of Clinical Radiology, University of Colorado Medi-
cal School, Denver, Colorado
“Vertebral Venous Function and Its Role in the Spread
of Cancer”
Oscar V. Batson, M.D. — Professor of Anatomy,
University of Pennsylvania Graduate School of
Medicine; Assistant Professor of Otology, University
of Pennsylvania, Philadelphia, Pennsylvania
“The Present Status of the Treatment of Pulmonary
Cancer”
Brian B. Blades, M.D. — Professor of Surgery, George
Washington University School of Medicine, Wash-
ington, D. C.
“The Place of Chemotherapy in the Management of
Leukemia”
Frank H. Bethell, M.D. — Professor of Internal Med-
icine and Associate Director of the Thomas Henry
Simpson Memorial Institute for Medical Research,
University of Michigan School of Medicine, Ann
Arbor, Michigan
“Ten Years of Progress with the Cancer Problem”
Cornelius P. Rhoads, M.D. — Medical Director, Me-
morial Center and Sloan-Kettering Institute for
Cancer Research, New York, N. Y.
The program concluded with Dr. Grover Pen-
berthy presiding at a panel discussion on current
cancer problems. All of the essayists served on
the panel. The dinner meeting at the Durant
Hotel, following a social hour, was highlighted by
an outline of the current problems in Washington
and their relationship with the international prob-
lems which pertain to the “cold war.” This schol-
arly presentation was given by Mr. Ray Henle,
the NBC “3-Star Extra” Editor, Washington,
D. C.
The Eleventh Annual Cancer Day Program
presented Wednesday, April 11, 1956, was as
follows ;
“Cancer of the Uterine Body: Its Diagnosis and Treat-
ment”
Newell W. Philpott, M.D. — Professor of Obstetrics
and Gynecology, McGill University, Montreal,
Quebec
“The Psychological Impact of Cancer and Its Therapy”
Arthur M. Sutherland, M.D. — Attending Physician,
Department of Psychiatry, Memorial Center, New
York, N. Y.
“Problems of Diagnosis and Therapy of Neoplasms In-
volving the Blood Forming Tissue”
Leon O. Jacobson, M.D. — Director, Argonne Can-
cer Research Hospital and Professor of Medicine,
University of Chicago, Chicago, Illinois
“Preventable Cancers of the Past and of the Future”
Carl V. Weller, M.D. — Chairman, Department of
Pathology and Professor of Pathology, Medical
School, University of Michigan, Ann Arbor, Mich-
igan
“Sarcomas of Soft Somatic Tissue”
Theodore R. Miller, M.D. — Attending Surgeon,
Memorial Center, New York, N. Y.
Panel Discussion of Current Cancer Problems
Moderated by Dr. Pollard
Members of Panel:
Drs. Philpott Sutherland, Jacobson, Weller, and
Miller
The principal objective of this program was to
emphasize the topics which had not been given
sufficient emphasis during the past five years.
This was especially true in Dr. Philpott’s discus-
sion of cancer at the upper extremity of the uterus,
Dr. Sutherland’s discussion of the psychiatric
problems in respect to cancer management, and
Dr. Miller’s discussion of soft somatic sarcomas.
The panel discussion moderated by Dr. Pollard
emphasized those points which gave rise to ques-
tions or were not sufficiently emphasized during
the previous part of the program.
Cancer, in reality, is recognized by microscopic exam-
ination of a biopsy specimen.
* * *
The victim of cancer should not, above all other
human ills, be subjected to medical quackery.
* * *
Every scientific advance in the direction of alleviation
or cure of cancer deserves the most devoted attention of
the medical profession.
* * *
Cancer detection surveys are best done by interested
physicians as part of office practice.
* * *
About 42 per cent of all cancers are accessible by a
minimum physical examination.
* * *
Cancer detection should be a phase of general
periodic health surveys.
Detection centers are unnecessarily costly, geograph-
ically discriminatory and frequently conducted by phy-
sicians with extremely limited interests.
* * *
Withhold all hormone therapy until a diagnosis has
been made to explain any irregular vaginal bleeding.
* * *
Always make a careful inspection, and biopsy, and
treat a diseased cervix before doing a hysterectomy on
such patients.
* * *
The importance of examining patients at their first
visit, even though vaginal bleeding is present, cannot be
overstressed.
* * *
The clinically silent retroperitoneum is an ideal site
for unhampered growth of tumor cells.
184
TMSMS
Dystrophia Myotonica
T^\ YSTROPHIA myotonica has in the past been
^ poorly understood and, unfortunately, has
been confused with many of the other diseases
which principally affect the myoneural unit. It
remains precisely in that same category today,
some forty years since the original articles de-
scribing its characteristics were published. It is
an abstruse disease that can be diagnosed by the
simplest history and physical examination. Truly,
the physician who takes care to shake hands with
his patients is as mindful of clinical medicine as
he is of social amenities.
Dystrophia myotonica is a “heredo-degenera-
tive” malady since it tends to occur in a more
severe form and at an earlier age in the offspring
of affected parents. It affects virtually every
organ system of the body, and is a familial, en-
dogenous, inherited disease which displays as a
prominent feature myotonia — an uncommon and
fascinating sign and symptom. Myotonia is de-
fined as a painless abnormal persistence of the
state of contraction. Waring and Ravin in 1940
and 1941 published very comprehensive studies on
the nature of myotonia, and have as thoroughly
discussed in allied articles the clinical pattern
found in dystrophia myotonica.
The existence of myotonia in an individual im-
mediately places the illness within the framework
of an intrinsic muscle disease, with the exception
of severe hypothyroidism in which myotonia is
occasionally seen. The differential diagnosis is
happily limited to either dystrophia myotonica,
myotonia congenita, myotonia acquisata, myotonia
intermittans, or one of the two paramyotonias,
the latter three of which occur only under the
influence of cold. The myotonia which is re-
ported to occur without a hereditary component
is called myotonia acquisata and most commonly
follows trauma.
Those patients afflicted with dystrophia myo-
tonica rarely complain of their inability to im-
mediately loosen their grasp. Much more dis-
turbing is the progressive, inviolable atrophy of
muscle which leads to the tragic weakness and
disability under which the severely affected pa-
tient suffers. All skeletal muscle with the pos-
By Stanley Bardwell, M.D.
Flint, Michigan
sible exception of the diaphragm is involved, but
in a dissimilar degree. The most pronounced
atrophy is found in the muscles of the forearm
and face, the quadriceps, and the dorsiflexors of
the foot. Quite typically, then, one finds a myo-
pathic facies, taut cord-like sternocleidomastoids,
a nasal twang, and impaired deglutition. It is
this profound muscle atrophy which differenti-
ates it from myotonia congenita, myotonia acqui-
sata, myotonia intermittans, and the paramyo-
tonias.
Characteristically, there are prominent multiple
endocrine gland deficiencies resulting from testicu-
lar, ovarian, adrenal, thyroid and anterior pitui-
tary atrophy. Consequently, menstrual irregulari-
ties, early menopause, infertility, and impotence
are found. Laboratory findings of a low basal
metabolic rate (the PBI is within normal limits),
creatinuria, and low twenty-four-hour urinary 17-
ketosteroid and pituitary gonadotrophic hormone
excretion lend strong support to the concept that
dystrophia myotonica is more than a simple muscle
defect. Most importantly, these constitutional ef-
fects further differentiate dystrophia myotonica
from all other diseases of muscle and the ap-
pendant charts indicate the comparative benig-
nity of the remaining myotonic diseases.
Case Reports
Case 1 .- — P.P., a twenty-year-old, white, unmarried
woman entered the hospital on March 15, 1955, with
a productive cough of insidious onset and of “several”
months’ duration, which had been preceded by in-
creasing muscle weakness and a 20-pound weight loss
during the previous year. She was referred to the
hospital by her physician with a provisional diagnosis
of “probable pulmonary tuberculosis” and “general de-
bility.” The examiner on shaking hands with the pa-
tient noted the patient’s inability to loosen her grasp.
She admitted that she had suffered this handicap since
early childhood, but happily stated that this particular
problem was slowly becoming less manifest, and that
her primary concern was that of increasing muscle weak-
ness which was responsible for her social and economic
dependence.
The patient felt that her childhood was uneventful.
The mother remembered the patient as being slow in
development. She is said to have sat at eight months,
walked at seventeen months, and talked at two and
February, 1957
185
DYSTROPHIA MYOTONICA— BARDWELL
one-half years. She had “drooled constantly as a
child and require a bib during her pre-school years
even while at play. Operations had been performed
on both ankles at the age of ten years because of in-
ability to free her toes of the ground while walking.
Fig. 1. Case 1. P.P., a twenty-year-old white woman
with advanced dystrophia myotonica. Note the high
frontal baldness, and thin cord-like sternocleidomastoid
muscle. Height, 4 feet 11 inches, 65 pounds.
A tonsillectomy was performed at the age of ten years
because of a nasal voice.
A maternal aunt apparently expired at the age of
thirty-four years of poliomyelitis, although little is
known of the circumstances surrounding her death. The
mother, forty-four years of age, required help on alight-
ing and boarding a bus because of muscle weakness.
She also walked with a steppage gait, and presented
frontal baldness and a mild myotonia. All of the family
members wore glasses but no specific history of cata-
racts was obtained.
The patient’s menarche was at age thirteen and one-
half years, and since the age of nineteen years she had
had irregular menses in duration and interval, and the
amount of flow had become increasingly scanty.
On physical examination, the patient’s height was 4
feet, 11 inches; her weight, 64 pounds. She was
apathetic and walked with a halting high steppage
gait. There was marked frontal baldness. She enun-
ciated poorly and had a distinct nasal twang. Her
head uncontrollably fell backwards when reclining from
a sitting position. The axillary and pubic hair was
sparse but of normal female distribution. The palate
was quite noticeably arched and high. The stemo-
cleidomastoids were cord-like, and the general muscle
mass was markedly diminished. The breasts were small
and undeveloped. The blood pressure was 96/60; the
heart rate was 50/minute. The rhythm was sinus
bradycardia with an occasional premature ventricular
contraction. The vaginal vault and uterus were small.
The patient was unable to smile or wrinkle her brow,
and there was gross weakness of all muscle groups for
the patient’s age and sex. Aside from the diminished
but equal deep tendon reflexes, the neurologic examina-
tion was within normal limits.
The hemogram, urinalysis, serology, PPD No. 1 and
No. 2, coccidiodin skin tests, BUN, serum Na, K, Ca,
P, uric acid, creatinine, urine calcium, alkaline phos-
phatase. total protein, A/G ratio, BSP, Thorne test,
PBI, BMR, cholesterol, and glucose tolerance test with
phosphorus determinations were all within normal limits.
The twenty-four-hour urine excretion of creatinine
was 178 mg. (normal: 700 to 2,000 mgs./24 hours);
the twenty-four-hour urine excretion of creatine was
found to be 90 mgs. (normal: 0 to 100 mgs/24 hours
for females). The creatinine index was 5.9 (normal:
18 to 30; defined as the ratio of creatinine in mgs.
excreted in the urine in twenty-four hours to the body
weight in kilograms). The twenty-four-hour urinary ex-
cretion of 1 7-ketosteroids was 3.7 mgs. (normal: 6 to
15 mgs. for females).
Case 2. — D.P., a twenty-six-year old, white, married,
typing teacher entered the hospital on October 8, 1955,
with a diagnosis of a lower respiratory infection of
two days’ duration. On obtaining the history, the
patient incidentally revealed that she had had painless
cramping of the muscles for a period of six years,
made worse by cold, and of a progressive nature. This
was more recently associated with muscle weakness and
was a hindrance in her occupation as a typing instruc-
tor. She preferred this to less technical classes, how-
ever. because after prolonged speaking she was affected
by a “cramping at the root of (her) tongue.” A
sister was similarly affected and both the patient and
her sister, a nurse, were benefited by quinine, but after
a bout of tinnitus discontinued use of the drug.
The patient's past medical history was uneventful ex-
cept for an appendectomy at age fourteen and a bout
of “diarrhea due to nerves” for which hospitalization
was required. The mother was afflicted with diabetes
mellitus. With the exception of the one married, child-
less sister with myotonia, no evidence of a heredo-
degenerative disease was elicited.
The patient’s menarche was at age twelve years and
had always been regular in duration, amount, and in-
terval. She had been married six years and despite
efforts to conceive had been quite unsuccessful.
Physical examination revealed the patient’s height to
be 5 feet 5 inches and her weight 95 pounds. She was
a thin, alert, intelligent woman with slight frontal bald-
ness and temporal hollowness. The total muscle mass
186
JMSMS
DYSTROPHIA MYOTONICA— BARDWELL
was diminished. There was marked arching of the
palate. Myotonia was severe and a lingering muscle
furrow was seen after percussion of the muscles of
the forearm. The blood pressure was 96/60, and the
heart rate 60/minutes with a sinus rhythm. The skull
films revealed a very small sella turcica and was sug-
commonly found as it was in both patients, but
most radiologists decry the use of its presence as
indicative of anything but a normal skull. En-
larged sinuses and an elongated mandible are
inexactly reported in some cases.
TABLE I. DISEASES AFFECTING MUSCLE
Myoneural Unit
Metabolic
Mechanical
Chemical
Degenerative
Mechanical
Chemical
Degenerative
Dystrophia Myotonica
Myotonia Congenita
Myotonia Acquisata
Paramyotonia Congenita
— of Eulenberg
— of Soldershott
Myotonia Congenita
Intermittans
Familial Periodic
Paralysis
^Disease of Anterior Horn Cell: Poliomyelitis
**Disease of Myoneural Junction: Myasthenia Gravis
Miscellaneous Disease: Thyrotoxic Myopathy
Myotonia of Hypothyroidism
Dystrophia Myotonica is an intrinsic muscle disease in which two important distinguishing
characteristics are profound muscle atrophy and myotonia.
gestive of hyperostosis frontalis interna. The deep
tendon reflexes were equal but were markedly dimin-
ished throughout.
The twenty-four-hour urine excretion of creatinine
was 618.8 mgs.; the twenty-four-hour urine excretion of
creatine was 18.2 mgs. The creatinine index was 14.4.
The twenty-four-hour urinary excretion of 17-ketoster-
oids was 3.2 and 11.1 mgs. on two determinations.
The twenty-four-hour excretion of pituitary gonado-
tropin (FSH) in urine was seven rat units, forty mouse
units, and 150 international units (normal: one to
twenty-five rat units; five to fifty-five mouse units;
fifty to 400 international units).
These two cases illustrate most of the features
described in dystrophia myotonica. Radiologic
studies are of distinct benefit as confirmatory
evidence for the diagnosis. Typically the sella
turcica is found to be in the 6x8 mm. range
(lower limits of normal: 8 x 10 mm.) as it was
in the first case. Hyperostosis frontalis interna is
Gunnar Wohlfart, in an excellent article pub-
lished in 1951, describes three stages in the muscle
of patients with dystrophia myotonica. Stage I
reveals inward migration of hypolemmal nuclei
with a mixture of hypertrophic and atrophic
muscle fibers. Stage II shows central rows of
nuclei, single hypertrophic and many atrophic
fibers separated by increasing amount of con-
nective tissue with fatty infiltration. Stage III
shows marked atrophy of fibers separated by in-
creasing connective tissue with fatty infiltration.
It is felt that the second stage is pathognomonic
of dystrophia myotonica if there is an associated
thick peripheral sarcoplasm. A muscle biopsy
in the first patient was consistent with Stage III
of this classification. Stage I is descriptive of
myotonia congenita, and Stage II is suggestive
of the histologic pattern of muscle in progressive
muscular dystrophy except for distinctive annu-
February, 1957
187
DYSTROPHIA MYOTONICA— BARDWELL
TABLE II. DISEASES OF MUSCLE
Disease
Myofibrositis
Epidemic
Myalgia
Progressive
Muscular
Dystrophy
Dystrophia
Myotonica
Myotonia
Congenita
Familial
Periodic
Paralysis
Myotonia
Acquisata
Myotonia
Congenita
Inter mi ttans
Paramyo-
tonia
Synonyms
Torticollis
Pleurodynia
Sylvests
disease
Bornholm
disease
Fascio-
scapulo-
humeral
(childhood)
Steinert’s
disease
Myotonia
atrophica
Thomsen’s
disease
of Eulenberg
of Solder-
shott
Age of onset
Adult
10-25 years
5-35 years
5-10 years
15-30 years
All ages
5-20 years
Adult
At birth
Etiology
Familial
cold; trauma
Infectious
Epidemic
Heredo-
degenerative
Heredo-
degenerative
Hereditary
Hereditary
Trauir a
Cold
Cold
Sex ratio
Equal
Equal
Equal
6:1 Male
Equal
Equal
2:1 Male
Equal
?
Pain
++
++
0
0
0
0 or +
0
0
4~
Weakness
0
0
+
+
0
Paralysis
in attacks
0
0
+
Myotonia
0
0
0
+ +
++
0
-1
+
0 — cramps
Muscle atrophy
0
0
+ +
4- 4-
0
0
0
0
0
Constitutional
Deep tendon
0
Fever
Chills
Abdominal
pain
0
Cataracts
Cardiac
Endocrine
deficiency
0
0
0
0
0
reflexes
Muscle
hypertrophy
Normal
Normal
Hypoactive
Hypoactive
Normal
Normal
N or mal
Normal
Normal
0
0
0
0 or +
0
0
0
0
Therapy
Symptomatic
Symptomatic
Glycine
Vitamin E
Cataract
surgery
Quinine
Quinine
Potassium
chloride
Quinine
Heat
Quinine
Prognosis
Excellent
Excellent
Death from
secondary
infection
after 10
years
Death from
secondary
infection
Excellent
Excellent
Excellent
Excellent
Excellent
lets which are not found in the muscle of patients
afflicted with dystrophia myotonica.
Thomsen, a Danish physician in 1876, first de-
scribed the signs and symptoms of myotonia con-
genita from which he and three generations of his
family suffered. Subsequently, the growing num-
ber of atypical cases reported in the literature
were clarified simultaneously and independently
by Batten, Gibb, and Steinert, and from their
studies arose the concept of a clinical entity of
myotonia atrophica in 1909. Numerous investiga-
tors have since emphasized the existence of the
disease and added to its many facets. Dystrophia
myotonica is the term now most commonly em-
ployed but either term can be justified.
Opthalmologists have played a significant role
in delineating the disease from those other mal-
adies previously mentioned which also manifest
myotonia. Since an early and singular type of
cataract formation is a cardinal finding, a slit-
lamp examination is of particular importance.
Cataracts rarely mature before the age of forty-
five years, and require ten to twenty years to ma-
ture after the onset of the first major symptoms
of dystrophia myotonica appear. They are de-
scribed as fine star-like opacities with green, bluish
hues and are found immediately beneath the
anterior and posterior capsules. The first patient.
P.P., was found to have a few fine bodies beneath
the anterior capsule of the lens. A chronic, non-
specific blepharitis and conjunctivitis is not in-
frequently found.
Dystrophia myotonica is said to occur more
frequently in Europe, America and Japan, but
little rationale for a particular geographic dis-
tribution is given other than nonrecognition of
the disease.
The laboratory diagnosis perhaps rests upon the
biopsy of muscle and the characteristic findings
of creatinuria, and decreased excretion of creati-
nine, and the 17-ketosteroid and FS hormones.
These, of course, also indicate the stage and
severity of the disease. A reduced creatinine
index (coefficient) is consistent with the diagnosis
but is found in such diseases as dermatomyositis,
lupus erythematosus, and progressive muscular
dystrophy.
Sinus bradycardia and hypotension are almost
constantly found. Nonspecific electrocardiograph-
ic changes reflect the atrophy of the myocardium.
A prolonged PR interval is found in 50 per cent
of cases, and prolonged QRS interval and ectopic
beats are not unusual findings.
High arched palates are more frequently de-
scribed in the last decade than in years past.
Mental changes reported in early articles are
most likely produced as much by the conditions
of life which the disease itself imposes as they
are inherent and do not form a particular pattern.
Amino-acetic acid, anterior pituitary extract,
188
JMSMS
DYSTROPHIA MYOTONICA— BARDWELL
testosterone proprionate, estrogens, cortisone,
ACTH, epinephrine, pilocarpine, thyroid, and
pronestyl are only a few of the many drugs which
have been tried, all with equivocal results. Qui-
nine is quite effective in the treatment of myo-
tonia, but it is rarely necessary. Patients can as
easily dissipate the myotonia by “warming up”
| as they can by its use. The second case is that
of a teacher of typing and bears witness to the
innocuousness of myotonia alone.
Therapy at the present time, clearly, is entirely
symptomatic. The muscle atrophy at this junc-
ture in therapeutic medicine can neither be
stopped nor reversed. Cataracts are successfully
removed surgically. Patients with severe dys-
trophia myotonica, in contrast to patients with
other myotonic diseases, eventually require social
and financial support.
Before the modern era of anti-infectious agents,
patients with advanced disease most commonly
succumbed to secondary pulmonary infections
(both of these patients were hospitalized for
respiratory infections), and aspiration pneumonia
is a constant hazard. Congestive heart failure
may be a cause of the demise because of myo-
cardial atrophy and refractoriness to therapy.
The responsible fundamental defect in dystro-
phia myotonica is unknown, and it continues to be
a curiosity despite the fact that its prevalence is
probably much greater than is generally supposed.
Summary
Dystrophia myotonica is an uncommon myo-
tonic disease of the heredodegenerative type af-
fecting equally both sexes. In its most advance
form there is severe muscle atrophy and multiple
endocrine gland deficiencies. The treatment is
entirely symptomatic and does not alter the course
of the disease. Two typical cases are presented.
Bibliography
1. Ravin, A., and Waring, J. J.: Studies in dystrophia
myotonica. I. Hereditary aspects. Am. J. M. Sc.,
197:593 (Jan. -June) 1939.
2. Waring, J. J.; Ravin, A.; and Walker, C. E. :
Studies in dystrophia myotonica. II. Clinical fea-
tures and treatment. Arch. Int. Med., 65:763
(Jan. -June) 1940.
3. Ravin, A.: Studies in dystrophia myotonica. III.
Experimental studies. Arch. Neurol. & Psychiat.,
43:649 (Jan. -June) 1940.
4. Batten, F. E., and Gibb, H. P. : Myotonia atroph-
ica. Brain, 32:187, 1909.
5. Benda, C. E., and Bixby, E. M.: Urinary excretion
of 1 7-ketosteroids in various conditions of oligo-
phrenia correlated with some autopsy findings. J.
Clin. Endrocrinol., 7:503, 1947.
6. Ravin, A., and Waring, J. J.: Studies in dystrophia
myotonica. IV. Myotonia: Its nature and oc-
currence. Ann. Int. Med., 13:1174 (July-June)
1939-1940.
7. Fisch, C.: The heart in dystrophia myotonica. Am.
Heart J., 41:525 (Feb.) 1951
8. Caughey, J. E.: Radiological changes in the skull
in dystrophia myotonica. Brit. M. J., 1:137 (Jan.)
1952.
9. Benda, C. E. ; Malestross, C. J. ; Hutchinson, J.
C.; and Thomas, E. M.: Studies of thyroid func-
tion in myotonia dystrophica. Am. J. M. Sc., 228:
668 (Nov.) 1954.
10. Nadler, C. S.; Steiger, Wm. A.; Troncelleti, M.;
and Durant, T. M.: Dystrophia myotonica, with
special reference to endocrine function. J. Clin.
Endocrinol., 10:630 (June) 1950.
11. Wohlfart, G.: Dystrophia myotonica and myo-
tonia congenita. Histopathologic studies with spe-
cial reference to changes in the muscles. J. Neuro-
path. & Exper. Neurol., 10:109 (April) 1951.
AMERICAN COLLEGE OF GASTROENTEROLOGY
A regional meeting of the Central Region of the
American College of Gastroenterology will be held in
Grand Rapids, Michigan, Sunday afternoon. March 17,
1957. The scientific sessions will be at the Hotel Pant-
lind commencing at 1:45 P.M.
Participating in the program will be Joseph B. Kirs-
ner, M.D., Chicago, Illinois; William Fuller, M.D.,
Grand Rapids, Michigan: Joseph Shaiken, M.D.,
F.A.C.G., Milwaukee, Wisconsin; C. Wilmer Wirts,
M.D., F.A.C.G., Philadelphia, Pennsylvania; Garnet
Ault, M.D., Washington, D. C.; Don W. McLean,
M.D., Detroit, Michigan: Frederick A. Coller, M.D.,
Ann Arbor, Michigan; Fred Hodges, M.D., Ann Arbor,
Michigan, and C. Allen Payne, M.D., Grand Rapids,
Michigan.
There will be three individual papers and a panel
discussion on “Gastrointestinal Bleeding” moderated by
Dr. Coller with the speakers of the afternoon as the
participants.
Arthur A. Kirchner, M.D., F.A.C.G., Los Angeles,
California, President of the American College of Gas-
troenterology, and James A. Ferguson, M.D., F.A.C.G.,
governor of the College for Michigan, will preside at the
sessions. Lynn A. Ferguson, M.D.. F.A.C.G., Secretary-
General of the College, is the chairman of the program
and arrangements committee.
The Central Region which consists of the states of
Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota,
Missouri, Nebraska, North Dakota, Ohio, South Da-
kota and Wisconsin, will be represented at the meeting.
Members of the medical profession are cordially in-
vited to attend.
February. 1957
189
The Modern Treatment of Uremia
T-'HE TERM uremia has had a broad and
somewhat vague meaning in the past, but
along with the progress in general medicine
through the years, it is much better understood
today, and therefore the condition should be
better treated than formerly. A simple practical
definition is that it is a disease, or toxic state,
resulting from the accumulation of retention
products in the blood, which are normally ex-
creted by the kidneys through the urinary stream.
However, uremia may be a very complex condi-
tion involving the multiplicity of renal function,
general metabolism and endocrinology, each of
which may be complex in itself. For purposes
of treatment, this paper will consider the excre-
tion of retention products and the regulation of
electrolytes as of primary importance for the
maintenance of life.
The etiologic factors in the production of
uremia are many and frequently complex. For
reasons of simplicity, they are classified as pre-
renal, intrarenal and postrenal factors. The pre-
renal factors are diminished fluid intake and a
reduction in the constituents of the blood as oc-
curs in hemorrhage, diarrhea and vomiting. The
intrinsic renal factors are those which produce
the syndrome known as lower nephron nephrosis,
such as crush injury, surgical shock, transfusion
reaction, sulfonamide anuria, and mercury poison-
ing. The postrenal causes are those which pro-
duce an obstruction to drainage of urine and are
not primarily defects of renal function.
For purposes of prognosis and treatment it is
useful to classify uremia as acute or chronic, or
as reversible or irreversible. One cannot expect
to alter greatly the course of an old chronic glom-
erulonephritis, with edema and with albumin
and casts in the urine, advanced to the stage
of uremia, whereas very dramatic results are fre-
quently obtained in patients with acute or revers-
ible renal insufficiency. Although even the arti-
ficial kidney has been used in chronic cases, no
lasting improvement has resulted, and the risks
involved scarcely seem justified.
The general principles of treatment of uremia
may be summarized as:
By Marshall W. Alcorn, M.D.
Bay City, Michigan
1. The use of antibiotics for the prophylaxis and
treatment of infection.
2. Restriction of electrolytes and fluid during the
period of oliguria.
3. Administration of high caloric intake as a means
of suppression of protein catabolism.
4. Avoidance of elective surgery, excessive transfu-
sion and other procedures which may increase
protein breakdown and the production of reten-
tion products.
5. Removal of retention products and correction of
body chemistry by artificial dialysis.
Neubauer and Dunsmore8 treated a series of
eighty-four patients suffering from uremia and
acidosis on the basis of intrinsic renal disease, with
a combined electrolyte approach. Their cases
could be classified as chronic. In patients with
coma, all therapy was given intravenously, and
fluid intake was kept at 2500 to 3000 cc. daily.
1. After drawing blood for chemistry in the a.m.,
1500 cc. 5 per cent glucose in water or 10 per cent
Travert Solution with 2 to 6 grams calcium gluconate
(10 per cent Solution) was given in a two to two and
one half-hour-period. Potassium Acetate 2 to 4 grams
was added if the serum value was low, but if the potas-
sium is elevated, 10 units of regular insulin was added
to the intravenous solution.
2. Three to four hours later, 120 to 240 mEq. of 1
or 1J4 molar sodium lactate with 15 grams amino-
phylin was given slowly for two hours. The 1-Molar
concentration was used when edema and cardiac em-
barrassment was suspected. The amount of sodium lac-
tate was determined by the clinical response and the
fall in blood urea nitrogen. When given as one-half-
molar, this was made up with equal parts of 5 per
cent glucose in water.
3. Three to four hours later, 1000-1500 cc. 5 per cent
glucose in water or 10 per cent Travert Solution,
with 2 to 6 grams of calcium gluconate and 10 units
ot insulin was given. Potassium was added as needed.
4. When a patient roused from coma and could
take oral feedings, the intake was maintained at 2500
to 3000 cc., with water, tea and sugar, and ginger ale.
The diet was gradually increased, from salt-free toast
and butter, mashed potatoes, and hard candy, to 1.0
gram salt and 20 grams protein.
5. As soon as practicable, oral electrolyte therapy was
begun with: (a) 40 cc. 1.0 molar sodium lactate,
four to five times daily; (b) 20 to 40 cc. 10 per cent
calcium lactate in Amphojel four times daily; (c) When
necessary, as judged by a falling serum value, 5 to 10
190
TMSMS
MODERN TREATMENT OF UREMIA— ALCORN
cc. 1 -molar potassium was given three to four times
daily. If there was a rising potassium value, this was
stopped.
Under this regimen, the majority of patients
in this chronic or relatively irreversible state of
uremia showed chemical and clinical improve-
ment. It is believed that sodium is better han-
dled as the lactate in hypertonic form. On forced
calories, sodium lactate and calcium lactate ther-
apy, all cases displayed a fall in urea and serum
potassium levels. The exact mechanisms of all
this are not clear, and future investigations and
experience will improve our understanding of
them.
In any discussion of artificial dialysis, the artifi-
cial kidney is of prime importance. W. J. Kolff
and Charles C. Higgins,7 who pioneered and
have greatly contributed to the development of
the artificial kidney, state that it should not be
considered a competitor, but rather as a valuable
adjunct to the medical management of acute and
chronic uremia. Certainly, much has been
learned through the use of the artificial kidney
concerning uremia and its treatment.
The conception and principles of the artificial
kidney are not new, since they were first intro-
duced on an experimental basis by Abel, Rown-
tree, and Turner in 1912. 1 However, it remained
for Kolff5 to make the first use of it in humans,
in 1945, when he dialyzed a sixty-seven-year-old
woman in complete anuria with a blood urea of
400 and serum potassium of 11.5 with a most
dramatic result. Following treatment, the blood
urea was reduced to 120, and the potassium to
5.8, after which complete recovery occurred.
Since then, Kolff and others have done much to
develop the method and now, ten years later, a
fair appraisal can be made.
In the use of the artificial kidney, blood is with-
drawn from a vein or an artery, and guided
through a system of membranes, with blood on
one side, and a rinsing fluid on the other. Dia-
lysis then occurs. All retention products, such as
urea, uric acid, creatinin and phenols pass readily
through the membrane. Heparin is used to pre-
vent the clotting of blood. Electrolyte equilibrium
between blood and the rinsing fluid occurs if
dialysis is continued a sufficient time. The plasma
electrolyte content can be changed at will, by
varying the composition of the rinsing fluid. By
this method, as much as 280 grams of urea have
been removed by one dialysis and the treatment
may be repeated in four to five days.
Experimentally, the artificial kidney has pro-
longed the life of dogs for twenty-five days after
bilateral nephrectomy. In the Korean War, the
army established a center for the treatment of
soldiers with renal insufficiency, and the mortality
for patients with anuria was reduced from 90
to 60 per cent by the artificial kidney. Why then
has not the artificial kidney come into common
usage, and why is it not available for any patient
who needs it?
Kolff'1 stated the dangers and complications in
its use as follows:
1. Pyrogenic reactions may occur.
2. Hemorrhage.
.3. Changes in blood volume occur as determined by
the flow rate from the artery.
4. Technical error such as bleeding through a hole
in cellophane membrane.
5. Hemolysis will occur, due to high temperature of
rinsing fluid or the ommission of salt, within two min-
utes.
6. Morphologic changes of blood, such as leuco-
penia, usually occurs during dialysis.
7. Hypertension when too rapid flow occurs.
8. Relative urinary suppression for one to two days
following dialysis.
In addition, the necessity for a trained team of
technicians, nurses and physicians makes the arti-
ficial kidney so far entirely impractical to use
except in a large medical center where such help
is readily available. For these reasons, the arti-
ficial kidney has remained in limited use, with
only a few in this country. Time and trial may
see it become a practical instrument for use in
most hospitals. Actually, it has the possibility of
being much more effective in the saving of lives
and restoration of health than the much publi-
cized “iron lung.”
In 1923 Ganter2 originated the method of peri-
toneal dialysis, which was not practical because
of peritonitis. In 1946, after the advent of peni-
cillin, the method came into use with much en-
thusiasm, but it was abandoned in 1951, because
of the high rate of fatal peritonitis and difficul-
ties in controlling water and electrolyte balance.
Recently, a method of intermittent peritoneal dia-
lysis was described by Waugh9 which gives prom-
ise of removing most of the objections and dan-
gers of peritoneal dialysis as formerly done.
This method consists of doing a routine ab-
February, 1957
191
MODERN TREATMENT OF UREMIA— ALCORN
dominal paracentesis in the midline below the
umbilicus and instilling the lavage fluid at body-
temperature through intravenous tubing attached
to the trocar. In a brief period, 3 to 3.5 liters
are instilled, the trocar is then removed, and the
skin wound is plugged with a rubber cap and
a dressing is applied. After two to four hours,
the patient is placed in a sitting position and the
dressing and the plug are removed, and the trocar
is reinserted. The lavage fluid is then drained
by gravity and the wound is redressed. This
method of dialysis may be repeated as often as
needed, even two to three times in one day.
Waugh showed that the blood urea and potas-
sium intoxication were reduced by this method,
and. in one instance, autopsy showed no evidence
of peritonitis after several dialyses over a period of
twenty-nine days. This method appears to have the
advantage of simplicity, availability and safety, and
with further experience it should prove to be a
valuable adjunct to the conservative treatment of
severe uremia or potassium intoxication.
Any treatment of acute renal insufficiency must
consider the potassium factor. Proteins and fruit
juices are rich in this electrolyte and must be re-
stricted in the diet. Muscular activity promotes
catabolism with the release of potassium ion and
therefore it must be restricted to the absolute
minimum. The administration of glucose and
insullin is protein-saving and allows the cell pro-
tein to retain or bind more potassium with less ten-
dency to hyperpotassemia. Calcium is adminis-
tered, as it is believed to counteract the toxic
effects of potassium on the myoneural junctions
of the conducting mechanism of the heart. Such
procedures are valuable, but they do not remove
this electrolyte from the blood at a time when
its plasma level poses a threat to cardiac function.
Hicks3 was the first to demonstrate the effective-
ness of lavage of the intestinal tract in removing
potassium in patients in acute uremia. His work
inspired Kelley and Hill’s investigations of two
problems of such an approach. One was the
development of an irrigating fluid which would
remove a maximum amount of potassium and
nitrogenous products with a minimum disturbance
of fluid, electrolyte, and osmotic balance. The
second problem was evaluation of the relative
efficiency of different portions of the gastrointes-
tinal tract as a dialyzing membrane to adjust any
electrolyte imbalance in the absence of renal func-
tion.
Kelley and Hill4 performed a series of experi-
ments in dogs in which they produced anuria
and uremia by bilateral ligation of the ureters or
by bilateral nephrectomy. In different animals
they then perfused the stomach, the duodenum
or the jejunum after the intravenous injection of
potassium, and they were able to show that the
jejunum is the most efficient site to secrete po-
tassium into a slightly hypertonic solution. In
addition they determined a hypertonic and iso-
osmotic solution to be the most efficient dialyzing
fluid as follows: NaCi 6 grams per liter, NaHCO^
3 grams per liter, Calcium Gluconate 1 gram
per liter, and Glucose 20 grams per liter. In
addition to potassium, they were able to extract
large amounts of urea and concluded that the
cells of the jejunum either have more inherent
capacity to secrete potassium into a slightly hy-
pertonic and essentially iso-osmotic perfusate or
else they act as a better dialyzing membrane.
The clinical application of this method of di-
alysis was carried out by means of both a Levin
tube and a Miller-Abbott tube. The Miller-
Abbott tube is passed to the jejunum, and through
the Levin tube in the stomach the perfusate so-
lution is allowed to drip and is aspirated from the
Miller-Abbott tube. The rate of perfusion is
adjustable, and as much as 24 liters in twenty-
four hours have been used. The method has
been found to be simple, practical, inexpensive,
and equally as effective in man as it was in the
experimental animals, rapidly reducing danger-
ously high levels of serum potassium to safe lev-
els, and at the same time adjusting fluid balance
and other electrolytes. Potassium levels above
7.5 mEq. may lead to intoxication and sometimes
the characteristic sudden death that occurs in
uremia. The signs and symptoms of hyperpotas-
semia are bradycardia, dyspnea, respiratory paraly-
sis, coma and cardiac arrest. Electrocardiographic
findings are characteristic. In cases where the
Miller-Abbott tube cannot be passed, a jejunos-
tomy can be performed and used for dialysis.
Case Reports
Case 1. — A seventy-eight-year-old white man was ad-
mitted to the hospital with complete urinary obstruc-
tion, due to a grade IV prostatic hypertrophy, which felt
benign. A residual urine of 900 cc. was obtained, and
a balloon catheter was left in place. The patient was
thin, with a poor appetite. Moderate anemia was pres-
ent, and the blood urea was 1 1 1 milligrams per cent,
and the serum acid phosphatase normal. One week
192
TMSMS
MODERN TREATMENT OF UREMIA— ALCORN
later, after correction of the anemia by transfusion, diet
and adequate fluid intake, the blood urea was 75, and
the patient’s appetite and strength still poor. The
Miller-Abbott tube was started down on the ninth day
of hospitalization; the following morning it was in the
jejunum, and the dializing fluid was started through the
Levin tube. Twenty-four hours later the blood urea
was 45.8 mg., which dropped to 36.8 the next day.
The tubes were then removed. The patient now had
a good appetite, and rapidly regained his strength.
Three days later the blood urea was 45, and the
patient was scheduled for transurethral prostatic resec-
tion. This was done in two stages, and he made a
normal convalescence, and was discharged on the thir-
tieth day of hospitalization, with residual urine of 25
cc. and blood urea of 48.
Case 2. — A forty-one-year-old white man developed
oliguria thirty-six hours following a left nephrectomy
for a giant hydronephrosis which contained an estimated
3 to 4 liters of hydronephrotic fluid. On the fifth post-
operative day, the urine output was 85 cc., and the
blood urea had risen to 123 milligrams per cent, from
a preoperative level of 21 milligrams per cent. A par-
alytic ileus occurred coincidentally, and hiccoughing be-
came distressing on the second postoperative day, when
a Miller-Abbott tube was started down. No relief of
distention occurred, and the blood urea rose to 331 on
the seventh postoperative day. A Levin tube was sub-
stituted for the Miller-Abbott tube, without benefit, and
repeated attempts to pass the Miller-Abbott tube past
the pylorus failed, because of the severe distention of
the bowel. On the eighth postoperative day, the pa-
tient was in serious condition, with blood urea of 422.
500 cc. of blood had been transfused during the opera-
tion, but none had been given since. His serum pro-
teins were 6.2 grams per cent, with a reversal of the
A/G ratio. The patient’s condition at this time was
moribund, and it was decided to do a jejunostomy. This
was done at midnight under a local anesthetic in the
patient’s room, and a large caliber catheter left in a
loop of the jejunum. The nurse was instructed to
irrigate the catheter with 50 cc. of the dializing fluid
every fifteen minutes. The following morning the
patient’s condition was much improved, diuresis had be-
gun, the distention had disappeared, and oral feedings
were started. Thirty-six hours after the jejunostomy
was done, the blood urea had dropped to 123, and to
44 on the fourth day. The patient then made a
complete recovery with a blood urea of 23.9 at the
time of discharge from the hospital. He has remained
well since.
Summary
Recent developments in the treatment of
uremia have been briefly reviewed. They offer
so much more to the patient with uremia than
formerly could be hoped for that every physician
called upon to treat this condition has as a
result a far greater responsibility than formerly.
KolfP has stated that today death from acute
renal insufficiency should be extremely rare.
When a patient is seen with acute renal insuffi-
ciency, with severe oliguria or anuria, a real med-
ical emergency exists, and prompt institution of
treatment is important. Antibiotics are adminis-
tered with avoidance of elective surgery, excessive
transfusion and other procedures which may in-
crease protein catabolism, and the production of
retention products. The correction of body chem-
istry and the removal of retention products by
some form of dialysis is needed. Of the different
methods of dialysis, intestinal lavage by means of
the Levin tube in the stomach for intake, and
the Miller-Abbott tube in the jejunum for suction,
is recommended. With this in mind, the Miller-
Abbott tube should be started down as soon as
the condition is recognized. The intermittent
method of peritoneal dialysis gives promise of
safety and effectiveness. The artificial kidney is
still reserved for use by the highly-trained team
in a specialized center.
References
1. Abel, J. J.; Rowntree, L. G. ; and Turner, B. B:
On removal of diffusable substances from the cir-
culating blood of living animals. J. Pharmacol. &
Exper. Therap., 5:275, 1913-1914.
2. Ganter, G. : fiber die Beseitegung giftiger Stoffe
aus dem Blute durch Dialyse. Miinchen. med.
Wchnschr., 70:1478-1480, 1923.
3. Hicks, M. H. ; Crutchfield, A. J.; and Wood, J.
E., Jr.: Intestinal lavage in potassium intoxica-
tion of lower nephron nephritis. Am. J. Med., 9:
57-62 (July) 1950.
4. Kelley, R. A., and Hill, L. D., Ill: Acute renal
insufficiency and the role of potassium with treat-
ment by intestinal lavage. J. Urol., 66:645-660
(Nov.) 1951.
5. Kolff, W. J. : New Ways of Treating Uremia;
Artificial Kidney, Peritoneal Lavage and Intestinal
Lavage. London: J. & A. Churchill, Ltd., 1947.
6. Kolff, W. J. : Treatment of uremia. Cleveland
Clin. Quart., 18:145-158 (July) 1951.
7. Kolff, W. J., and Higgins, Charles C.: Dialysis in
the treatment of uremia; artificial kidney. J. Urol.
72:1082-1094 (Dec.) 1954.
8. Neubauer, Richard A., and Dunsmore, Lillian:
Electrolyte therapy in the control of uremia; with
special reference to postobstructive uremia. J.
Urol., 72:1074-1081 (Dec.) 1954.
9. Waugh, W. H.: Successful use of a simplified
method of intermittent peritoneal diolysis. J. Urol.
72:1095-1103 (Dec.) 1954.
February, 1957
193
Sterilization of Ureteral Catheters
A LL CYSTOSCOPISTS agree that ureteral
L ^ catheters should be sterile. Many methods
of sterilization are in use, but apparently the
catheters remain unsterile and are used in that
condition.
Noting the consistent contamination of cultures
taken at cystoscopy, we turned to past and current
literature and to urology textbooks in the hope of
finding a more satisfactory means of sterilization.
A search of the literature yielded but three refer-
ences,1'3 and only one of these (from 1920) was
directly related to the sterilization of cystoscopes
and ureteral catheters. Textbooks on urology
offered no further aid. They all stated that sterile
catheters must be used, but the methods of
sterilization were rarely mentioned. In no instance
was a procedure given in such detail that it could
be set up from the description.
As a result of these experiences, we began ex-
periments to determine the degree of contamina-
tion in ureteral catheters and to find an adequate
method of sterilization.
Procedure and Results
Several experiments were carried out. In the
first, catheters were obtained from several cysto-
scopists. The catheters were immersed in flat GU
sterilization pans containing Detergicide or 1 : 1000
mercury oxycyanide. After a thirty-minute period
of immersion they were removed under sterile
conditions, cut with sterile scissors into two-inch
lengths, and the sections dropped directly into
trypticase soy broth (Baltimore Biological Labora-
tory) . In every case the catheters were found
to be contaminated. The five most common or-
ganisms cultured from the catheters were Pseu-
domonas aeruginosa, Proteus mirabilis. Bacillus
subtilis, Aerobacter aerogenes, and Staphylococcus
albus.
In the second experiment, ureteral catheters
ranging in size from #4 to #6 were injected
with broth cultures of the five organisms isolated
in the first experiment. After contamination, the
catheters were immersed for sixty minutes in
By J. M. Hammer, M.D., M. J. Hickman, M.D.,
R. J. Hubbel, M.D. and J. R. MacGregor, M.D.
Kalamazoo, Michigan
separate flat GU pans containing 2 per cent
Westcodyne, 2 per cent Amphyl, 2 per cent Osyl,
Detergicide, and 1 : 1000 mercury oxycyanide. The
catheters were removed from the pans, cut into
sections, and cultured as before. The organisms
were recovered in every case.
In the third experiment, catheters were in-
jected with cultures of the same five organisms
and autoclaved for thirty minutes at 121° C. and
fifteen pounds pressure. When the catheters were
cut into two-inch sections and cultured, no growth
was obtained.
Ureteral catheters were injected with broth cul-
tures of the five organisms and sealed in plastic
envelopes in the fourth experiment. The en-
velopes were exposed to three million r.e.p.* in
the van de Graaf machine (an electron beam).
No growth was obtained when these catheters were
cut into sections and cultured.
To demonstrate that sterilizing solutions do not
always come in contact with the entire surface
of the catheters, two twelve-inch lengths of poly-
ethylene tubing were immersed in a 1 per cent
eosin solution, one in a flat pan and the other
in a cylinder. When the length of tubing was
placed in the flat pan, an air bubble was trapped
in the lumen and prevented the eosin from enter-
ing except for a short distance at each end. In
contrast to this, the air was rapidly replaced by
the eosin solution in the length of tubing placed
vertically in the cylinder.
When this experiment was repeated, using con-
taminated catheters in place of the tubing, and
mercury oxycyanide and Westcodyne in place of
the eosin, the contaminating organisms were re-
covered in each instance. The tiny lumens of the
catheters prevented the solutions from rising inside
the catheters.
Studies were made to determine the effect of
several sterilizing agents on the shellac of cath-
eters. When catheters were immersed in mercury
oxycyanide and Westcodyne for thirty days, no
*Roentgen equivalents physical.
194
IMSMS
STERILIZATION OF URETERAL CATHETERS— HAMMER ET AL
effect was observed on the catheters in the mercury
oxycyanide. However, the shellac on the catheters
in the Westcodyne was softened. When catheters
were sealed in cellophane envelopes and sterilized
in the autoclave for twenty minutes at 121° C.
and fifteen pounds pressure, no deleterious effect
was found after twenty autoclavings. After this,
the catheters deteriorated during the next two or
three periods of sterilization.
Discussion
A delicate natural balance exists between the
normal bacterial flora of a host and numerous
pathogens or potential pathogens. When this
balance is undisturbed, a symbiosis exists between
the host and the normal flora in certain areas of
the body. The pH of these areas is favorable for
the maintenance of the normal flora, and at the
same time the bacterial flora helps to maintain
the pH. If this balance is disturbed by the ad-
ministration of wide-range antibiotics, the pH may
be altered with the resultant disappearance of the
normal bacterial flora or the normal flora may be
wiped out by the antibiotics with a resultant
change in pH. Such changes make conditions
favorable for the growth of organisms which
are usually nonpathogenic. With the inhibiting
effect of the normal flora removed and the change
in pH, fungi, viruses and antibiotic-resistant bac-
teria grow rapidly and may become pathogenic.
A large percentage of the patients being cysto-
scoped have developed their infections because of
obstructing lesions along the genitourinary tract
or from ascending or blood-borne infections. A
great variety of organisms is responsible for these
infections, and, since the patients have been
treated with sulfa drugs or antibiotics usually for
considerable periods of time before cystoscopy, the
causative organisms have become antibiotic re-
sistant. When the patients are cystoscoped, the
organisms are introduced into the catheters, which
are then theoretically sterilized. If the steriliza-
tion process is not effective, the same organisms
( Mycobacterium tuberculosis in some cases) are
introduced into the renal pelvis of the next po-
tential host. From this, it is obvious that sterile
ureteral catheters are essential.
Apparently the main reason for the lack of
sterilization in ureteral catheters is the failure of
the sterilizing agent to reach the organisms. The
catheter is a long, hollow cylinder and when it
is placed longitudinally in a pan it can remain
there indefinitely without the sterilizing agent
reaching the entire inner surface.
Two methods of sterilization produced sterile
catheters: exposure to the electron beam of the
van de Graaf and autoclaving. The van de Graaf
machine is available only at the larger research
centers, although exposure of catheters to gamma
rays from the cobalt bomb is becoming increas-
ingly available. No studies have been made as
to the effect of this amount of radiation on the
shellac of the catheters.
Sterilization in an autoclave is available in all
hospitals. With this method, the catheters should
first be cleaned by injecting distilled water through
them to remove urinary sediments, blood clots
and any other solids. The catheters are then
packaged individually, with or without stylets,
in cellophane or plastic envelopes. The packaged
catheters are autoclaved for twenty minutes, the
timing period being started after the pressure has
reached fifteen pounds and the temperature 121°
C. Since the catheters have been packaged in-
dividually before sterilization, they may be stored
indefinitely before use without contamination.
In the past, the objection that autoclaving
shortens the life of a catheter has been raised.
If it does, the difference is not appreciable. Auto-
claving is the one means of sterilizing which con-
sistently produces sterile catheters, and in con-
sideration of the patient it would be the only
feasible one even if it meant an increase in cost
to the cystoscopist. Disposable sterile catheters
would offer another solution to the problem.
Roth et al‘ have attacked this problem by mix-
ing wide-range antibiotics in the retrograde pyelo-
graphic media and have concluded that Neomycin
was the most satisfactory.
It is taken for granted that the rest of the equip-
ment used at cystoscopy is cleaned and sterilized
with cold sterilizing methods.
Conclusions
1 . Present methods of sterilizing ureteral
catheters are not completely satisfactory.
2. Alternate methods of sterilizing ureteral
catheters are presented.
Acknowledgment
The authors wish to express their gratitude for valu-
able technical assistance in this problem to: W. W.
Allen, M. A. Banks, Sister John Casian, Sister Diane,
N. A. Drake and I. A. Pearson.
( References on Page 244)
February, 1957
195
Abdominal Pregnancy
Report of Two New Cases
VY 7ITH THE definite increase in ectopic preg-
’ * nancies, it is almost inevitable that ab-
dominal pregnancies will become more common.
Because of the rarity of this condition in the past
and because of its potential seriousness, it was
thought important to review the literature rela-
tive to the clinical management of this condition
so that maternal and infant mortality might be
kept as low as possible.
It is of little value to attempt to determine the
incidence of abdominal pregnancy. Few in the
literature are in agreement. It will suffice to
say that the condition at present is not common.
It is generally agreed that most cases, if not all,
are secondary to tubal pregnancies. The preg-
nancy apparently continues following either tubal
abortion or tubal rupture.
The importance of making the correct pre-
operative diagnosis cannot be overemphasized.
Not to do so is to invite serious trouble. There
are several salient features in the history. In a
very large percentage of cases there occurs some
type of abnormal uterine bleeding during the first
trimester. More often this abnormality is in the
form of oligomenorrhea. An important symptom
is the history of a sudden episode of severe lower
abdominal pain which subsides spontaneously in
the first twenty-four to forty-eight hours. The
onset of this pain is usually in the first eight weeks
and probably represents the tubal abortion, and
usually nausea and vomiting continue throughout
pregnancy. Cramping abdominal pain is com-
mon through the entire gestation and becomes
more severe with the movement of the fetus.
In many instances, fetal parts may be palpable
very superficially, however this is not always the
case. Many times there is sufficient tenseness of
the fetal sac so as to give the examiner the same
impression as that of a uterine fundus. It is not
uncommon for “uterine contractions” to be pres-
ent. Accurate bimanual examination is often dif-
From the Department of Obstetrics and Gynecology,
Highland Park General Hospital, Highland Park!
Michigan.
By Bernard Levine, M.D.,
and Max Blaine, M.D.
Highland Park, Michigan
ficult. With the presence of the large pelvic mass
and the associated tenseness of the abdominal wall,
the uterus, which enlarges to that of a two and
one-half month gestation, is not easily or definitely
outlined. An important diagnostic aid is the ab-
dominal roentgenogram. The presence of a high
breech or a high transverse with unusual skeletal
distortion is essential to the consideration of the
diagnosis. These positions occur in almost all re-
ported cases. The inability to visualize the uterine
wall radiologically is also important. The only
absolutely diagnostic procedure is the hysterogram.
Certainly no patient should undergo laparotomy,
where this condition is suspected, without a hy-
sterogram. The importance of establishing the
diagnosis greatly overshadows any minimal risks
involved in the procedure. In those patients who
are seen at or near term, mild cramping pains
simulating labor are quite common, and are ex-
aggerated with fetal movement. It is not uncom-
mon for patients to exceed forty weeks’ gestation.
There is nothing in the literature to support the
old idea that surgery should be done as soon as
the diagnosis is made. Serious pre-operative com-
plications with the exception of ileus, are quite
infrequent. Surgical technical difficulties are no
greater at term than at any other time during
the pregnancy. There is no evidence to indicate
that maternal mortality is increased by allowing
the pregnancy to continue to term. Certainly
infant mortality is decreased. A mother with an
abdominal pregnancy at or near term has about a
25 per cent chance that the infant will survive and
a 10 per cent chance that it will be completely
normal.
The mother faces her greatest danger from
hemorrhage. It is directly or indirectly responsible
for nearly all cases of maternal mortality. One
major cause of hemorrhage is the accidental cut-
ting of the placenta during surgery. The most
judicious incision is a paramedian incision on the
side opposite the placental implantation. Incis-
ing the placenta is an accident of major propor-
tions. Shock and death may rapidly ensue unless
196
TMSMS
ABDOMINAL PREGNANCY— LEVINE AND BLAINE
Fig. 1. Case 1. Note the high trans- Fig. 2. Case 1. The distortion of Fig. 3. Case 1. Hysterogram taken
verse position and the distorted ap- the fetus is apparent. preoperatively.
pearance of the fetus.
blood in large quantities is readily available and
the source of bleeding rapidly brought under con-
trol. Another major cause of hemorrhage is the
attempted removal of the placenta. Certain au-
thors hold the view that the placenta should be
removed if possible, however, the dangers in-
volved in determining this fact are great. Some
placentas have been removed successfully but
many have not. Where the attempt has been
unsuccessful it has resulted in serious consequences
for the patient. Confronted with placental hemor-
rhage, hemostasis as rapidly as possible is essential.
The most widely used methods have been packing,
suturing and pressure. Where there has been an
appreciable amount of placental bleeding there is
the invariable development of postoperative pelvic
abscess. If possible, cul-de-sac drainage is ad-
visable. The preferred management of the pla-
centa is to leave it in situ. The cord should be tied
and cut as close to the placenta as possible and
a primary closure of the abdomen without drain-
age be done. With this type of management an
uneventful postoperative course is the rule. 1 he
placenta is subsequently absorbed although it may
take from one to two years. Positive pregnancy
tests persist from one to two months.
With emphasis placed on the necessity of the
correct pre-operative diagnosis, with judicious
management of the placenta and with the avail-
ability of blood, maternal mortality should be very
uncommon and infant survival definitely improved.
Case Reports
Case 1. — A colored woman, aged twenty-seven, gravid
1, para 0, was first seen in consultation at about six
and one-half months’ gestation. She was supposedly
in premature labor and was having irregular abdominal
pain but no apparent progression of labor. Her last
normal menstrual period was April 6, 1953. In both
May and June she had scanty bleeding of two days”
duration. Following this there was amenorrhea. Her
menstrual history was as follows: onset at age eleven;
occurance every twenty-eight days; duration three to
four days; menstrual cramps moderate. Her past his-
tory: pulmonary tuberculosis at age eleven, for which
she was hospitalized for eighteen months, and discharged
as cured. She underwent appendectomy in December,
1944. In June, 1953, at approximately eight weeks’
gestation this patient had a sudden onset of sharp right
lower quadrant pain which was associated with spotting.
After twenty-four hours the pain subsided. The pa-
tient's major complaint since that time has been inter-
mittent abdominal cramps. Prior to her admission to
the hospital she had the onset of nausea and vomiting.
On abdominal examination it was not definitely possible
to outline a uterus nor were any uterine contractions
palpable. The abdominal mass was 4 cm. above the
umbilicus and her abdominal pain was synchronous with
fetal movement. Palpation of the fetus gave the im-
pression of its being very superficial. Fetal heart was
of good quality. Rectal examination revealed no pre-
senting part and no cervical dilatation. Abdominal
pregnancy was suggested at this time and abdominal
roentgenograms were taken (Figs. 1 and 2). The
patient remained hospitalized for several weeks until her
abdominal symptoms subsided, and was readmitted in
November at about eight and one-half months’ gesta-
tion for an elective laparatomy. Before surgery, how-
ever, a hysterogram was done to confirm the diagnosis
(Fig. 3). On Nov. 16, 1953, a laparotomy was done
February, 1957
197
ABDOMINAL PREGNANCY LEVINE AND BLAINE
with the delivery of a full-term female infant from the
abdominal cavity. The infant failed to breathe and
attempts at resuscitation failed. The placenta was at-
tached to the region of the right broad ligament. The
cord was tied and cut, the amniotic fluid was aspirated
and the placenta was left intact. There was no placental
bleeding and the abdomen was closed without drainage.
The patient made an uneventful recovery and left the
hospital on the eleventh postoperative day. She was seen
in January, 1955, at which time her condition was good
and the mass in the right adnexa was 3 to 4 cm. Autopsy
showed that the infant had diffuse pneumonitis with
aspirated amniotic fluid. The patient was again seen
in December, 1956, at which time her menstrual periods
were normal and there was no evidence of a pelvic mass.
Case 2. — A colored woman, aged thirty-one, para 3,
gravid 5, had her last normal menstrual period on
July 13, 1954 and her EDC was April 20, 1955. The
patient was first seen on September 7, 1954, with what
appeared to be a normal pregnancy, with some nausea
and vomiting. Physical examination was negative and
she gave no history of previous abdominal pain. She
was not seen again until February 19, 1955, when she
was thought to be in labor. Examination revealed a
transverse presentation which was confirmed by x-ray
(Fig. 4). After the “labor” stopped the patient was
discharged from the hospital. She was readmitted on
February 25, 1955, because of the recurrence of ab-
dominal pain. At this time she also had severe anor-
rhexia and had lost seven pounds in six days. Hemo-
globin was 9 gms. Following a blood transfusion, a
hysterogram was done (Fig. 5), which confirmed the
diagnosis. Two days after the hysterogram was made,
the nausea, vomiting, and abdominal pain became severe
and the patient developed abdominal distention. She
improved following the passage of a long tube. On
March 2, 1955, a laparotomy was done and a living
infant was delivered which survived for twelve hours.
Prematurity was considered to be the cause of death.
The placenta was found to be adherent to the region of
the right broad ligament but extended to the anterior
abdominal and lateral pelvic wall. There were several
areas of brisk bleeding from the placenta which had been
accidentally cut. These areas were controlled by sutur-
ing, electrocoagulation, and oxycel pack. The abdo-
men was closed without drainage, and the patient was
given 1,500 cc. of blood while in the operating room.
Her postoperative condition was uneventful until the
eighth day, when she developed a purulent-sanguinous
discharge from one point in the incision. Through this
fistulous tract there also was extruded pieces of oxycel.
There was drainage for fifty-nine days, after which the
tract gradually closed. Six months after the operation
the patient was seen and her condition was good and
she had gained thirty-seven pounds. A small adnexal
mass was the only residue.
Bibliography
1. Arrington. R. J., and Williams, D. G. : Advanced
abdominal pregnancy; case report. J. Michigan M.
Soc., 49:805-806 (July) 1950.
2. Beacham, W. D., and Beacham, D. W.: Abdominal
pregnancy; review of present knowledge based partly
on reported cases and partly on experience of
Charity Hospital of Louisiana at New Orleans dur-
ing the period July 1, 1937 through June 30, 1945.
Obst. & Gynec. Surv., 1:777-805 (Dec.) 1946.
3. Brown, W. W., Jr., and Rucker, C.: Abdominal
pregnancy: birth by rectum. South. M. J., 40:905-
908 (Nov.) 1947.
4. Branscomb, L. : Advanced abdominal pregnancy.
Am. J. Obst. & Gynec., 54:874-878 (Nov.) 1947.
Fig. 4. Case 2. Note the high trans- Fig. 5. Case 2. Note the change of
verse position. position into a high breech.
198
IMS MS
ABDOMINAL PREGNANCY— LEVINE AND BLAINE
5. Bowen, G. L. : Abdominal pregnancy with living
baby delivered near term. Am. J. Obst. & Gynec.,
61:455-457 (Feb.) 1951.
6. Barrett M. E.: Abdominal pregnancy. Am. J. Obst.
& Gynec., 64:1061-1072 (Sept.) 1952.
7. Burleson, R. J., and Bragg, J. C.: Full-term ab-
dominal pregnancy. J.A.M.A., 147:1349-1350
(Dec.) 1951
8. Broomes, E. L. C.: Full term abdominal pregnancy
with delivery of living child. J. Indiana M. A.,
44:127-129 (Feb.) 1951.
9. Bourgeois, G. A., and Shapiro, M. W.: Abdominal
pregnancy secondary to rupture of accessory uterus
with survival of mother and infant. New England
J. Med., 247:84-87 (July 17), 1952. (Correction
in: 247:289 (Aug. 21 ) 1952.)
10. Beggs, L. F.: Ectopic pregnancy. J. Indiana M.
A., 42:904-908 (Sept.) 1949.
11. Cross, J. B. ; Lester, W. M. ; and McCain, J. R.:
Diagnosis and managament of abdominal pregnancy.
Am. J. Obst. & Gynec., 62:303-311 (Aug.) 1951.
12. Deming, F. S.: Extrauterine pregnancy at term
with delivery of normal living child and living
mother. Am. J. Obst. & Gynec., 56:962-965 (Nov.)
1948.
13. Dorman, D. B.: Full-term abdominal pregnancy.
New England J. Med., 245:207-210 (Aug. 9) 1951.
14. Douglass, G. F.; Douglass, G. C.; and Douglass,
G. F., Jr.: Ectopic pregnancy. J. Internat. Coll. Sur-
geons, 15:28-37 (Jan.) 1951.
15. Eisaman, J. R., and Ziegler, C. E.: Abdominal
pregnancy. J.A.M.A., 104:2175 (June 15) 1935.
16. Elzey, N. D.: Primary abdominal pregnancy in
lesser peritoneal cavity. West. J. Surg., 56:410-413
(July) 1948.
17. Easterling, T. G.: Early abdominal pregnancy. J.
Louisiana State M. Soc., 105:21-25 (Jan.) 1953.
18. Gardner, A. R., and Middlebrook, G. : Abdominal
pregnancy. Am. J. Surg., 66:161-167 (Nov.) 1944.
19. Hazlett, W. H.: Repeated term abdominal preg-
nancy. Obst. & Gynec., 1:313-316 (March) 1953.
20. Lester, W. M. : Bartholemew, Calvin; and Grims,
Fich.: Two successful abdominal pregnancies as-
sociated with uterus bicornis unicollis. Am. J. Obst.
& Gynec., 65:411-412 (Feb.) 1953.
21. MacGregor, A. S.: Abdominal pregnancy. Am. J.
Surg., 82:365-371 (Sept.) 1951.
22. Pearson E. A.: Abdominal pregnancy. West J.
Surg., 58:712-713 (Dec.) 1950.
23. Posner, A. C., and Beer, M. A.: Full-term ab-
dominal pregnancy with living mother and child.
New York State J. Med., 51:1185-1186 (May 1)
1951.
24. Reed. C. B. : Abdominal pregnancy; full term sur-
viving infant and mother. Texas State J. Med.,
46 : 379-381 (June) 1950.
25. Redgwick, J. P. ; Rumbolz, W. L. ; and Nace, F.
M.: Advanced intraligamentary pregnancy. West. J.
Surg., 58:424-426 (Aug.) 1950.
26. Siegal, H. A.: Advanced abdominal pregnancy
with fetal and maternal survival. J. Internat. Coll.
Surgeons, 18:77-85 (July) 1952.
27. Wichser, C. G.: Advanced abdominal pregnancy.
New Orleans M. & Surg. T., 102:70-71 (Aug.)
1949.
AMA NEWS NOTES
(Continued from Page 154)
list of both direct and indirect causes of obstetric
death. The latter informaion coordinates the
code numbering system of the ‘'Standard Nomen-
clature of Diseases and Operations” with the
categories established by the Sixth Revision of
the International Lists of Diseases and Causes of
Death.
AMA PREPARES NEW EXHIBIT
ON DIGESTION
Plans are underway by AMA’s Bureau of Ex-
hibits for a new health education exhibit showing
the anatomy and mechanics of digestion. Color-
ful three-dimensional anatomical models and
drawings will give the lay person a good idea
of the human digestive processes. This exhibit will
be added to the existing list of displays on the
human body, including “You and Your Body, ’
“Your Bones and Your Muscles,” “We See,” “We
Hear,” and the ever-popular “Life Begins.” The
Bureau hopes to have this exhibit available for
the forthcoming state and county fair season.
“HOME CARE” INFORMATION
AVAILABLE FROM AMA
Because of increased interest among medical
societies in organized “home care” programs — -
such as the one inaugurated by Montefiore Hos-
pital (New York) several years ago — the AMA’s
Council on Medical Service recently undertook
a study of existing programs throughout the coun-
try. The new study includes information on the
organization, development, financing, medical
services provided, and problems encountered in
the various home care programs. Any medical
society desiring further information should con-
tact the Council.
February, 1957
199
Esophageal Hiatus Hernia
"D ECENTLY we encountered several patients in
whom it was extremely difficult to determine
whether symptoms were due to hiatus hernia, to
concomitant heart disease, or to other associated
lesions of the gastrointestinal tract. Representative
of such cases was that of a fifty-year-old lady with
episodic attacks of severe epigastric and retroster-
nal oppressive pain radiating into the left arm,
lasting a few hours, and not related to exertion or
food intake. Following the first such episode, the
patient had been hospitalized for several weeks
with a diagnosis of myocardial infarction, although
subsequent review of her electrocardiograms indi-
cated that they were normal except for ventricular
premature contractions.
Intensive study of this patient revealed only an
esophageal hiatus hernia and a tendency for exer-
cise to precipitate bigeminal rhythm due to ventri-
cular premature contractions. Repeated serum
amylase determinations during attacks and two
cholecystographic studies were normal. Despite
the postexertional bigeminy which suggests under-
lying coronary artery disease, we felt that the
patient’s difficulties were not primarily cardiac in
origin, and when medical therapy of the hiatus
hernia with small feedings, antispasmodics, and
elevation of the head of the bed failed to relieve
her symptoms, we advised surgical repair.
The hernia was successfully repaired through a
transthoracic approach, but the patient’s attacks
of pain continued to recur. The gall bladder series
was repeated again and cholelithiasis was found
on this third examination. At subsequent laparo-
tomy for cholecystectomy, chronic pancreatitis was
evident. The patient’s difficulties did not recur
after cholecystectomy, and it seems clear that her
attacks of pain were due to recurrent pancreatitis
associated with cholelithiasis, that the bigeminal
rhythm was reflex in origin, and that the hiatus
hernia was merely an incidental and misleading
finding.
This case emphasized for us the occasional falli-
From the Medical Service, Mount Carmel Mercy Hos-
pital, Detroit, Michigan.
By Julian M. Guidot, M.D.,
Hugh F. Kerrin, M.D., and
I. Donald Fagin, M.D., F.A.C.P.
Detroit, Michigan
bility of cholecystography in the diagnosis of gall-
stones and the difficulty of diagnosing chronic
pancreatitis in the absence of calcification or other
x-ray signs. It also taught us that, if faced with
similar uncertainties in the future, we should insist
on manual exploration of the upper abdomen
prior to repair of the hiatus hernia.
Stimulated by this and similar experiences, we
reviewed the hiatus hernias found at our hospital
during the year 1954, to determine the incidence,
the clinical features, the frequency of symptoms
attributable to the hernia, and the frequency of
associated lesions, to give us background data
against which to evaluate subsequent cases.
TABLE I. AGE AND SEX INCIDENCE OF 224
HIATUS HERNIAS
Age: Males (103) Range — 31-82 years Average — 54.7 years
Females (121) 29-81 years 57.2 years
Incidence by decades:
21-30 years 2 patients
31-40 years 20 patients
41-50 years 46 patients
51-60 years 81 patients
61-70 years 48 patients
71-80 years 24 patients
81-90 years 3 patients
Material
During 1954, the upper gastrointestinal tract
was examined roentgenologically in 2,597 patients:
224 (8.6 per cent) were found to have esophageal
hiatus hernias. These hernias may be classified
on various bases: anatomic, etiologic, visceral con-
tent, et cetera. In our series, 216 were of the
true hiatal type wherein the esophagogastric junc-
tion was displaced above the diaphragm; six were
paraesophageal hernias wherein a part of the
stomach slips through the hiatus alongside the
esophagus while the esophagogastric junction re-
mains subdiaphragmatic ; in two patients the hernia
was associated with a congenitally short esophagus.
The hernias varied in size from a two centimeter
pouch to almost complete paraesophageal hernia-
tion of the stomach, but the majority were from
four to six centimeters in diameter.
The sex and age incidence of these 224 patients
is detailed in Table I. The youngest patient was
200
JMSMS
ESOPHAGEAL HIATUS HERNIA— GUIDOT ET AL
TABLE II. ASSOCIATED GASTROINTESTINAL LESIONS
IN 224 PATIENTS WITH HIATUS HERNIA
TABLE III. MAJOR COMPLAINTS IN 53 SYMPTOMATIC
HIATUS HERNIAS
Upper Gastrointestinal tract
Normal
Peptic ulcer
Duodenal ; . 35
Gastric „ 4
Esophageal 3
Diverticula
Duodenal 29
Esophageal 2
Gastric 1
Gastritis
Esophageal stenosis, achalasia, deformity of duodenum
Lower Gastrointestinal tract (studied roentgenologic ally in
104 patients)
Normal
Diverticulosis
Carcinoma
Ulcerative colitis
Tuberculous ulcer
Irritable colon
Biliary tract (studied by cholecystography in 71 patients)
Normal
Cholelithiasis .'
Non visualization
152
42
32
4
1 each
59
36
5
2
1
1
52
12
7
a twenty-nine-year-old woman who developed
symptoms in the sixth month of pregnancy, and
the oldest patient was an eighty-two-year-old man
in whom the hiatus hernia was incidental to a
carcinoma of the colon. There was no significant
sex differential, and as might be anticipated, 90
per cent of the patients were over forty years of
age.
A surprisingly high incidence of associated lesions
of the gastrointestinal and biliary systems was
found. These findings are tabulated in Table II.
The frequent coexistence of hiatus hernia and
diverticula of the duodenum and/or colon sug-
gests that a predisposition to these lesions may
reflect a constitutional defect in supporting tissues
as well as an aging factor. This high incidence of
concomitant lesions makes it difficult to determine
which particular lesion is responsible for the pa-
tient’s symptoms, if any.
Of the 224 patients, 158 were inpatients with
complete clinical records available for evaluation
of their complaints. Of these 158 patients, 105
were found to have other gastrointestinal dis-
orders, heart disease, or diseases of other systems
which satisfactorily explained their difficulties. In
these patients, the hiatus hernia was considered
an incidental finding, not contributing to the
patient’s illness. Undoubtedly in some of these
patients the hiatus hernia did play a role in their
complaints, but we could not separate this factor
from the more prominent and more logically caus-
ative lesion.
In the remaining fifty-three inpatients, the
hiatus hernia was believed by us to be the factor
responsible for the patients’ symptoms and find-
Pain
(a) Abdominal
(b) Chest
(c) Interscapular
( d ) Shoulders
(e) Neck
Nausea and/or vomiting
Gastrointestinal bleeding
Heartburn
Dysphagia
Dyspnea with eating
Persistent hiccoughs
29
16
9
2
2
37
23
14
7
6
5
1
ings. There were no major age or sex differences
between this group of fifty-three symptomatic
hiatus hernias and the total group of 224. The
major complaints in these fifty-three patients are
listed in Table III, and are discussed in more
detail below.
Symptoms
Pain was present in thirty-seven cases (70 per
cent). The most common location of pain was in
the epigastrium or retrosternal area, with the epi-
gastrium more common in females and the retro-
sternal area in males. Interscapular pain and left
anterior chest pain also was noted frequently.
Radiation of the pain to the neck, shoulder, and
upper or lower quadrants of the abdomen was
not uncommon. The pain was described in most
cases as burning in character, and varied in severi-
ty from mild discomfort to severe disabling dis-
tress. Upper abdominal fullness or bloated sensa-
tion frequently accompanied the pain. The pain
was occasionally colicky but more often nonremit-
tent, lasting from a few minutes to several hours,
often precipitated by eating or starting one to two
hours postprandially, and varying in severity with
changes in position. The classic pattern of pain
developing with or aggravated by recumbency with
relief in the upright position occurred in nine of
the thirty-seven patients. In one patient a reverse
pattern was noted, with pain being relieved by
recumbency.
Nausea and/or vomiting occurred in twenty-five
patients (seventeen women and eight men), usu-
ally jiostprandially and usually in association with
pain. In only two patients was the nausea and
vomiting so severe and persistent that it was the
primary reason for hospitalization. Vomiting often
produced relief of pain.
Gastrointestinal bleeding attributable to the
hiatus hernia occurred in fourteen patients of the
fifty-three (26 per cent). Bleeding occurred with
equal frequency in both sexes, seven males and
February, 1957
201
ESOPHAGEAL HIATUS HERNIA— GUIDOT ET AL
seven females. In six patients, five of whom were
males, hematemesis was prominent; in five pa-
tients, four of whom were females, bleeding was
manifested by melena; in one patient melena and
hematemesis occurred simultaneously. One patient
had occult blood in her stools; and another patient
had a moderately severe anemia secondary to
chronic blood loss. This rather high incidence of
bleeding surprised us, particularly in view of the
fact that in only two cases was the bleeding asso-
ciated with demonstrable ulceration, one exhibit-
ing an ulcer of the lower third of the esophagus
and the other with an ulcer in the herniated por-
tion of the stomach. In the remaining twelve
cases, bleeding probably arose from superficial
erosions in the herniated portion of the stomach or
in the esophagus where it is subjected to pressure
effects and to the regurgitation of gastric contents
through an incompetent cardia. We are unable
to account in any logical fashion for the apparent
predilection of males to have hematemesis and
females melena, and we believe it is probably a
fortuitous occurrence associated with the small
number of cases. It interested us to note that six
of the patients with bleeding had no other symp-
toms related to the hernia.
Heartburn was a major complaint in seven
patients, five of whom were women. Heartburn
is a difficult symptom to evaluate since the term
has varying connotations to different patients; it
probably occurred in many more patients in this
group, in some of whom it was probably disre-
garded and in others overshadowed by pain.
Dysphagia occurred in six patients, three men
and three women. The sensation of dysphagia may
be referred to the retrosternal area, the xiphoid,
or to the left infraclavicular area. It occurred most
commonly with solid foods, but occasionally even
with liquids.
Dyspnea with ingestion of food occurred in five
patients (two men and three women). At first
thought, it might seem that the dyspnea could be
explained on the mechanical basis of interference
with the ventilatory function of the lung by dis-
placement due to hernia ; however, we were unable
to demonstrate any correlation between the size
of the hernia and the occurrence of dyspnea, and
we feel that probably some reflex mechanism
which we cannot yet define is operative.
Persistent hiccough was responsible for hospital
admission in one patient. The hiccoughs subsided
following a phreniclasis. In another patient, there
was a history of persistent hiccough ten years pre-
viously also responding to phreniclasis, but we
were unable to determine whether the hiccoughs
were related to the hiatus hernia at that time.
Comment
Surgical repair of the hernia was performed in
eleven of these fifty-three patients (21 per cent) ;
two repairs were prompted by severe bleeding,
one by esophageal ulcer, one by esophageal stenosis,
and one by lodging of a meat bolus in the hernia
pouch. The remaining six patients subjected to
surgery probably represented failure of medical
management. In one patient, the hernia recurred
following surgical repair.
The accepted medical management for hiatus
hernia consists of smaller, more frequent meals,
elevation of the head of the bed, weight reduction
where indicated, antacids and antispasmodics for
symptomatic relief, sedation, elimination of smok-
ing and other irritant factors when necessary.
This regimen is successful in effecting relief from
symptoms in most cases.
The only complications encountered in our
series were three cases of esophageal ulcers, one
of gastric ulcer in the hernia pouch, one of eso-
phageal stenosis, and one of impacted foreign
body (meat bolus) in the pouch. We had no cases
of perforation or incarceration.
As noted previously, we were impressed partic-
ularly with the following features in this series.
1. The relatively high incidence of esophageal
hiatus hernia.
2. The high incidence of associated lesions of
the gastrointestinal tract, which makes differential
diagnosis sometimes exceedingly difficult.
3. The high incidence of gastrointestinal bleed-
ing as a major manifestation of hiatus hernia.
4. The success of medical management in most
cases of hiatus hernia.
Summary
1 . Two hundred and twenty-four cases of hiatus
hernia were studied with reference to age and sex
incidence, and the incidence of associated lesions
of the gastrointestinal tract.
2. Of this group there were fifty-three patients
with symptoms referable to the hiatus hernia. The
symptoms and their frequency are presented.
202
TMSMS
What's New in Drugs?
Fredrick F. Yonknian, M.D.
Summit, New Jersey
<l\ is feai'fuHy and wonderfully made”
•kV.1 said the psalmist1 many years ago. How
true. Even as I stand, in this discussion with
you today, I am charged with electrochemical
impulses, most of them quite well mediated and
directional, leading to some end result. Proprio-
ceptive impulses are traversing sensory pathways
from my muscles and tendons, up and across spe-
cific spinal and cerebellar pathways, and after
central mediation with all that such implies, they
are returning through spinal motor columns to
effector nerves, thence back to certain antag-
onistic or opposing muscles, thus to permit me to
remain in some semblance of balance. The effect
of space and position upon the semicircular canals
of the inner ear, as well as the effects of light
upon the rods and cones of the retina with their
specific and respective pathways, cranial nerves
VHI and II, add to the complicated picture2
(Fig. 1) of maintaining this sense of balance.
And then when one realizes the strange bio-
chemical and electrical natures of living func-
tional tissues, one appreciates the real depth of
the psalmist's statement, “Man is fearfully and
wonderfully made.” This recently has been said
somewhat differently by Rodbard and Katz3 with
special emphasis on cardiovascular regulation.
“If all the vascular beds of the body were to open
simultaneously to their full capacities, the total per-
ipheral resistance would disappear and the cardiac out-
put would be swallowed up, leaving no trace of an
arterial pressure. In order, therefore, to permit the
circulatory pumps and vessels to carry out their proper
functions, most of the blood vessels of the body must
be partially or even severely constricted a great deal
of the time. To accomplish this, vasoconstriction must
be balanced neatly against vasodilatation, with both
attuned to cardiac output and to tissue needs.
“The control of the degree of vasodilation of the
blood vessels is achieved primarily by the interplay of
peripheral mechanisms. These include the effects of
metabolic vasodilators, produced by muscles and other
working tissues, which act directly or through axone
reflexes. These local mechanisms are supplemented by
a system of efferent vasodilator nerves transmitting mes-
sages from the central nervous system. When these
vasodilator influences are unchecked, a state of vascular
collapse and shock may ensue.
“Against these tendencies, a group of powerful vaso-
constrictor mechanisms is available and in constant func-
tion. Their role is to reduce unnecessary blood supply
to tissues. This vasoconstriction is guided by an hier-
Fig. 1.
archy whereby certain favored organs insure their own
blood supply, particularly the brain, the heart and the
kidney. The control of the degree and sites of vaso-
constriction, depends predominantly on the action of
the central nervous system and the influence of hormonal
action including the permissive effects of the steroids
and other substances. The relative distribution of the
cardiac output to the various organs is influenced by
the vasomotor center of the medulla oblongata, which
responds to impulses from all the tissues of the body,
including the other portions of the brain itself. This
center therefore ultimately sets the appropriate level of
systemic blood pressure. This control can best be il-
lustrated by considering some of the driving forces
of vascular regulation.”
What a wise fellow, that psalmist!
February, 1957
203
WHAT’S NEW IN DRUGS?— YONKM AN
Astounding it is that at times we seem to be
just so many automatons (Fig. 2), controlled by
set reflex patterns many of which regulate purely
vegetative or autonomic functions. One glance
at a diagramatic sketch of the autonomic nervous
Many clinical conditions observed in the circle of
one’s own relatives and friends soon convince one
that the psyche frequently has powerful control
over the soma (Fig. 4) as for example, Hirsch-
sprung’s disease, migraine headaches and neuro-
INTRACRANIAL
VESSELS
CIUARY
GANGLION
lACRYMAl
MEDULLA
SPHENOPALATINE
• ^GANGLION
PAROTID
subungual A
SUFMAXILIARY
GLANDS
OTIC
GANGLION
SUBMAND.
GANG HON
PERIPHERAL
CRANIAL VESS!
TRACHEA
SWEAT
GLAND
BRONCHI AND
LUNGS
HEART
CELIAC
GANGLION
GREAT
SPLANCHNIC
^lERVE
PERIPH
VESSEL
STOmaCm
> NCR LAS
ADRENAL
GLAND
LIONET
HAIR
FOLLICLE
IMF
GangiIdn
=0%ASTRIC
PL
PELVIC
NERVE
PELVIC
PLEXUS
SYMPATHETIC
CHAIN
system lends confirmation to this statement. Note
the superimposition of the brain with its auto-
nomic capacities (Fig. 3), but under potential
influence by higher and finely integrated cerebral
processes which may affect psychosomatically those
end organs under the control of the autonomic
nervous system, either for better or for worse.
genic hypertension, peptic ulcer and irritable
colon, as well as Raynaud's disease with cold
hands and feet. How could one be other than
greatly impressed with the autonomic nervous
system as being associated etiologically, at least
in part, with some of these clinical conditions.
The importance of these autonomic dyscrasias is
204
JMSMS
WHAT’S NEW IN DRUGS ?— YONKM AN
probably best portrayed by the plethora of stimu-
lants and depressants of both the sympathetic
and parasympathetic portions of the autonomic
nervous system. And this leads me directly to
today’s assignment.
ADRENERGIC CONTROL
Drugs, 1956" but after I received a preliminary
copy of the program, I read the following: What’s
New in Lung Cancer?; New and Old Methods
of Managing Burn Wounds; Diuretics and the
Treatment of Congestive Heart Failure; Clinical
Evaluation of Sinthrom, a New Oral Anti-co-
agulant; What’s New in Vitamin and Hormone
Treatment of Arthritis?; Rauwolfia in Hyperten-
sion; What’s New in Diabetes?; What’s New in
Antibiotics?; What’s New in Cerebral Palsy?;
What’s New in Pediatrics?; Tips on the Treat-
ment of Skin Diseases; What’s New in Ulcerative
Colitis?; and A New Approach to the Clinical
Management and Treatment of Behavior Prob-
lems.
All of these topics, being handled by experts,
I naturally had little hesitation in asking Dr.
Hull and Dr. Foster for permission to gear my
remarks in a vein other than that originally anti-
cipated, namely — how do we get something new
in drugs; how do they come into being and
into rational use.
In this regard, the greatest requirement at the
experimental and the clinical level is careful
observation, more observation and still more ob-
servation, followed by association, and I should
like to give you a few illustrations of pure ac-
cidents leading investigators to important applica-
tions of their observations. In most instances our
drugs, as you and I know them today, came to
February, 1957
us by accident rather than by intent, that is,
chemical compounds were often made not be-
cause they were intended to attack certain organ-
isms or specific diseases but with the hope that
they might do so and in a favorable vein. Then
Peripheral vascular disease
A rterio- obliterans
Lymphedema
Diabetic gangrene
Post-traumatic edema
Thrombo-angiitis obliterans
F rostbite
Raynaud's syndrome
Scleroderma
Livedo reticularis
Endarteritis
Acrocyanosis
Herpes zoster
Causalgias
Post-herpatic neuralgias
Trench and immersion foot
Popliteal aneurysm and
Thrombophlebitis
embolism
Acute ischemia (polio)
Dysmenorrhea (neurospastic)
Hypertension
Cerebral “accidents”
Thrombotic and vasospastic
Fig.
4.
too, the use of a certain compound or drug for
one indication often led to another use, because
some investigator had made a pertinent observa-
tion of an unanticipated action of that compound.
And that is one of the chief reasons why this
game of developing new drugs becomes so in-
triguing and fascinating, and likewise rewarding.
In this country it is most gratifying that those
of us in the laboratories have the splendid co-op-
eration of scientifically minded physicians at the
bedside. This avenue of co-operation is not one-
way, it is two-way, for not only is the clinician
willing to test developments of the laboratorian’s
dreams but the clinician very often finds a labora-
torian who is most eager to co-operate with him
to test the basic features of some important ob-
servation made in the clinic.
And here we come back to the simple but
powerful word — observation, the basis of all re-
search. Well do I recall the encouraging advice
of my first graduate preceptor, Dr. Wilbur W.
Swingle, then at Yale and now at Princeton, who
said, “Young man, you don’t have to know every-
thing to do successful research. When you add
two and two and get five, and then wonder why,
you are on the road.” Why did the unanticipated
appear; what might be its meaning; in other
words, observation leads to investigation, and in-
tense reinvestigation often leads to basic prin-
ciples and their application to man’s welfare.
Well do we recall when our laboratory' as-
sociates were first working with one of the pure
alkaloids of Rauwolfia, namely reserpine, in an
attempt to study its antihypertensive effects. Such
205
WHAT'S NEW IN DRUGS? — YONKMAN
Fig. 5. Fig. 6.
studies were made in anesthetized animals and
later in unanesthetized monkeys. When one ob-
served a condition of anger and probably fear
(Fig. 5) change to one of nonchalance (Fig. 6),
(or what would you call it -perhaps disinterested
complacency?), you may well imagine that the
efforts of workers4 in our laboratories were re-
directed toward those changes observed after Rau-
wolha in the clinic as cited by Dr. Wilkins,5
. . and Rauwolfia 1 tablet a day. Even after
discussing her husband, her blood pressure was
only 160/100. The patient remarked frequently
on her symptomatic improvement, and ‘change
in personality.’ When quizzed about the latter
she said, ‘I am not less ambitious, I’m not less
aggressive, I'm not less effective. I just don’t seem
to have to do the things 1 used to. Before, I felt
I had no control over myself. I had to do things.
Now I don’t care, I don’t even notice things.
Dust doesn’t annoy me now. Before, I knew
it wasn’t important, but I had to clean it up.
Now I let it go for 2 weeks, and it doesn’t
bother me.’ ”
As Dr. Wilkins also said, good-naturedly yet no
doubt with sincerity, to his Boston medical friends,
“Rauwolfia is good psychotherapy in pill form.”8
So you see, careful observation led us all from
one held, namely, antihypertensive capacities of
this botanical contribution to that of modulation
of symptoms of anxiety and tension in the men-
tally ill.
Another experimental observation made in the
laboratory while Rauwolfia and reserpine were
being studied was that of bradycardia which
usually accompanied this drug-induced hypoten-
sion. This desirable feature of reserpine’s action
was soon applied by various clinicians to modulate
or antagonize the tachycardia produced by cer-
tain antihypertensive agents such as hydralazine,
thus permitting not only more comfort for the
patient during hypotension but reduction in dos-
age of that agent, hydralazine, which had in-
duced the tachycardia.
It was also early observed in the laboratory that
reserpine increased gastrointestinal motility of
various experimental animals; this knowledge
alerted interested clinicians to potential unde-
sirable and desirable side effects to be anticipated
in their patients; in other words, diarrhea could
be severe, but, on the other hand, modified dosage
might be of real advantage7 to the patient with
a sluggish gastrointestinal tract.
Another most important example of the value
of careful observation concerns the field of corti-
costeroids. You well know the story. May I pose
a few questions from which you may draw your
own conclusions as to whether drugs are dis-
covered by accident or by intent. So many of
our modern day developments in any line, but
especially in science, specifically in medicine, are
circumstantial. For example, would we be using
cortisone, hydrocortisone and prednisone today
206
JMSMS
WHAT'S NEW IN DRUGS?— YONKM AN
.
in the treatment of rheumatoid arthritis if Hench,
the clinician, and Kendall, the biochemist, had
not been at the Mayo Clinic at the same time?
What if Hench had not been desperate for some-
thing, anything for that matter, for his arthritic
patients? Where would we be if Kendall had not
much earlier isolated and described his Compound
E, thus permitting the excellent chemists of Merck
& Company of Rahway, New Jersey, to make
working amounts of this material which was so
difficult to prepare? What might have happened
if Hench and Kendall had decided to give less
than the unknown, guessed at, effective amount
of 100 mg. per day for a few days? In his Nobel
lecture8 Hench stated: “Dr. Kendall and I de-
cided to use for this first rheumatoid patient daily
doses of 100 mg. intracuscularly, so that we might
not commit the error of underdosage.” He con-
tinues, “Thus, on September 21, 1948, Dr. Slocum
began to administer to the above-mentioned pa-
tient daily doses of 100 mg. of Compound E in
the form of a crystalline suspension in saline solu-
tion. Within three days the patient was markedly
improved and continued to improve until the
daily dose was reduced to 25 mg.” What if the
dosage regime had been reversed? It is reason-
able to believe that there might not have been
any favorable results to report with Compound
E in rheumatoid arthritis, and Hench and Kendall
and Reichstein might never have won the Nobel
Prize.
And as to subsequent developments in this
field, where would we have been if it were not
for Dr. George Thorn’s eosinophilia test,9 for you
will recall that this simple test, performed in
man but now also in the lowly white mouse, was
the chief factor in arousing the keen interest of
the scientists at Schering in those steroids now
known as prednisone and prednisolone. Had these
two valuable steroids not suppressed the eosino-
phils in laboratory mice according to Thorn’s tech-
nique, I wonder whether they would have their
current well earned reputation.
Circumstantial you say — why not? Would we
have had insulin as early as 1923 if Drs. Banting
and Best had used only six or eight dogs instead
of dozens? For you well recall Paul DeKruif’s
accurate account10 that no favorable hypoglycemic
effects had been observed with the Toronto pan-
creatic extracts until dozens of animals had been
carefully studied. Well, you say, if insulin had
not been discovered by Banting and Best, then
probably it would have been by Murlin of Roch-
ester or by dozens of other investigators the world
round. How true; but how many diabetic lives
might have been lost in the interim, had it not
been for a few extra dogs in Toronto?
Appropriate to our theme, namely, the impor-
tance of observation, one might recount the de-
tails of many valuable experiences such as Dr.
Withering and his curious interest in his neigh-
bor’s purple foxglove (digitalis) for dropsy; the
development of cocaine as a local anesthetic
because of the observations of certain Jesuit
priests in the indefatigability of pack runners
in the Andes; of Domagk of sulfa drug fame,
because of his mundane screening studies to de-
termine any potential antibacterial effects of
hundreds of compounds which apparently were
good for nothing except as dyes or intermediaries
for the production of dyes; of Fleming’s innate
curiosity in a contaminating mold during his
studies of Staphylococci leading him to the de-
velopment of penicillin, the forerunner of all sub-
sequent antibiotic agents now in medical use.
Yes, there are many other illustrations of the
importance of observation. One of the most
fascinating was recently cited by Dr. Fabing11 of
the Christ Hospital, Cincinnati, in his address at
the meetings of the American Pharmaceutical
Manufacturers’ Association held in New York last
December. He said:
“Hoffman, working in the Sandoz Laboratories in
Basle, Switzerland, sucked up something in his mouth
from a pipette. He had been working with ergot
extracts, and was making esters of one of its com-
ponents, lysergic acid. In less than an hour he was
muddled, confused and hallucinated. Frightened, he
left the laboratory and got on his bicycle. He pedaled
what seemed like 5,000 miles to his home which was
in reality only a short distance away, but he had lost
time and space perception. He called his doctor who
managed to get him to gulp down all the milk in the
house, but his psychotic state persisted until he fell
into a fitfull sleep late that night. Four days later he
returned to his laboratory, looked over his notebooks
and decided that he had swallowed the dextro-rotatory
diethylamide of lysergic acid. Gingerly he measured
out a very minute amount of the material and took
another swallow. The psychosis returned, this time
worse. He pedaled 10,000 miles home, and again
drank all the milk in sight, to no avail. Thus LSD-25
was born (Fig. 7).* Here was an experimental way
of producing a psychosis which had very much the
*Other important hallucinogens of plant origin are
included in Figure 7. as are those of animal origin in
Figure 8.
February, 1957
207
WHAT'S NEW IN DRUGS?— YONKMAN
look and feel of schizophrenia. It takes about one-
seven-hundred-millionth of a healthy young man's weight
of this material to produce a model psychosis of five
to ten hours.
HALLUCINOGENS OF
LYSERGIC ACID DIETHYLAMIDE
Neurology 5:9;
One thing leads to another; observation, asso-
ciation and frequently circumstance lead to new
developments of drug usage. For example, Fab-
ing continues:
VEGETABLE ORIGIN
IBOGAINE
604, 1955
Fig. 7
1 he minuteness of the dose and the magic of its
effects have been tested and retested all over the world.
One would have to be a stick or a stone not to have
his imagination completely captivated by the drama
of an LSD psychosis. Hoffman’s observation has fired
clinicians, chemists, enzymologists and pharmacologists
into new activity everywhere. It has caused us to take
a new look into old things.”
Fabing, however, also looked into new things
and it is fortunate that he did. One of these
new things was a chemical made by the Merrell
Company of Cincinnati, called Frenquel. Many
of you are familiar with it. Its formula is shown
in Figure 9. Oddly enough, Frenquel will an-
tagonize or negate that chemical psychosis in-
duced by LSD-25 which is a schizophrenic type of
syndrome12 and it was on this basis that Fabing
employed Frenquel with dramatic results in some
of his hospitalized patients with psychotic mani-
festations. In this regard his presidential address
in Neurology 13 is most delightful reading.
“One day I was sitting in my father-in-law's hospital
room forty-eight hours after he had undergone a
prostatectomy. I had just come downstairs from where
we had been doing a mescaline experiment. Suddenly
I realized that my father-in-law was talking just like
the mescaline subject had been doing upstairs. He was
disoriented, confused, frightened and hallucinated. He
had sensations of levitation as though he and his bed
were slowly swinging through space, and he complained
of being bitterly cold. His post-operative confusion
became worse as I sat there, and when he tried to
climb out of bed and pull out his catheter, I realized
that something had to be done. It was so like the
mescaline reaction! Why not try Frenquel. I gave him
50 mg. of the drug intravenously and watched his psy-
chosis melt away during the next half hour.”
“This’’ says Fabing. “has launched us on an inquiry
into post-operative psychoses. Frenquel has been almost
uniformly good in relieving approximately seventy-five
cases of this type. Proctor at the Bowman-Gray School
of Medicine in Winston-Salem has relieved sixteen of
nineteen cases of delirium tremens quickly with Frenquel.
Senile patients often go through troublesome confusional
periods. Frenquel has helped us with these on many
occasions too. Our best friends in this have been the
208
IMSMS
WHAT’S NEW IN DRUGS ?— YONKMAN
nurses. They run a quieter hospital and require less
restraint for disturbed patients. We are enjoying a
popularity with them which we never had before. One
nice advantage of this drug is that it produces no side-
reactions.”
treatment of certain psychiatric patients. Then
how come its large usage in this area today?
Purely because of observation and step-by-step
development. For example, chlorpromazine, a
HALLUCINOGENS OF ANIMAL ORIGIN
ADRENOCHROMF
HOOC
I
H_C COOH
2 I I
h2c ch2
\ /Ach2nh2
N
H
PORPHOBILINOGEN
Neurology 5:9; page 605, 1955
Fig. 8.
alpha Meratran
Alpha (2-piperidyl) benzhydrol
gamma Meratran
Alpha (4-piperidyl) benzhydrol
Ba- 14469
2 Diphenylmethyl piperidine
Ritalin
Phenyl -pipe ridyl-(2)-methylacetate
Fig. 9
And then, how about chlorpromazine? How did
this new drug come about? When first made as a
chemical compound (Fig. 10) it was never in-
tended that it should be of real value in the
chemical relative of Phenergan,® was intended to
be used as an antihistaminic drug. It reduced
body temperature when given in a large dosage,
and for that reason Laborit14 a French surgeon.
February. 1957
209
WHAT’S NEW IN DRUGS ?— YONKMAN
made up his so-called “lytic cocktail” to produce,
as he termed it, artificial hibernation with or
without the use of ice packing for the reduction
of body temperature for certain surgical proced-
cal compounds, the result of which was the
clinical use of Equanil® or Miltown ,®
Now one more example before concluding. A
series of interesting observations led to the devel-
THE ATARAXICS
RESERPINE
CH10RPR0MAZINE
Neurology 5:9;
FRENQUEL
page 609, 1955
Fig. 10.
ures. During recovery, this type of patient was
often very calm and quieted but definitely alert.
This led other investigators15 to study the so-called
psychic effects or phrenotropic features of chlor-
promazine, and can’t you now imagine the furious
activity going on in many laboratories and clinics
in restudying some of the old, never introduced,
antihistaminic agents for phrenotropic properties?
Who knows but what some derivative of Bena-
dryl,'1 Pyrrolazote,® Chlor-Trimeton,® yes, even
Pyribenzamine,® might find its way into the suc-
cessful treatment of the anxious or the severely
mentally disturbed patient either from a prophy-
lactic or corrective point of view.
More recently considerable attention has been
paid to the “relaxing’’ effects of mephanesin (Tol-
serol® ) ; while this drug relieved skeletal muscular
spasm, it simultaneously ameliorated and associ-
ated anxiety and tension in many cases. This
observation led to further study of related chemi-
opment of a new compound, methyl-phenidylace-
tate (Ritalin®). In narcotized animals Meier et
al demonstrated that it shortened the period of
narcosis while in normal animals it increased their
activity.16 In unanesthetized dogs orally treated
for months with daily doses of reserpine result-
ing in marked sedation and droopy nictitating
membranes, this stimulant, thirty minutes after
oral ingestion, caused a retraction of the nicti-
tating membrane (Fig. 11) and an alert ani-
mal without elevation of blood pressure.17 This
type of analeptic activity led to its clinical ap-
praisal, and the pioneer in this area of activity
is Dr. John T. Ferguson of the Traverse City
State Hospital. His is the first clinical report on
this interesting chemical which was presented a
year ago in February, 1955, before that august
body, the New York Academy of Sciences.18 He
vividly demonstrated the unique analeptic prop-
erties of this drug not only in primary depression
210
JMSMS
WHAT'S NEW IN DRUGS?— YONKMAN
EFFECTS OF RESERP1NE AND RESERPINE + RITALIN ON THE BEHAVIOR,
BLOOD PRESSURE AND EYE OF THE UNANESTHETIZED DOG.
CONTROL
RESERPINE 60#/Kg/DAY ORALLY
Vz Hr. POST RITALIN
3mg/Kg ORALLY
mmHg
0-
H.Rr92
ALL PUPILS DARK ADAPTED
Fig. 11.
per se but also as an anatogonist of the depressant
and other undesirable side reactions of reserpine7''
and chlorpromazine.* ** His amplified report of
these studies you may have read in the Journal
of the American Medical Association ;19 it was this
report in exhibit form at the Boston meetings of
the Midwinter AMA sessions last November
which prompted the keen interst and commenda-
tion of that esteemed expert on rehabilitation, Dr.
Howard Rusk of New York City.
Mental illness represents disturbed neurobio-
chemistry; certain biochemical reactions to vari-
ous chemical stimuli are illustrated (Figs. 12 and
*For a vivid account of personal experiences in this
regard may I suggest that you read DeKruif s presenta-
tion as given before the October meeting of the New
York Academy of General Practice23; it is delightful!
**Ayd24 confirms these findings except for the “de-
pressant” effects being antagonized.
13) in this instance20 by the interrelationship of
reserpine, serotonin and methyl-phenidylacetate.
In an anesthetized animal, the rise in blood pres-
sure following serotonin is augmented by methyl-
phenidylacetate but in turn this is diminished
or nullified by the reserpine molecule. If Gad-
dum’s suggestion21 be true, and this seems to have
gained support from the work of Brodie,22 sero-
tonin or 5-hydroxy tryptamine as it normally oc-
curs within our systems may be associated with
if not directly responsible for certain schizoid
symptoms or manifestations. These, likewise, in
turn can be modified by various chemical mole-
cules such as reserpine, chlorpromazine, Frenquel
or Ritalin and perhaps hosts of other chemicals
still to be studied. In all these studies, and
especially in this important field of the mentally
February, 1957
211
WHAT S NEW IN DRUGS?— YONKM AN
ill, which is now Public Health Problem No. 1
in our country, the importance of meticulous
observations cannot be stressed too strongly, for
what may seem to be only a very minor event, as
References
1. The Holy Bible, Psalm 139, 14th Verse.
2. Best, C. H., and Taylor, N. B. : The Physiological
Basis of Medical Practice, Second Edition, 1939,
page 1 500.
ANESTHETIZED DOG -MALE
NOVEMBER I, 1955
FEMORAL ARTERIAL PRESSURE
DOSES/Kgm IV
NEMBUTAL-32 Omg /Kg IV
40 . SEROTONIN SEROTONIN RITALIN _ SEROTONIN _ SEROTONIN
-2ay 25y 2Drog. 25y — — 25y
BP
mmHg
TIME IN MINUTES
INTERACTIONS OF SEROTONIN, RITALIN AND RESERPINE ON DOG BLOOD PRESSURE
mmHg
240-
200-
5 mins.
Fig. 12 (above). Fig. 13 (below).
observed during initial or preliminary studies,
may become of major moment or import when
applied to the clinical subject. Your valuable
clinical co-operation with your co-workers and
with ours in various scientific laboratories will
result, without a doubt, in better health for our
fellow men, provided, however, that after “we
add two and two to get five instead of four, we
continue to wonder why!”
Dedication
This paper is respectfully dedicated to our esteemed
friend and associate, Professor Rolf Meier, Manager,
Ciba Limited, Basle, Switzerland, on the occasion of
his 60th birthday anniversary, April 7, 1957.
212
3. Rodbard, S., and Katz, L. N.: Circulation, 12:448
(September) 1955.
4. Schneider, J. A., and Earl, A. E.: Neurology,
4:657 (September) 1954.
5. Wilkins. R. W.: Mississippi Doctor, 30:359 (April)
1953.
6. Wilkins, R. W.: New York Acad. Sc., 59:36
(April 30) 1954.
7. Harris, R. : Ann. New York Acad. Sc., 59:95
(April 30) 1954.
8. Hench, P. S.: Ann. Int. Med., 36:1, 1952 (Nobel
Lecture) .
9. Thorn, G. ; Prunty, F. T. G. ; and Forsham, P. H. :
Tr. A. Am. Physicians, 60:143, 1947.
10. DeKruif, P.: Men Against Death, Fifth Edition,
1932, page 59.
11. Fabing, H.: The Prescriber, 3:24 (Feb.) 1956.
12. Fabing, H.: Science, 121:208, 1955.
(Continued on Page 233)
TMSMS
Lung Function in Asthma and Emphysema
By William Appel, M.D.
Kalamazoo, Michigan
T N BRONCHIAL asthma the vital capacity,!
one second vital capacity,! maximum breath-
ing capacity,* * and the expiratory flow rate,** are
decreased in proportion to the severity of the
disease. The residual volume§ is increased. Fol-
lowing an injection of epinephrine (usually 0.25
cc. of 1 : 1000 dilution is used) or inhalation of
Isuprel,® there is an increase in the vital capacity,
one second vital capacity and maximum breathing
capacity. Pulmonary infection (bronchitis, et
cetera) if present will decrease the degree of im-
provement in the above lung function tests fol-
lowing the use of bronchodilators.
In pulmonary emphysema, depending upon the
severity of the disease, vital capacity, one second
vital capacity and maximum breathing capacity
are also decreased. The residual volume is in-
creased. With the use of bronchodilators ( epi-
nephrine injection, inhalation of Isuprel) there is
little or no change in these lung function de-
terminations.
The amount of work which an individual with
emphysema has to do in order to merely breathe
is considerably increased as compared with the
normal individual, and he expends a greater
amount of oxygen than the normal individual in
order to breathe.
t Vital capacity — The maximum amount of air which
can be exhaled after taking the deepest breath possible.
XOne-second vital capacity — The amount of air which
can be exhaled in one second after taking the deepest
breath possible. This figure normally is at least 80
per cent of the vital capacity.
* Maximum breathing capacity — The maximum
amount of air which can be inhaled in a given unit
of time, usually twenty to thirty seconds.
**Expiratory flow rate — The rate with which air is
exhaled.
§ Residual volume — The volume of air remaining in
the lungs after the deepest exhalation.
Normally ventilation is so regulated that the
oxygen tension in the alveoli and in the arterial
blood is maintained at 100 mm. of mercury and
the carbon dioxide tension at 40 mm. of mercury.
In the emphysematous person, depending upon
the severity of the disease, this oxygen-carbon
dioxide ratio is disturbed and the oxygen tension
may go as low as 40 to 50 mm. of mercury and
the carbon dioxide tension to 90 to 100 mm. of
mercury.
While in emphysema the one second vital
capacity is reduced, in mitral valvular disease it
remains normal, i.e., over 80 per cent of the total
vital capacity, although the total vital capacity
may be reduced in the latter disease.
Ordinarily, in persons with pulmonary emphy-
sema there is no secondary polycythemia. The
hemoglobin content of the arterial blood is not
increased, although the size of the red blood cell
and the mean corpuscular volume do increase.
When there is marked polycythemia, there is usu-
ally chronic right ventricular failure with cor pul-
monale and pulmonary arteriosclerosis.
While the material in this brief article is ob-
viously not original, an attempt has here been
made to state concisely certain consistent findings
with regard to lung function tests (vital capacity,
timed vital capacity, maximum breathing capac-
ity, et cetera) in asthma and emphysema. These
tests are easily performed, can be made available
in hospital laboratories if physicians will employ
them, and furnish very valuable objective informa-
tion with regard to the state of lung function in
asthma and emphysema and the degree of im-
provement achieved by our medical treatment in
these diseases.
However successful our treatment of tuberculosis in
children and young adults may be, unless we control
the disease in the higher age groups we shall be a
long time reducing the incidence of the disease in the
population. The active cases in elderly men and women
are going to form the hard core of infection in the
community that may give rise to local epidemics of
acute cases among the young contacts. It behooves
us, therefore, to discover, treat, and if necessary isolate
these dangerous old men and women and to do all we
can to protect our children and young adults from the
risks to which they are exposed. F. R. G. Heaf, M.D.,
]. Royal Inst. Pub. Health and Hygiene, November,
1955.
February. 1957
213
Narcotic Addiction Among Physicians
By J. DeWitt Fox, M.D.
Detroit, Michigan
'-p ODAY mothers and fathers are alert to the
ever-increasing danger of narcotics addiction
to their children. The American public is open-
ing its eyes to the dope menace. We abhor the
crime stories of teen-age youth having marihuana
parties, then “hot-rodding” their way down our
highways at eighty miles an hour. Parents shud-
der at the thought of some “pusher” seducing
their sons and daughters into houses of ill-fame.
But while the public is looking at its own narcot-
ics problem, the physician, the man nearest to
the narcotic needle, should not overlook the
menace in his own medical bag.
It is estimated that the narcotics addiction rate
among the general public is 1:10,000 general
population. The rate among physicians is 1 : 100.
This means that one student in each medical-
school class of 100 is destined to end a narcotics
addict. The entire output of one of our seventy-
six medical schools is lost each year into the
ranks of narcotics addicts.
Look at it still another way: Take any medical
convention. Count down the seats. One of each
100 doctors present is destined to spend part, or
all, of his remaining professional life as a narcotics
slave.
Dr. Harris Isbell, Director of the U. S. Public
Health Service Hospital in Lexington, Kentucky,
the nation’s leading treatment center for addiction,
says, “Scarcely a week passes that a physician who
is a Demerol® addict is not admitted to our insti-
tution.” (Since Demerol made its appearance
most new physician addicts take to it rather than
morphine.)
If you personally feel secure against narcotic
addiction, and think that it is only some worthless
“no-account” with no brains and no future in
medicine who takes to the needle, then listen to
this case:
A California physician, Dr. Jackson, we will call
him, was one of the most brilliant students in his
class. He graduated magna cum laude, took a residency
and research fellowship with one of the nation’s leading
scientists.*
Under the stress and strain of postgraduate study
*Dr. Andrew C. Ivy.
he became tense. Finding no time for exercise or
breathing spells between tedious hours in the laboratory,
he started taking barbiturates in order to get his rest
at night. But these didn’t do the job. One night
he decided to try a little Demerol. It worked well. He
swooned off into a wonderful sleep, relaxed completely,
and had no worries about insomnia that night.
The doctor had found just what he needed. He had
easy access to the drugs in the laboratory, and soon
was taking more and more. It wasn’t long until he
was discovered and was immediately discharged from
his fellowship.
He set up practice in a small town, where he failed
miserably because he continued to take narcotics. He
is in an institution today.
His loss is the tragic loss of any doctor who
becomes a “dope” — he must renounce his long
years of education for the world’s most honored
profession, a brilliant future, money, prestige. But
worst of all, the world lost a doctor and gained a
patient.
Barbiturates to Demerol
Here is the heartbreaking story of another gifted
physician :
“After my internship I settled in an Eastern city.
The war came along, and I was declared essential for
civilian practice. From the first my business boomed.
Going night and day, I would come home so tired
and tense that sleep was impossible. I began taking
Nembutal capsules, but they took too long to work.
To speed things up I filled a syringe with IV Nembutal
and slipped it into my vein. Before I hit the bed I
was asleep. Impossible as this may sound. I thought
it was smart. Just look at all the time I was saving
getting to sleep. Imagine a doctor thinking like that!”
“But how did you start on Demerol?” I asked.
“One evening I came home tired out. My back
was aching, my feet were sore and swollen. But I
had promised my little fifteen-year-old daughter I’d
take her roller-skating. I was sure I wouldn’t be able
to put on a pair of skates if I didn’t do something for
the pain. Surreptitiously I went into the bedroom, took
a vial of Demerol from my bag, and gave myself a
shot. I went skating and felt swell : in fact, I never
had a better time.
“That started me ofiF. I had found an escape from
my pain and fatigue. But I little realized that I was
falling through a trap door into hell.”
If you think the cases of doctors taking narcotics
are few and far between, look at one Eastern hos-
214
JMSMS
NARCOTIC ADDICTION AMONG PHYSICIANS— FOX
pital, where a regular epidemic occurred. The in-
terns at this institution were taking to dope like
ducks take to water. Within the space of a few
years no less than five interns ended up dope ad-
dicts. Two died tragically, one addicted his wife,
one has partially recovered.
Medical School Dean Addict
Even professors and deans of medical schools —
the shining examples to students — are today suc-
cumbing to this insidious “disease.” Take the
case of Dr. X.
Although he was dean of a university medical
school,* Dr. X didn’t operate from an ivory tower.
He took an active part in its experimental work.
He had been studying pain-killing agents in an
effort to find the human pain threshold. Some-
times he made tests on himself, using drugs in
the experiments. The outcome was that not long
ago Dr. X voluntarily entered the U.S. Public
Health Service Hospital at Lexington, Kentucky.
One of his colleagues at the university said,
“Nobody will ever know exactly what caused the
addiction, but Dr. X’s close association with drugs
may have had something to do with it.”
Why Doctors Start
Of course, all physician addicts are individuals,
and their stories concerning the onset of addic-
tion are different, but there are three common
patterns into which physician addicts fall. Accord-
ing to Dr. Isbell these are : ( 1 ) Alcoholic physi-
cians who relieve hangovers with opiates, (2) tired
doctors who habitually blot out fatigue with a
narcotic, and (3) doctors suffering pain from
disease, who overdose themselves with opiates.
The alcoholic physician who finds it difficult
to carry on his practice the day after a debauch
may be given or he may take an opiate, which
relieves all the symptoms of his hangover — the
mental dullness, headache, nausea, or gastric pain.
This he falls back on periodically. Finally he
begins to take the opiate instead of the alcohol.
Then the doctor is a dope!
The overly fatigued physician is all too common.
He loses sleep several nights, receives another call,
which he feels he cannot make without a “stimu-
lant” to keep him going. He takes a dose of
morphine, methadone, or Demerol, and goes
ahead and makes his call. Finding such an escape
a great relief he repeats it, until he too falls
through the trap door into addiction.
*South Dakota Medical School.
The doctor who develops a painful disease,
usually chronic in nature, is another candidate for
addiction. He is given an opiate for relief of
pain or after an operation. He returns to work
too early, still has pain, continues the drug, until
he is chained as a narcotic addict.
These common patterns seem to be excuses for
the beginning of narcotic addiction, but Dr. Is-
bell points out that “we always find a serious
emotional disorder in the background which leads
to addiction.”
The emotional upset may be anything from a
marital rift to income tax trouble. What every
physician must remember is that he is human.
Even though in his bag is an escape through
a needle, he must never allow himself the pleas-
ure of using it. For that narcotic in his bag is
like a veritable serpent in Eden, which can lead
only to his being thrown out of the Garden of
his profession.
The Average Physician Addict
A detailed study of forty-seven physician addicts
admitted to the U.S. Public Health Hospital, Fort
Worth, Texas, gives the picture of the average
physician addict:
He is married, has two children and practices
in a small urban or rural community.
He begins using drugs at the age of thirty-nine
and his addiction lasts thirteen years, during which
time he makes three voluntary attempts at cure.
The longest period of abstinence found within
the addiction span was thirty-two months.
In a six-month, follow-up study of doctors who
underwent treatment, 50 per cent were still off
drugs; 27 per cent had relapsed. Of the remainder,
some had died, and no information was available
on the others.
Physician Addiction Pattern
The course after the onset of addiction varies.
Alcoholics who change to opiates usually give up
the alcohol, and for a time their adjustment and
social productivity appear to improve. But in the
end those who use Demerol have even greater
impairment of their ability to work than those
who use alcohol.
Ordinarily the physician addict tries to cover
his addiction by charging off to various patients
the narcotics he is taking. His increase in the
narcotics prescriptions leads to an investigation by
the narcotic agent. The doctor then tries a “cure”
in a private sanitarium. He will succeed in getting
February, 1957
215
NARCOTIC ADDICTION AMONG PHYSICIANS— FOX
off narcotics, blit ordinarily he returns to his
practice much too soon, and promptly relapses.
His relapse is usually due to the emotional dis-
order that led to the addiction in the first place.
By now he is in trouble with the narcotic agents
and his medical society. He loses his narcotic
license and his license to practice medicine. He
turns voluntarily to one of the Federal hospitals
for narcotic addiction at Lexington, Kentucky,
and Forth Worth, Texas.
A large number of physician addicts relapse
time and again, just as other addicts do. The
reason : They are human. They are susceptible
to the same emotional stresses and strains, only
more so. that their patients suffer. As every doctor
knows, the worst patient he can ever have is
another physician.
What most physicians need is a good night’s
sleep, more vacation time, release from tension,
a quiet place for meditation. Yet few of us are
willing to take time from a busy practice. When
a person gets “wound up” tight nervously he may
do a lot of reckless things. Even a doctor is not
immune to the temptations that lure the layman
in search of nervous release. In fact, a physician
is in greater danger than any layman, because
of the tense, tiring life he lives, and because of his
easy access to the drugs.
Yet little or no instruction on narcotic dangers
is given among physicians or in medical schools.
It is high time that medical schools begin telling
students the dangers and pitfalls they will face
once they get a narcotic license, and have easy
access to morphine, Demerol, codeine, and the
other narcotic drugs.
The outstanding feature of these cases of physi-
cian addicts appeared to be lacking of warning-
young doctors before they went out to practice.
One addict told me, “During my student days
not a single professor told us a word about narcotic
addiction. We had plenty of lectures on how
to prescribe narcotics, but not a word on the
personal dangers — the hell on earth that comes
after a doctor takes his first dose.
“We were warned repeatedly to stop narcotics
two or three days post-operatively. However, not
a word of warning was sounded about what would
happen if the doctor took them for an aching
back or painful joints when he had to keep going.
“It’s time professors of medicine stopped taking
for granted that young, inexperienced medical
students know everything they should know. They
should warn them of the dangers. These young
men ought to know about tragic cases such as
mine. They are immature. Their knowledge is
still spotty. They can’t realize how much they
still have to learn. It takes a lot of living to
become aware of all the pitfalls of life.”
Medical Students Warned
This matter of warning against the perils in
easy access to drugs is a point every medical
student and intern should have drummed into
his very being. Even tavern owners tell their
bartenders that their period of usefulness ceases
the instant they start drinking liquor themselves.
Warnings evidently had not been sounded at
a California hospital where an intern was dis-
covered who knew how much “fun” a Demerol
jag was. He had started a resident to taking it
also, and before long they had drawn a nurse
into their little party. Not until horrified hospital
authorities found out what was going on were they
out of danger.
Then not realizing the jeopardy to other interns
and residents, the authorities hushed the matter
up, and in spite of their sad experience they never
gave a single medical student, nurse, or hospital
doctor a word of admonition before sending him
on the hospital floor.
Naturally every medical institution must guard
its reputation. But if it values its reputation deep-
ly enough, it will instruct its personnel adequately
for their own safety and for the safety of the
patients.
It is time every doctor — you and me — and every
medical student — be told the “facts of life” when
it comes to narcotic addiction.
Maryland Leads the Way
Fortunately, at the University of Maryland
Medical School, Dr. John Krantz, professor of
pharmacology, is spearheading a campaign of
narcotics education among medical students and
practicing physicians. Each year he has Mr.
Harry V. Anslinger, commissioner of narcotics of
the United States Treasury Department, come
over to Baltimore from his Washington office and
address the students on narcotics and their poten-
tial dangers to the physician as well as the layman.
“After hearing these down-to-earth lectures on
a problem so close to home to the medical stu-
dent and physician,” says Dr. Krantz, “my boys
have no excuses. They know the dangers. From
216
TMSMS
NARCOTIC ADDICTION AMONG PHYSICIANS— FOX
then on they are on their own. But I’m sure
this is going to do much to shake medical students
to their senses and make them avoid narcotics
like the plague.”
Some of these lectures are to be put into films
to be distributed to medical schools around the
United States. If you or your medical school
desire further information on this vital subject,
write to Dr. Krantz.
It behooves every medical school to follow the
lead of the University of Maryland.
Physician Peddlers
Another solemn word of caution given by the
U. S. Treasury narcotic T-men is:
“Doctor, don’t be a narcotics peddler! You’ll
get caught every time.”
One unfortunate doctor in a western state
tragically learned this fact. He had been playing
the races and lost heavily. In debt, he needed
money quickly. A dope addict was tipped off
to the doctor’s plight. He stopped by the doc-
tor’s office, offered him $25 for a prescription for
Demerol. This was not enough. The addict
upped it to $100, and the doctor saw the answer
to his indebtedness.
After he had written several $100 prescrip-
tions, a dope peddler stopped in at his office to
warn him that if he didn’t write a “big” prescrip-
tion for him he’d be turned in for treating the
addict without notifying the authorities. The
doctor was in a corner. He wrote the prescrip-
tion for a large number of tablets, and within
hours was picked up by the T-men.
His narcotic license was immediately revoked,
he was disgraced in his community by newspaper
publicity and had to leave town. His only com-
ment to the T-men: “Oh, what a dope I was!”
Prescription Precautions
Here is a list of “Don’t” for physicians on the
prescribing and use of narcotics as outlined by
the Bureau of Narcotics, Treasury Department,
Baltimore :
Don’t leave prescription pads around. Addicts
want them for effecting narcotic forgeries.
Don’t write a narcotic prescription in lead pen-
cil. Avoid writing any Rx in pencil; many are
changed to call for morphine.
Don’t write for narcotics this way: Morphine
HT l/2 # X or Morphine HT # 10. Several
X’s or zeros can be added to raise the amount.
Use brackets, or spell out.
Don’t carry a large stock of narcotics in your
bag. Addicts are constantly on the lookout for
these in doctors’ offices and cars.
Don’t leave your car unlocked if your bag con-
tains narcotics. This is an invitation for the ad-
dict to steal narcotics.
Don’t store your office supply where patients
can get at it. Avoid storage near sink or urinal.
The patient may ask to use these.
Don’t fall for a good story from a stranger
claiming ailment that usually requires morphine.
The addict can produce bloody sputum, simulate
bad coughs or other symptoms. Make your own
diagnosis.
Don’t give a narcotic prescription without see-
ing the patient. Addicts have posed as nurses to
get doctors to prescribe narcotics.
Don’t write for large quantities of narcotics un-
less unavoidable. Diversion to addicts is a profit-
able business: as much as $3.00 for *4 gr. Mor-
phine Sulphate.
Don’t prescribe narcotics on the story that an-
other doctor had been doing it. Consult that phy-
sician, or the hospital records, whenever possible.
Don’t leave prescriptions signed in blank at the
office for nurses to fill in. Signed blanks are bad
practice and many have been stolen by addicts.
Don’t treat an ambulatory case of addiction.
Addicts must be under proper control. Addicts
go to several doctors at a time. Notify your Nar-
cotics Bureau.
Don’t dispense any narcotics without keeping
a record of it. Bedside and office administration
are permitted without a record.
Don’t buy your office narcotic needs in the
name of a patient. The law requires you to use
an official opium order form.
Don’t resent a pharmacist’s call for information
about a prescription you have written. The phar-
macist is held responsible for filling forgeries.
Please co-operate.
Don’t hesitate to call your Bureau to get, or
give, information. It will be held strictly con-
fidential.
Rules to Remember
Finally, to protect yourself against the insidious
danger of narcotic addition, remember:
(Continued on Page 226)
February, 1957
217
The Evolution of Psychiatry as an
Integral Part of Medical Practice
MY ORIGINAL title for rthis paper was “Rev-
olution in Psychiatry.” Such a title is short
and to the point, but it sounded a bit too dramatic,
so I substituted another. The first title still in-
trigues me. It phrases very succinctly one fact
that I want to emphasize, that psychiatry today
is far different from the psychiatry of twenty-five
years ago, and that the change in many ways
actually has been dramatic and revolutionary.
I’ll start in a light vein. Twenty-five years ago
all of the jokes about psychiatry expressed criti-
cism and hostility; in them psychiatrists and their
ideas usually were the object of ridicule. But
now, jokes are told in which psychiatrists actually
are fairly sensible people, and there’s even one
that indicates that a psychiatrist might have some-
thing to contribute to medical practice. It goes
this way:
Once there was a man who was the most famous
pickpocket in the country. He was so expert and
skillful that the police finally decided to stop
wasting their time trying to catch him in the act.
One day he was picking pockets in Grand Rapids.
As he was immersed in his own work, he felt a
hand in his own pocket. He grabbed the hand,
and pulled the person around. He was amazed
to find that it was a woman, a beautiful woman.
He recognized her as the most famous woman
pickpocket in the world. They began to talk.
They had much in common, they fell in love,
they married, and she became pregnant. It is
necessary for the story to say they have a midwife,
not an obstetrician. They had daydreams of pro-
ducing the most famous pickpocket of all time
(with its double heredity and the training they’d
give it) . But tragedy struck. The child was born
with a clubbed hand, and of course it could never
pick a pocket. The distraught parents saw their
hopes of producing the great genius shattered.
They called in an internist, an orthopedist, a
neurologist, but all said that the case was hope-
less. Finally a psychiatrist was called. Since the
Presented at the Annual Session of the Michigan
State Medical Society, Grand Rapids, September 28,
1955.
By Maurice Levine, M.D.
Cincinnati, Ohio
child was only fifteen days old, a good interview
was impossible, so the psychiatrist decided to get
the history from the parents and then to sleep
on the problem and see if he would come up with
a good idea. This he did, and came up with the
idea that in this case the Lamarckian theory of
evolution might hold true. The next day he saw
the child, took the clubbed hand in his, and with
his other hand he slowly and gently pressed the
fingers up, one at a time, and there in the middle
of the palm was — the midwife’s gold wedding ring.
And then there’s another indication of a re-
markable and revolutionary change in psychiatric
treatment, at least in Cincinnati. One secretary
in our clinic is a marvelous typist, except for one
word, “therapist.” In typing this word, she in-
evitably puts a space after the third letter, so
that it becomes “t-h-e r-a-p-i-s-t.” Our case
histories are full of interviews in which the patient
said so and so to the rapist and the rapist said
so and so to the patient, and the patient then said
so and so to the rapist. It looks, gentlemen, as if
our work with patients is so successful that they
can sit down calmly and thoughtfully and have
productive discussions with their rapists, a truly
revolutionary change since our days in medical
school.
But jokes are not the only indication of the
changed status of psychiatry. Before our days in
medical school, psychiatry was practiced chiefly
in the state hospitals, in private sanitaria, and
in the private office of neurologists. Then in our
days in medical school, Adolf Meyer and others
had taken the first steps in bringing psychiatry
into the general practice of medicine. Their in-
troduction of a psychiatric division on the campus
of a general hospital brought psychiatry closer
to general medical practice. And the architectural
closeness led to some participation, but psychiatry
was in most ways still a foreign body in the field
of medicine, helpful chiefly in the handling of
medical patients who become psychotic, or as a
way of unloading chronic patients from the medi-
cal clinic.
218
JMSMS
EVOLUTION OF PSYCHIATRY— LEVINE
Twenty-five years ago, psychiatrists had become
interested in the problems of general medical prac-
tice, and frequently would exhort their medical
confreres to pay attention to the personality prob-
lems of their patients, but then had too little to
offer in the way of implementing their good ad-
vice. Psychiatrists at that time had achieved a
fair knowledge of the kinds of psychoses and
neuroses which appear in psychiatric practice —
paresis, schizophrenia, depressions, delirious states,
phobias and compulsions and the like, but when
they had to deal with the medical conditions and
problems that were the chief concern of the non-
psychiatrist physician, they were able merely to
talk in such vague and unsatisfactory terms as
constitutional weakness, undue stress and strain,
and autonomic imbalance. Obviously, this is not
enough. If psychiatry was to become an integral
part of medical practice, it had to turn its atten-
tion to the ways in which specific medical condi-
tions or problems were in part caused by or in-
fluenced by specific psychologic problems, and
on the basis of such research come up with
specific and practical methods of treatment, either
by psychiatrists or by physicians in general. And
in the past twenty-five years, this has been done.
Now at this point in my preparation for this
paper, I had to make a choice between two types
of presentation. In the past twenty-five years,
the integration of psychiatry into general medicine
has been essentially along two lines. The one,
which usually goes by the name of psychosomatic
medicine, comprises the systematic studies of par-
ticular medical disorders, such as peptic ulcer,
hypertension, migraine, ulcerative colitis, bron-
chial asthma, hyperthyroidism, neurodermatitis
and some others — studies usually by teams of psy-
chiatrists, internists, physiologists and others, and
usually using the profoundly important concepts
of psychoanalysis, studies which have led to a
significant body of knowledge of value to all
practitioners of medicine. Essentially, the findings
can be summed up this way. In the etiology of
such disorders, somatic and psychologic factors
both are of great importance, and conscious and
unconscious emotions and drives and anxieties and
defenses play a significant role. Still further, if
psychotherapy is based on the specific problems
of importance in each disorder, e.g., suppressed
rage and resentment in the hypertensive patient,
such psychotherapy may be of some value in
individual patients — and often this can be a psy-
chotherapy of the sort that is safe and effective
in the hands of the nonpsychiatrist.
This material of the research on the so-called
psychosomatic disorders is now readily available
in books by Alexander, by Weiss and English, and
in our recent multi-author book on Dynamic Psy-
chiatry, edited by Alexander and Ross.
Consequently I feel free to emphasize the other,
perhaps less dramatic, perhaps more significant,
way in which psychiatry, in the past twenty-five
years, has become a more integral part of medical
practice. Essentially it is this: It has become clear
that medical practice can be enriched by paying
attention to the emotional problems that appear
in many situations in medical practice, not merely
in the psychosomatic disorders. For example, the
very fact of being sick or disabled or in need of
an operation produces emotional and personal
reverberations that color the whole clinical picture
and must be dealt with in some fashion. Such
an approach may be called a more comprehensive
medicine, or some title of that variety. Now
that sounds very close to the sort of thing you
may have heard some years ago. The difference
is that it now has substance and clarity, and
principles of understanding, and techniques of
treatment. In these twenty-five years, basing its
studies on such psychoanalytic concepts as the
unconscious, and anxiety and defenses, psychiatry
has developed a body of knowledge and tech-
niques, of direct value in medical practice.
Let me elaborate on this conception of a more
comprehensive approach, but instead of giving an
abstract exposition, let me quote a few typical
cases, a way of presentation which is more effec-
tive for an experiment group such as this. The
principles involved are obvious in the case mate-
rial.
Case Reports
Case 1. — The patient, a man, forty-five years old,
was admitted to the medical service with a severe
cardiac decompensation. He was gravely, critically ill.
He was given the usual heroic medical treatment, which,
however, was interrupted every hour or two by the
patient’s insistence on getting out of bed, throwing
wide open the nearby window and doing deep knee-
bends and gymastics. Psychiatric consultation revealed
that his whole life had centered around his need to
show strength and masculinity; he would fight at the
drop of a hat ; his cardiac decompensation had directly
followed a fight in which he had been knocked down
for the first time in his life; he then had raced up
four flights of stairs to show that he still was a man,
February, 1957
219
EVOLUTION OF PSYCHIATRY— LEVINE
and that when the cardiac decompensation began, he
developed enormous fears of weakness, of being a sissy.
His deep knee-bends were his method of proving to
himself that his cardiac disorder would not leave him
weak and helpless. The medical residents thought that
it might be necessary to force him to stay in bed,
since there was serious danger that his gymnastics might
lead to sudden death. The psychiatric consultant,
despite some anxiety of his own, advised taking the
calculated risk, and the patient continued his combined
myocardial and athletic regime, gradually improved
and was discharged from the hospital. He failed to
return for outpatient care, and several weeks later he
again was admitted to the hospital in cardiac decom-
pensation, of approximately the same degree of severity.
In the meantime the medical residents had rotated to
another hospital service and a new group of medical
residents was in charge. When the patient began
hopping out of bed to do his deep knee-bends at the
window, he was tied to his bed, struggled violently
for a short period, then lay completely quiet and inert,
and in two hours was dead. Now let me not be mis-
understood, psychiatrists do not plan a campaign against
having decompensated patients be treated with optimal
physiologic rest; the advice in such a case as this is
that attention to powerful emotional drives may neces-
sitate a flexibility in routines to have such a patient
actually achieve maximal physiologic relaxation.
Case 2. — The patient, a woman, twenty-eight years
old, had had clinical thyrotoxicosis for a year. She had
been persuaded, time after time, to enter the hospital
to prepare for surgery. Each time, shortly after she
was put to bed in the hospital, she would sign out on
one pretext or another. On her fifth admission, she was
sent to the psychosomatic unit. On evaluation, it was
evident that she had many very severe psychologic prob-
lems, some of which seemed to be so pertinent and
important that they might be contributing to the devel-
opment of her hyperthyroidism. She seemed, however,
not to be a good candidate for intensive psychotherapy
because her past life had been so extremely traumatic
and full of conflict and her present life so full of actual
deprivation and pressure. Consequently, the decision
was made that thyroidectomy was the treatment of choice
and that an attempt would be made to avoid her sign-
ing out pattern, and to prepare her for operation. In
spite of her four-plus sign out history, this was not too
difficult. Her life history indicated that she had a
constant personality trait of being exceedingly attentive
and giving to others. Outside the hospital, she had
given full reign to this proclivity, often to the point of
self-deprivation. Her dominant pattern of life behavior
was of caring for others. Even at the age of sixteen,
she had had the reputation of being the neighborhood
mother. It was evident that coming into the hospital each
time, and being put to bed, had blocked this pervasive
activity, and had made her so uncomfortable that each
time she had signed out. Therefore, on this admission,
she was not required to stay in bed full time. Her per-
sonal tendency to do things for others was utilized, and
she was strongly encouraged to help the nurses and
other patients in their routine needs. She entered into
very protective relationships with several patients and
despite being mildly “busy” a good part of the time,
her pulse rate and basal metabolic rate gradually fell.
She adjusted placidly to hospitalization and subsequently
underwent successful surgery.
Perhaps these cases will indicate the validity of
my comment, that a study of the feelings, the
emotions, the wishes, fears and defenses of pa-
tients has a practical value in everyday medical
practice. In a sense, this may be called a more
comprehensive medicine.
And let us amplify this by discussing the prob-
lems of patients who have had a coronary occlu-
sion. The best way to understand the emotional
state of another individual is to put aside one’s
highly prized, Michigan-trained intellect for a
moment and to use the very primitive but re-
vealing process that we call empathy. By this
we mean the process of putting oneself in the
other’s shoes, in his situation — of identifying one-
self with him for a moment or two, and then
looking inward, noting how one feels. The ques-
tion one puts is — “If I were in his shoes, if I had
his sickness, how would I really feel — not how
should I feel if I were superman, or completely
mature, or pure as the driven snow, but how
would I feel, actually, honestly, sincerely?” Now
suppose that you empathize with a patient who
is having or has just had a coronary occlusion,
how would you feel? Put yourself in his shoes
for a moment, and let yourself feel. The answer
is obvious, and you know that no matter what
he shows on the surface, he has tremendous anx-
iety, a fear of death, of final catastrophe, of being
a cardiac cripple, of a loss of independence. Now
such feelings are of course deeply unpleasant and
disturbing, and our finding is that coronary
patients react to such anxiety in many ways, per-
haps in two more than others. Such reactions
are called defenses against anxiety. The first
defense, used by many coronary patients, is the
defense of denial. Such a patient covers up and
conceals his anxiety and lessens its discomfort
by a flat and emphatic denial that there’s any-
thing wrong with him. Such a patient insists
that all that he has is a mild indigestion, that
he need not go to bed or to the hospital, that
the doctor is only an alarmist. Such a defense
does lessen or minimize the anxiety, but of course
it is a dangerous defense. In a word, the patient
is unco-operative, but not because he’s an un-
220
TMSMS
EVOLUTION OF PSYCHIATRY— LEVINE
co-operative, “ornery” human being but because
he’s forced to deny his overwhelming anxiety.
The second defense used frequently by the cor-
onary patient is called regression. By regression
we mean the widespread tendency of human be-
ings, when they are threatened by serious anxiety,
frustration or disappointment, to revert to earlier
types of adjustment, in which they felt or seemed
to feel more secure, more satisfied, more success-
ful, more at peace. Many a coronary patient,
under the impact of his pain and his overwhelm-
ing anxiety, regresses to a baby-like attitude and
manner, becomes whining and complaining, ap-
peals for sympathy, demands attention and time,
and wants nurses and doctors to treat him as a
small child and not as a man. This is not because
he’s an “ornery cuss,” trying to make life miser-
able for those around him. He is behaving that
way because he is responding to his inner fear by
trying unconsciously to revive the old situation,
when, as a child, he was hurt and in pain, he
could run to the all-powerful mother who would
protect him from evil.
Now these examples, the two cases plus the
comments about the emotional responses of cor-
onary patients, lead to my final set of comments
about treatment.
We can say that present day psychiatry, then,
has something to offer to medical practice, first,
in the understanding of the specific psychosomatic
disorders; second, in the development of a more
comprehensive understanding of a wider variety
of medical problems; and third, in suggestions as
to specific methods of handling and treatment.
In my book on Psychotherapy In Medical Prac-
tice, and more recently in my section on treatment
in the Alexander and Ross Dynamic Psychiatry,
I tried to summarize this third topic, suggestions
for treatment. Today I want merely to point up
one or two items which often are unclear or over-
looked.
The first is that the suggestions for treatment
arising out of psychologic considerations are not
to be taken as being contradictory to the usual
good medical practice. It is not an either-or mat-
ter, of psychotherapy or medical-surgical treat-
ment. Rather the psychologic approach is to
be regarded as an enrichment or broadening of
the physician’s work with patients. A patient
with a bleeding peptic ulcer needs the usual ac-
tive medical or surgical treatment, along with
whatever handling of his dependency needs may
be suggested by an understanding of his personal
conflicts.
My second comment about treatment is that
the work of the past twenty-five years indicates
that the most important tool in psychotherapy in
general practice is the patient-physician relation-
ship, rather than some specific technique ®f psy-
chotherapy such as hypnosis or pentothal inter-
viewing or interpretation of the unconscious. The
psychologic well-being of the patients of the gen-
eral physician is in part dependent on his ability
to utilize constructively his personal relations with
his individual patients. The feeling of security,
of strength, of firm leadership, of dependability,
which a patient achieves in a good relationship
with a physician is of very great importance in-
deed. And the physician may, in addition, use
certain specific aspects of the relationship as part
of his therapeutic approach. For example, he
may stress a mothering, protective approach in cer-
tain peptic ulcer patients who need a gratifica-
tion of their drives to be dependent and cared for
— with the usual caution, of course, not to overdo
the protective giving attitude. Or the physician
may develop and emphasize his function as an
accepting, nonpunitive father-confessor in certain
patients, e.g., in some patients with bronchial
asthma who may get extraordinary relief from a
confession of their peccadillos or temptations. Or
the physician may emphasize the reliability of his
role, and his refusal to have an attitude of rejec-
tion or criticism, in some hypertensive patients
who are so prone to provoke rejection or to see
it where it does not exist.
But this powerful tool of the patient-physician
relationship is one which cannot be taken for
granted. All physicians want to have good and
productive relations with patients, but problems
arise, some obvious, some more subtle. To illus-
trate this point, we can refer again to the patients
with coronary occlusion: A patient who uses
the defense of denial, is unco-operative, refuses
to take his condition seriously, and regards the
physician as an alarmist, can provoke the physi-
cian into attitudes that are nonproductive and
perhaps even harmful. The physician may be-
come angry and try to frighten the patient into
being co-operative which of course may increase
the patient’s basic anxiety, which by the way can
be shown experimentally to increase the work-
load of the heart very considerably. If, however,
the physician knows that such an unco-operative
February, 1957
221
EVOLUTION OF PSYCHIATRY— LEVINE
attitude is merely a defense against anxiety, he
can deal with it rationally and constructively, by
giving strong, firm explanations and direction, by
putting across the fact of his own ability to deal
with the situation, by being patient and tolerant
and understanding; in a word, he can provide the
patient with a better set of defenses against anx-
iety, without increasing the anxiety itself.
And with the other coronary patient who re-
guesses to a whining baby state, again it is not
easy for the physician to develop and maintain
a good patient-physician relationship. His temp-
tation is to be repelled by such behavior, to reject
and perhaps to avoid the patient, to be critical
and a bit contemptuous — or if the physician has
an overly sympathetic type of personality, he may
respond to the complaints and pleas for sympathy
of the patient by too much coddling. But if the
physician recognizes the fact that the patient is
reacting to his anxiety with an unfavorable set
of defenses, he can retain his good leadership, can
handle the defenses in a tolerant fashion, can
deal with the underlying anxiety, and still retain
a respect for the basic worthwhileness of his pa-
tient, even when the patient’s behavior is as un-
pleasant as it can be.
And now, in conclusion, let me deal directly
with a question, a doubt that I know is in the
minds of many of you. This is interesting stuff,
you will say, and you will remember one or more
specific cases in which personal problems were
directly producing or influencing a medical prob-
lem. But, you might say, will attention to such
problems make our medical students or our prac-
ticing physicians overemphasize the human prob-
lems of their practice and so neglect important
physical diagnostic work, or delay some life-saving
operations? Will they be so seduced by the drama
of love and sex and hate, of fear and anxiety, of
inner and outer conflict, that they will substitute
this approach for the vitally important job of an
organic approach to medicine? Now let me say
emphatically that I agree with you that this is
a real danger, and that medical students and doc-
tors are only human, and may take an easy, lazy
way out of difficulties. Therefore, in our teaching,
we lay tremendous emphasis on the need to have
a balanced and complete approach. And it can
be done. On our service, we repeatedly make a
diagnosis of a brain tumor in a patient who sup-
posedly is an hysteric. Recently we made a diag-
nosis of silicosis in a patient sent to us with a
diagnosis of breathing difficulties based on anx-
iety. Our autopsy permission rate often is higher
than that of the other departments in the hospital,
indicating to the students that we are seriously
interested in somatic as well as in psychologic
findings. And when the curriculum committee
multiplied by five our teaching of the third year
students, I asked the most outspoken “doubting
Thomas” in the other clinical departments to act
as a one-man committee to observe the students
when they worked with him in the fourth year,
to see if they emphasized the patient as a person
to the detriment of their study of the anatomic,
physiologic or other disturbances of the parts of
the patient or of the disease process. Two years
later, he told me that students on ward rounds
bored him to death with their comments about
the life-problems of the patients, but had not
ignored their responsible consideration of somatic
problems.
And so I’m sure that it can be done, difficult
as it is. Medicine is a hard taskmaster. The
needs of our patients require that our approach
be comprehensive, that we respect facts as they
are, and that we know that in various cases bac-
teria, neoplasm, fear and hatred, are all etiologic
agents that cannot be ignored.
It is the tradition of science to change theories
to fit new facts. It is the tradition of medicine
to have the needs of our patients be the overriding
consideration, and if now, it becomes clear that
the organic approach to medicine, enormously
productive as it is, is incomplete, we can expect
with confidence that medical practice will come
to include those aspects of psychiatry which can
be shown to be scientifically valid and of prac-
tical importance for the well-being of our pa-
tients.
In one series, 17 per cent of non-toxic nodular
goiters were malignant; in another series 19 per cent
were found to be malignant.
* * *
More perspiration and less publicity are needed in
cancer research.
In one series of 184 cases of retinoblastoma there were
only five survivors with eight children, seven of which
had bilateral retinoblastoma.
* * *
Survivors of retinoblastoma should not have children.
JMSMS
222
New Drugs in Psychiatry
By Richard J. Lilly, M.D.
Birmingham, Michigan
i WOULD like to summarize my reasons for
feeling that reserpine and chlorpromazine are
not very good drugs in the treatment of mental
illness. The claims made in behalf of these drugs
are, I feel, much over done.
They are considered to be particularly effective
in the treatment of psychotic patients. One of
the most distressing features of the recent en-
thusiasm for the pharmacologic treatment of
functional psychoses is the almost complete lack
of rational explanation as to how these substances
are supposed to act. The pharmacology of these
preparations is largely unexplained. The litera-
ture discusses the end result of the treatment,
the alleviation of symptoms, but does not explain
why this favorable outcome occurs.
These drugs allay anxiety and induce tran-
quility. This may or may not occur. Even if it
does occur, we must ask ourselves if this is desir-
able. Anxiety is a useful warning to the individu-
al that all is not well. This warning enables the
individual to attempt to modify the situation. This
enables him to take steps which result in diminu-
tion of anxiety. The important thing to remem-
ber is that the anxiety serves to stimulate the
individual to take steps which result in a more
satisfactory status for that individual. The anxiety
then serves both the patient and the therapist
in pinpointing the source of the difficulty. This
is an extremely valuable therapeutic tool. Diminu-
tion of anxiety by drugs may then be of question-
able therapeutic value.
These drugs are recommended for use on pa-
tients showing disturbed schizophrenic behavior.
If we can put any credence in the contribution
to psychiatry by psychoanalysis, we must accept
that this psychotic behavior has a meaning, and
that it is a product of faulty personality develop-
ment. This psychotic behavior has its roots in
developments which occurred many years earlier
and this psychotic behavior is a symbolic expres-
sion of early trauma. This behavior is a logical
development of the early pathology. The symp-
toms are not the disease. Treatment of the symp-
toms cannot logically be expected to exert any
influence on the disease process itself. Reports
have stated that these drugs exert a beneficial
effect on hallucinations and delusions. These
restitutional symptoms are not the primary disease
process at all, but are secondary defects elaborated
by a shattered ego. These restitutional symptoms
are an attempt to regain intrapsychic harmony
even at the expense of misinterpreting reality.
These drugs may act through lowered or at least
altered cerebral metabolism. The individual may
be sedated. If this is true, we have a tranquil
patient, but a patient who has only a part of his
personality available. To sedate for long periods
of time would mean that the individual would,
of necessity, live on a lowered biologic plane. The
literature frequently refers to these drugs as non-
sedative. With this I must take issue. I have
frequently observed the sedative effect with both
the reserpine and chlorpromazine.
These drugs, according to the literature, can
make the patient accessible to psychotherapy.
Psychotherapy, to be meaningful, must be directed
toward the solution of the patient’s difficulties.
Bypassing the psychotic material through the use
of drugs means that an opportunity to under-
stand the conflict, and perhaps give insight to the
patient, has been missed.
Another goal to be achieved by the use of these
drugs is decrease in demand on the time of at-
tendants and professional people. I do not think
that this is a worthwhile goal, because we are
committed to a policy of treating the sick, not
giving custodial care. Because a schizophrenic
patient is disturbed is no reason to administer
medication that merely tranquilizes him. We
should tiy to determine why the individual is
disturbed and what the psychotic behavior means
to him. If we find the meaning of the outburst,
we are on the way to removing the cause of the
outburst. This treatment, if followed through,
will. I think, result in fewer recurrences of dis-
turbances and will enable the patient to exercise
more freedom, and then fewer demands will be
made on attendants and others.
Evaluation of results obtained has been almost
without exception a very favorable one. The
method used to evaluate results has been the
February, 1957
223
NEW DRUGS IN PSYCHIATRY— LILLY
same in the several studies that I have read. This
method consists of measuring the degree of be-
havioral adaptation to the hospital routine. It
is considered favorable if the patient conforms
better. This may or may not represent any actual
improvement. It may, of course, represent an
improvement, a remission, or even a cure. On
the other hand, it may indicate apathy or despair.
It may simply indicate the impaired function of
depressed nervous tissue. The meaning of a
change in behavior can only be evaluated by one
specially trained to understand the action that
unconscious material exerts on overt behavior.
In other words, a modification of a set of symp-
toms can only be evaluated in light of the knowl-
edge of the total personality. An attendant, re-
gardless of his ability and devotion, lacks the
knowledge of unconscious material and so his
evaluation of the patient must only be superficial.
The personality is complex and cannot be evalu-
ated solely by overt behavior.
Improvement should not be measured by at-
tendants alone because their point of view is
such that they will unduly value conformity and
passivity in a previously disturbed patient. On
recently admitted disturbed patients, good re-
sults are the rule rather than the exception. I
think we are not justified in concluding that the
good results are due to these drugs. Other factors
are involved. Favorable results may be due to:
1. Psychological factors. Together with the
administration of the drug, the attendant also
administers personal attention. This, in itself, is
a value in permitting the patient to regain his
self-esteem. Concrete evidence that others are
interested in him enables the patient to value
himself higher.
2. Many reports are not adequately controlled.
The human characteristic of wishful thinking can
play a large role, particularly in evaluating quali-
ties which are not sharply defined.
3. Spontaneous remissions do occur. They are
more the rule than the exception on disturbed
wards of the receiving units. All of us who have
worked with the psychotic patient for a few' years
know many examples of patients who, very dis-
turbed on admission, now have ground permission
or are home again. It is extremely difficult to
say that reserpine or chlorpromazine are not re-
sponsible in those instances where they were ad-
ministered, and yet similar results are seen in
those who did not receive this drug.
Another type of reported improvement is that
group of patients whose restitutional symptoms are
no longer in evidence. These patients appear
improved, but continue to be incapacitated for
life outside of the institution. They have moved
from a disturbed hall to a comfortable hall. Their
psychosis has, in effect, gone underground. This
type of patient has been tranquilized, because he
no longer feels anxiety. This tranquility itself
must be evaluated. It may be the end result of
apathy and despair and may signify only resigna-
tion. An individual living in a mental institution
is subject to certain necessary restrictions and
regulations. Anxiety under these circumstances is
an expected phenomenon. Lack of anxiety is a
poor prognostic sign, even when drug induced.
I think that to evaluate these agents properly,
intensive rather than extensive studies would be
of value. An attempt should be made to study
modification of characteristic mental mechanisms
or patterns of reaction during the administration
of the drug. This could be done by free associa-
tion techniques, by studies of dream material, or
utilization of projective techniques. Unless there
is actual modification of unconscious material,
tranquility should not be considered curative.
I think that treatment directed towards the
brain substance itself presupposes that pathology
exists in those tissues. This is not so. In function-
al pychoses, particularly in schizophrenia, no tis-
sue pathology has even been demonstrated that
adequately explains the development of the psy-
choses. Drugs which act on the central nervous
system should not be expected to act on the disease
process. In functional psychoses no pathology has
been demonstrated in the brain substance. Drugs
acting on the brain substance producing dimin-
ished aggressiveness and increased tranquility do
not act on the etiologic agents of the disease.
Their effect can only be achieved by limiting the
capacity of the human organism to react to stress-
ful situations. Diminished capacity to react can
only indicate impaired brain tissue function. Im-
paired brain tissue function is too big a price to
pay for tranquil patients.
865 Norwich
The superintendent of Pontiac State Hospital, Ivan
A. LaCore, M.D., has authorized publication of this
paper, although he does not share the author’s opinion
as expressed.
224
J.MSMS
Detroit Surgical Association
Meeting of September 24, 1956
THE USE OF FROZEN SECTION IN
CANCER DIAGNOSIS
E. R. Jennings, M.D., and J. W. Landers, M.D.
Department of Pathology, Woman’s Hospital,
Detroit
The advantages and disadvantages of frozen
section at operation in the diagnosis of cancer
are discussed. Certain principles guiding the cor-
rect use of the method are set forth, and the
responsibilities of the surgeon and pathologist de-
fined.
The authors’ recent experience with the frozen
section method is analyzed. Of a total of 412
examinations, a definite diagnosis of benign or
malignant was made in 94.9 per cent. An er-
roneously negative diagnosis was given in six
instances; an erroneously positive diagnosis in
none.
It is concluded that: (1) frozen section is a
useful diagnostic tool in the surgical treatment
of cancer; (2) the method must be used frequent-
ly to be reliable; (3) false positive diagnoses of
cancer must not be made; and (4) the limita-
tions of the method must be understood by the
pathologist and surgeon alike.
THE TREATMENT OF INJURIES OF THE
HAND CAUSED BY HOMEMADE BOMBS
F. Augustus Arcari, M.D. and Joseph L.
Posch, M.D.
Department of Surgery, Grace Hospital, Detroit
Fifty per cent of explosive injuries of the hands
in children are caused by homemade bombs, and
forty per cent of these cases have associated in-
juries of the face.
Two cases were presented in detail characteriz-
ing the destructive extent of these injuries in-
volving all tissues and giving rise to massive loss
of digit.
Consideration of these two cases indicated the
need for planning the therapeutic program from
the time of first treatment, the necessity for being
extra conservative in primary debridement, and
the hazards inherent in primary flexor tendon
repair.
Emphasis was laid on the importance of plan-
ning the first procedure, keeping in mind the
probable necessity for secondary procedures, and
the aim — maximum function.
Meeting of October 22, 1956
CRYPTORCHIDISM IN INFANTS AND
CHILDREN
By Clifford D. Benson, M.D., and
Charles R. Reiners, M.D.
Correction of cryptorchidism is indicated for
the following reasons:
1. The testes is more susceptible to trauma
when located in the inguinal canal.
2. Torsion of the undescended testis is not a
rare complication.
3. Fertility. Testes which remain in the canal
of abdomen have no spermatogenic function. If
these testes are positioned prior puberty they can
be shown to be fertile. Recent work shows that
fibrotic changes occur in the undescended testis
beginning at ages four to six. This has stimulated
many surgeons to advocate operative correction
before school age.
At operation, mobilization of the cord structures
by sharp dissection is paramount so that the testis
can be positioned without tension or compromise
of blood supply. A modification of the usual pro-
cedure is advocated in which the testis is placed
in a pocket constructed between the dartos and
the scrotal skin. Retraction of the testis is pre-
vented by a silk suture placed through the lower
pole of the testis and fixed to the thigh with a
rubber band. This is felt to be superior to the
Torek procedure because it avoids tension which
can damage blood supply.
Ninety-four patients are reported. In thirty-five
the Torek procedure was used and in forty-nine
the modified procedure, in the last five years.
EVALUATION OF PERITONEAL
ASPIRATION AS A DIAGNOSTIC AID
By Thomas D. Grekin, M.D.
Department of Surgery, Wayne County General
Hospital, Eloise, Michigan.
Aspiration of the peritoneal cavity has been
used regularly as a diagnostic procedure in all
acute conditions of the abdomen in which the
diagnosis was not obvious. The procedure has
special value when applied to those cases of trauma
225
February, 1957
DETROIT SURGICAL ASSOCIATION
where intraperitoneal hemorrhage is suspected.
Experimental data are presented to show that
peritoneal aspiration is a safe procedure. From
a review of our experience with a large number
and large variety of cases, we conclude that this
procedure is frequently more helpful than any
other diagnostic aid. We suggest certain indica-
tions for, and a method of carrying out, peri-
toneal aspiration.
VASCULAR DYNAMICS IN HEMORRHAGIC
SHOCK AND ITS THERAPY
By Don E. Ingham, M.D., Harry M. Nelson,
M.D., and Herbert J. Robb M.D.
Department of Surgery, Wayne State University,
Detroit Receiving Hospital and Dearborn Veter-
ans Hospital.
Hemorrhagic shock is universally treated by
blood replacement; however, on occasion, when
blood is not available it has been treated with
Vasoconstrictive drugs. By use of the stereo dis-
secting microscope it has been possible to study
the difference in response to these two methods
of treatment. For facility and because of similari-
ty to the human vascular pattern, the transillumi-
nated bowel wall of the rabbit is used for the
study. Carotid artery and superior venacava!
catheters with attached manometers are used to
record changes in blood pressure. Changes are
brought about by removal and replacement of
measured amounts of blood and administration of
various vasoconstrictive drugs. By use of cine-
photomicrography the changes which occur have
been recorded on the 16 millimeter motion picture
film.
In the film the normal capillary and precapil-
lary vessel pattern is demonstrated. With the re-
moval of 30 per cent of the circulating blood there
is a narrowing of the precapillary vessels, decrease
in their pulsation and a marked decrease of their
flow and the flow in the capillaries. Blood pres-
sures drop from a normal of 100 mm. Hg. to 75
mm. Hg. A return of the heparinized blood brings
about a restoration of blood presure to 100 mm.
Hg. and a return to normal size and flow in the
vessels.
A second rabbit is placed in identical shock
with a blood pressure of 75 mm. of mercury. This
animal in contrast however, is treated with suf-
ficient vasoconstrictive drug in a diluted solution
to return the blood pressure to 100 mm. Hg. A
segmental arterial spasm and tissue blanching
unlike that found with blood replacement develops.
This progresses to a thread-like uniform spasm in
the small arteries. When the drug is stopped, the
blood pressure not only drops to the pretreatment
level of shock but continues to drop to around
20 mm. Hg. At this point, restoration of blood
volume improves the pressure. This improvement
is only partial and temporary, however, for pres-
sures again drop to severe shock levels and usually
death. Once vasoconstrictive drugs have been used
there is an apparent relative refractivity to blood
replacement therapy and normal body compen-
satory mechanisms.
NARCOTIC ADDICTION AMONG PHYSICIANS
(Continued from Page 217)
1. You are human, subject to the temptations
of laymen.
2. Never let easy access to narcotics be an ex-
cuse for your first “shot.”
3. Don’t get overly tired and fatigued. When
you are worn out, take a vacation. It’s a lot
safer, and a lot more fun.
4. Don’t drink. Alcoholism can lead to drug
addiction.
5. If you have surgery or become ill don’t ever
take narcotics on your own. Keep in mind what
Benjamin Franklin said: “The man who treats
himself has a fool for a doctor.”
6. As a monitor against easy escape from an
emotional problem, always think of your family,
your future, and your prestige. Best of all,
breathe a prayer for God to keep your hand off
any narcotic during time of stress.
7. Take time to relax each day and meditate
on the many blessings God has given you. This
will “up” your spirits. Only depressed doctors
take dope. Keep a happy mental outlook, and
you do much to prevent the world’s most insid-
ious and most hopeless habit.
If observed, these hints will do much to reduce
the 100 new doctor-addicts lost from our pro-
fession each year.
16834 Rosemont
Detroit 19, Michigan
226
J.MS MS
Operation Armor
By action of The Council of the Michigan State Medical
Society, “Operation Armor” was created on December 12,
1956. '
Operation Armor is a promotion applied to an old story.
That old but important story is the need for all children and
adults to be properly vaccinated against dread diseases such
as poliomyelitis, smallpox and diphtheria.
On December 21, 1956, telegrams, special delivery letters
and telephone calls went out to all Michigan newspapers,
radio, and television stations, and to county medical societies
pointing up Operation Armor.
The MSMS message was that millions of polio shots are
now available, that they might soon go to waste. Many
children have had one or two of the series of three shots.
We urged doctors of medicine to contact their patients, com-
plete the series for children already started, and encourage
all persons under age forty to be vaccinated against polio-
myelitis.
It was pointed out that the diphtheria attack that recently
struck Detroit in near epidemic proportions occurred in those
areas where a large proportion of people were not inoculated
and that all immunizing programs should be reviewed and
strengthened.
Our Society believes that here and now the medical pro-
fession has a golden opportunity to render significant public
service by spearheading the vaccination program. We must
not allow inertia and apathy on the part of ourselves or the
public to cause large segments of our people to remain un-
protected.
Some states have resorted to compulsory immunization
laws. Michigan has stayed ahead of compulsion by the sup-
port of mass communication media and the efforts of each
practicing doctor of medicine.
Operation Armor is not a short term campaign — it must be
a continuing effort. The medical profession should take the
leadership. We must go “all out” to see that a minimum
of 75 per cent of Michigan residents are properly vaccinated.
Talk to your patients, talk to your friends, talk Operation
Armor now and every day of the year.
President, Michigan State Medical Society
President S
essacji
February, 1957
227
Editorial
PRIVATE MEDICAL PRACTICE
IS AT STAKE
Our medical profession has passed
through many critical trials. During the
hard times of the ‘■‘thirties” and the eco-
nomic stress, when many of our patients
had no money and no work and when post-
payment had failed, farsighted members
conceived the idea of relief brought to our
public by substituting an insurance idea for
the previously discouraging method of pay-
ment. National officers of our medical asso-
ciations frowned and insurance companies
were aghast — “medical services were un-
insurable.” Labor and politicans sensed the
condition and proposed, as so many Euro-
pean countries had done, that the State
should assume the burden and establish a
National Compulsory Health Program “at
no cost to the consumer.”
Some of our Michigan doctors and many
others throughout the land found an an-
swer — prepaid health services. An un-
chartered course, trial, error, discourage-
ment, resentment from our own members,
disavowal from national officers but en-
couragement from Senators Vandenberg
and Taft, and a dogged persistance in solv-
ing a momentous problem, resulted finally
in establishing Michigan Medical Service
and Michigan Hospital Service. Later,
similar groups were formed in nearly every
state. The need was universal; the answer,
as history has always shown, came from
least expected points — the visionaries, the
dedicated, the never-say-die members of
the profession in our state and elsewhere.
Prepayment stopped the march to statism
in medicine.
The course was not easy. It involved
ninety per cent of our doctor members
agreeing to care for in-hospital patients,
and promising to accept the remuneration
our plan’ could give. For a period of ten
months, Michigan Medical Service did
prorate accounts, and delayed payments as
long as possible. Errors of estimating utili-
zation had given Michigan Medical Serv-
ice too small premiums. When that was
corrected — one of the trial and error meth-
ods— a new era in medical practice devel-
oped and the socialized threat was met and
defeated. (Incidentally, the prorated bills
were all paid in full in due time.)
Problems of financing, increased costs of
services — largely hospital services — and the
growing unrest of our own participating
doctors who fail to recognize Michigan
Medical Service as their own heart’s blood,
considering it instead a “rich insurance
company,” during the past year have
brought on a Governor’s Commission in-
vestigation to find a way to “furnish more
and better health service” for less. The
unions began to demand more complete
coverage. Much of the testimony before
the Governor’s Commission emphasized the
wish for such items as office or outpatient
surgery, diagnosis, radiology, x-ray (thera-
peutic as well as diagnostic), physical
medicine and consultation. All these are
extensions of Michigan Medical Service’s
program which can be given for an in-
increased premium, and which, after an
exhaustive study, the Board is ready to
offer. Methods of administering must be
found to avoid the malutilization found to
be present by MSMS Medical Advisory
Committee to MHS.
The Commission hearings and the pub-
228
J.MSMS
EDITORIAL
licity in the metropolitan press over much
of last year have given the medical profes-
sion “black eyes,” encouraged disaffection,
and recently stimulated the proposed estab-
lishment of the Community Health Asso-
ciation by a pressure group.
Community Health Association is said to
be not fully developed, but has announced
many plans and programs. CHA offers
home and office calls, and practically com-
plete “comprehensive” care. Prices are not
mentioned, but the definitely expressed
plan is to employ doctors part time or full
time and have them work in out-patient
departments or under group practice con-
ditions. If a few “super specialists” are
needed, they will be on a fee or retainer
basis. The promise is that the subscribers
will positively never have to pay any
“extra” fees over and above the subscrip-
tion rate.
We must face this fact. CHA will put
the portion of the medical profession
needed to serve its subscribers on a definite
salary arrangement, paid by a pressure
group. Where will the doctors come from?
A liberal salary to a just-finished intern
with no financial worries was all Perma-
nente needed.
This latest threat to the private practice
of medicine is so real that the Council of
the Michigan State Medical Society at
its annual meeting on January 24, 25, 1957,
after two days’ discussion, directed the
Speaker of the House of Delegates to call
a special meeting as soon as four active
committees can formulate a program. Only
once before has a special meeting of the
MSMS House been called — when the So-
ciety considered our problems grave. So
does it now.
When called, every delegate and every
alternate should attend. Concerted and
vigorous action, with complete and full
support from every member may be the
price of averting the present danger.
Private medical practice on an indepen-
dent basis is at stake.
A DAY DEVOTED TO THE
STUDY OF CANCER
Why should every physician, irrespective of the
nature of his practice, take at least one day out
of each year and devote it exclusively to the study
of cancer? Many answers can be brought forth
to respond to this question. Probably no one
could designate which response was the best and
then convince the majority that his selection was
the most valid. In the writer’s humble opinion,
each physician needs to be equipped with sufficient
knowledge of the nature of cancer to be able to
detect or suspect the presence of cancer when
he has opportunity to interview or examine any
region of the potential host. Any patient, irrespec-
tive of age, is a potential cancer host.
The American Cancer Society, other organiza-
tions, and a number of individuals, have made
numerous studies relative to the benefits of the
so-called cancer detection clinics. The vast
majority agree that there is a place only for a
limited number of critically selected clinics for
research and advanced teaching. Such clinics, if
established in every sizable community, would im-
pose a prohibitive extravagance on the American
public, strain the available medical personnel too
severely, and benefit very few people.
Cancer detection programs must be carried out
in every physician’s office and at every bedside
if they are to give rise to the benefit that they
should. Lurking cancer, when best suited for any
form of therapy, rarely gives rise to symptoms;
however, it behooves the physicians to be mindful
of the fact that a goodly number of their clientele
have been educated to beware of asymptomatic
lumps and bumps. The validity of cancer detec-
tion efforts needs no further emphasis. It is agreed
that every physician must be a cancer detector.
It now remains for each physician to demonstrate
how good a detector he is. Ability to detect
cancer is directly proportional to one’s ability to
think intelligently about cancer.
The Genesee County Cancer Day Programs are
dedicated to the premise of enabling every physi-
cian to improve his knowledge and thinking in
respect to perplexing problems of cancer, irrespec-
February, 1957
229
EDITORIAL
tive of the nature of his practice. In addition,
the programs are so designed that those actively
engaged in cancer management can always pick
out enough pearls from the program to reward
them adequately for taking off a day for an
annual trip to Flint.
Hardie B. Elliott, M.D.
THE WORD— PRINTED AND SPOKEN
Our offices, homes and libraries are bursting
at the seams with a suffusion of the printed word.
Whether you are awake or asleep, at the oper-
ating table or in the laboratory, on the golf course
or in front of your TV screen, somewhere a com-
pulsive scientist is writing an article that you must
try to read. We even have an appreciable bibli-
ography pertaining to methods of covering this
plethora of material.
You may have your secretary choose and file,
but you still must read the material or soon she
will be the better informed. You can subscribe
to many abstracts, quarterly reviews, and digest,
but that just adds reading material to unread
material.
On the chance that you are the distressingly
conscientious type who reads non-illustrated ar-
ticles and editorials in your State Journal, I am
writing this to point out the advantage the spoken
word may have for you.
A man facing you is forced to express himself
with meaning and clarity. His paper is not based
on a “publish or perish” dictum. He has left
the security of his desk and the acquiescence of
his dictaphone to present his material to you in
person. He risks question and difference of opin-
ion. Therefore, he must be prepared for the
practical give and take of verbal communication
that can be so valuable for all concerned.
These are the conditions under which outstand-
ing teachers will present their material at the An-
nual Cancer Day meeting in Flint, Michigan,
April 17, 1957. Each speaker will have the time
to develop his topic and present his total experi-
ence. He will be available to discuss specific
questions that will arise during the day.
Have you been told that cobalt therapy is just
another form of x-ray — and wondered? Or have
you been told it has unique properties — and still
wondered? What did you hear about chemo-
therapy as an adjunct to surgery in large bowel
cancer? What are the valid considerations in the
technique of resecting bowel lesions? Should
doctors give up and let the statisticians treat breast
cancer? Is chemotherapy advancing, or are we
just getting acquainted with the rest of the nitro-
gen mustard family? And what about cancer of
the prostate? Did John Hunter complete the
job with that first castration?
The paper writers are currently asking a great
many questions without following through with
very many answers. Why don’t you give the
spoken word a chance and listen to six of the men
who are studying the material and accumulating
the experience on the frontiers of cancer therapy?
Join the group at the annual Cancer Day meeting
April 17 in Flint. (See program on Page 140.)
Max Dodds, M.D.
GENESEE COUNTY MEDICAL SOCIETY
This issue of The Journal is devoted to the
Cancer Day Program of the Genesee County
Medical Society which this year is presenting its
Twelfth Annual Cancer Day. We are indebted to
Hardie B. Elliott, M.D., of Flint for his very able
assistance. He has been in charge of these pro-
grams for many years, and has prepared for The
Journal an historical sketch and an editorial, a
program, and several articles for the scientific
pages. We also wish to give our sincere thanks
and approbation to Mr. Donald E. Johnson, pub-
lisher of the Flint News Advertiser , who has been
the financial sponsor of these Clinics since their
inception.
MEDICINE S CONTRIBUTION TO
WORLD PEACE
Medicine is universally recognized as one of the
great world-wide arts and sciences that bind
humanity together with a language and a pur-
pose transcending all differences of race, creed
or color.
To make the language of medicine more articu-
late in the cause of international peace and
human progress, the doctors of the free world
are united in The World Medical Association,
whose membership now embraces fifty-three na-
tional medical associations.
But it is never enough to establish great in-
stitutions. Only when individuals are given an
opportunity to play an active part does any
human organization “come alive” and begin to
realize its basic purposes.
230
J.MSMS
EDITORIAL
Every American doctor knows first hand the
vital role he may play in guiding and protecting
his profession by becoming an active member of
his county, state and national medical societies.
Today, every American doctor has the oppor-
tunity— and the imperative challenge — to help
make our profession a stronger influence for
world peace. This he may do by joining our
own United States Committee of The World
Medical Association.
Similar “supporting committees” have been or-
ganized in a number of other leading nations
whose national medical societies, like the AMA,
are members of WMA.
In a timely action, WMA, at its Tenth General
Assembly in Havana in October, adopted a six-
point program to implement one of its constitu-
tional purposes: to promote world peace. This
program includes the development of mutual ex-
change visits of foreign doctors; exchanges of dis-
tinguished medical teachers; establishment by
each WMA member national association of an
“international visitor’s bureau” ; stimulation of
visits by representatives of member associations to
the annual meetings of other member associa-
tions; holiday exchange programs between doc-
tors and their families; and exchanges of text
books and medical and scientific publications.
To implement this program takes money — and
interested members. You may play your part by
joining the U. S. Committee of WMA. Active
membership dues for 1957 are $10.00. To join
the U. S. Committee — and to learn how you can
contribute to this great cause — communicate with
William A. Hyland, M.D., Grand Rapids.
MEDICARE
The Medicare program went into effect in
Michigan without a hitch and is proving a bless-
ing in many ways. Many of the dependents have
not yet been issued cards specifying their eligibil-
ity for service, but the doctors are co-operating,
giving the services and making the reports. Some
of the patients do not even know they are eligible.
The Editor’s first case was a young mother,
with a cross-eyed baby of twenty months and a
husband overseas, who was concerned about how
she would pay for the baby’s care. She was
elated at the Medicare news.
The program is settled in every state and ter-
ritory but two. The state medical society of one
state refused to agree as a society to accept the
fees as full coverage. One state could not agree
on fees. In both cases the Military Forces’ Medi-
care’s Administrative Officer, Major General Paul
I. Robinson assigned a commercial company,
Mutual of Omaha, as the fiscal agent.
BLUE SHIELD ACTS TO MEET
NEW CHALLENGES
Ten years ago forty-five struggling local Blue
Shield Plans had a combined enrollment of less
than two million people. Today, seventy-three
Blue Shield Plans cover some thirty-eight million;
and if their present rate of growth is maintained,
these Plans will pass the forty-million mark in
enrollment during 1957.
Several factors have conspired in recent years
to alter and complicate the basic problems of
Blue Shield enrollment. For one thing, most of
the windfall apples have fallen off the tree, and
enrollment men are having to climb ever higher
in the tree to fill their baskets. Most local “blue
chip” industrial groups have long since been en-
rolled by Blue Shield or some other agency, and
the remaining local prospects are predominantly
small groups, the self employed and rural dwellers.
Another vital new factor has been introduced by
the tremendous growth of new industrial giants
resulting from corporate mergers, and the con-
comitant tendency of labor unions to negotiate
welfare benefits on a national scale. These big
corporations and unions are demanding nation-
wide hospital and medical care programs, offering
at least the same scope of benefits for their work-
ers in all parts of the country.
Blue Shield is an association of strictly auto-
nomous local Plans, having similar purposes, but
offering a considerable variety of specific benefits.
The constitution of Blue Shield Medical Care
Plans recognizes that “state and local medical
care plans should be autonomous in their opera-
tions so that the needs, facilities, resources and
practices of their respective areas can be given due
consideration, but that the health and welfare of
the public is advanced by the co-ordination . . .
of methods, coverages, operations and actuarial
data.”
The Plans have sought, by voluntary agree-
ment, to co-ordinate their efforts and to develop
a basic program which each local Plan may offer
the members of inter-Plan groups within their
local Plan areas.
February, 1957
231
EDITORIAL
Without sacrificing an iota of local independ-
ence, more than three-fourths of the Plans have
recently reached agreement on a standard scope
of Blue Shield benefits, all or any of which each
Plan will make available to any group of sub-
scribers desiring this pattern of benefits. Nearly
all the other Plans have promised to “go along”
in the near future.
While this degree of co-ordination of benefits
(in terms of covered services) has been found
necessary to meet Blue Shield’s enrollment chal-
lenge, each Plan will still make payments to
physicians according to its local negotiated sched-
ules, and will calculate its own subscription rates.
This significant achievement of Blue Shield
shows its ability to meet new conditions and proves
the capacity of medicine’s voluntary prepayment
movement to solve whatever problems it may en-
counter.
MICHIGAN MEDICAL SERVICE
It is time our members understood explicitly
some of the major problems our Blue Shield pro-
gram must face, the most important being finances.
The records for the year 1956 are not all com-
plete, but for ten months up to October 31, 1956,
expenditure was considerably more than income.
We will report the results for our Medical-Surgi-
cal and Surgical Plans. The Veterans work al-
ways breaks even. It amounted to $750,470.30
during the ten months, which can be added to
our other figures for gross amounts.
Subscription Fees $35,832,871.16
Services Rendered (paid) 34,721,466.40
Administration Expense 2,770,423.39
Operating Loss (1,659,018.63)
Miscellaneous Income 2,563.35
Investment Income 294.562.02
Net Loss (1,361,892.36)
Reduced to percentages, Michigan Medical Ser-
vice spent on services to policy holders:
1956 96.80%
1955 91.34%
1954 90.66%
1953 89.82%
1952 86.44%
In the beginning, for each patient served,
Michigan Medical Service made out one set of
records and one check for payment. Now each
recorded case receives 2.7 services. At first only
one doctor was involved, but now 2.7. This is
one reason for increased costs. The average
number of services per member has changed. In
1950, with 2,000,000 members, there were 24,000
services per month. The usage has rapidly in-
creased in 1956 with 3,400,000 members receiving-
98, 000 services per month — an increase of two
and one-half times.
The premium rates for the $2,500 contract
were increased in 1941, 1942 and on March 1,
1950. On that date, the $5,000 contract was
sold and its rates have not been changed. The
Board of Directors has, however, at various times
on the recommendation of the Medical Advisory
Committee, readjusted or increased allowances
for many and various items when inadequacies
were shown. Formerly some x-ray, pathology,
electrocardiograms, et cetera, were paid as hos-
pital services. Michigan Medical Service as-
sumed these costs recognizing medical services.
The result of such changes, and the inclusion of
various liberalizations has been a gradual advance-
ment of proportionate costs, so that Michigan
Medical Service is now paying 24 per cent more
for the average service.
There are still many items which individuals
or groups claim are not in line and should be
readjusted upward. Liberalization has reached
the limit, and this year Michigan Medical Service
is operating at a deficit. There is a reserve which
can carry the load for a while, but the trend is
established. On December 31, 1955, the reserve
was $8,057,741.87. On October 31, 1956, it was
$6,695,849.51. The two months of November
and December may show a better figure — as a rule
December utilization drops.
Michigan Medical Service is not just another
insurance company with vast resources as too
many of our members seem to believe. It is an
integral part of our medical society. It started
with nothing but $17,000 borrowed from the
Michigan State Medical Society, and proved to
the world that medical care is an insurable quan-
tity. Our leaders had begged the insurance com-
panies to establish some form of prepayment
(insurance) which could be sold and could care
for the hospital and/or medical needs of our
patients. We were told medical care was un-
insurable. The profession at great sacrifice has
demonstrated otherwise. Now, insurance compan-
ies are giving great competition and some of them
resent our continuing in the prepayment field.
232
JMSMS
EDITORIAL
Reassurance. — Socialized medicine, a term we
seldom hear now, was an ominous spectre some
sixteen years ago, promising medical services to
vast members of people who could not provide
for themselves except at great and many times
catastrophic sacrifice. We demonstrated the
economic ability and willingness of the medical
profession in times of stress. Our plan and its
accomplishments are sacred to those who bore
the burden of creation! It must not prove inad-
equate. Our patients have grown to depend on
it for their needs.
Extended Service. — Demands are being made
for extended services in many fields. Our doctors
are advising many changes, mostly in the matter
of readjustment of fees paid. Some are advocat-
ing removing the service connotation and chang-
ing into an indemnity plan. Other doctors ad-
vocate a deductible feature to be included in
every contract.
Our patients and our subscribers are asking for
many extensions of service which the Board is
studying and hopes to be able to offer. We have
mentioned some of these before: surgical services
in office or in out-patient departments, anesthesia
in office or out-patient departments, diagnostic
radiology in office or out-patient department,
therapeutic radiology, physical therapy, E.K.G.,
B.M.R., E.E.G., E.G. pathological tissue examina-
tions, all in out-patient departments or doctor’s
offices, and the hospital services necessary to
accomplish these.
These services could be sold as a rider or an-
other contract for a price to be determined. When
such services are made available to subscribers,
the liberalizations voted during the past several
years, which have tended to increase the deficit,
should be eliminated. By so doing a rate increase
might possibly be avoided.
Most of our members will remember the furor
caused by the over utilization and unnecessary
service charges made a few years ago. Those
grew out of many things and many misuses, but
some were due to abuse of privileges by some of
our hospitals, doctors, and patients. Some means
of control may be necessaiy, but doctors surely
would rather be their own policemen. Michigan
Medical Service has had enough misuse and
abuse with the limited services offered these many
years, but, with an extension which could pos-
sibly double the amount of benefits, it is hoped
our members will always bear in mind that our
life-saving Michigan Medical Service is our own
pocketbook.
Proportionate Value. — A very considerable
number of our members are complaining of the
inequality of some fees for services as compared
to others, especially surgical charges. That is a
problem the profession has had since surgery be-
gan. The profession has not made adjustments
where some thought returns were out of line.
Medical Service should never be asked to make
that adjustment.
Twenty years ago in Michigan we attempted to
establish a fair unit rating of all medical services.
We found no key. A little later California found
the same difficulties. Two years ago another
report in Los Angeles completed a two-year study
and published an extended schedule — but divided
the profession into four groups. Their values were
much as had been determined twenty years be-
fore, but they admitted they needed four schedules
instead of one.
WHAT’S NEW IN DRUGS?
(Continued from Page 212)
13. Fabing, H.: Neurology, 5:603, 1955.
14. Laborit, H., and Huguenard, P. : Presse med.,
59:1329 (October 13) 1951.
15. Delay, J. ; Deniker, P. ; and Hard, J. M.: Ann.
med.-psychol., 110:267 (July) 1952.
16. Meier, R.; Gross, F.; and Tripod, J. : Klin.
Wchnschr., 32:445 (May 15) 1954.
17. Plummer, A. J.; Maxwell, R. A.; Earl, A. E., and
Rutledge, R.: Federation Proc., 15:468, 1956.
18. Ferguson, J. T. : Ann. New York Acad. Sc., 61:101,
(April 15) 1955.
19. Ferguson, J. T. : J.A.M.A., 160:259 (January 28)
1956.
20. Plummer, A. J.: Personal communication. (See al-
so Reference 17).
21. Gaddum, J. H.: Ciba Foundation Symposium on
Hypertension, London, 1953, page 75.
22. Brodie, B. ; Pletscher, A.; and Shore, P. A.: Science,
122:968 (Nov. 28) 1955.
23. DeKruif, P. : Tricks against old age. J. Michigan
M. Soc., 55:544 (May) 1956.
24. Ayd, F. J., Jr.: J. Clin. & Exper. Psychopathology,
1956. In press.
February, 1957
233
Michigan Clinical Institute
Medical Color Television— A Changing Picture
Compatible color television will make its debut
performance before the Michigan Clinical Insti-
tute at its annual meeting convening in Detroit,
March 13-15. The newly acquired equipment
represents the first major change in the basic
color TV facilities provided the Institute meetings
by Smith, Kline & French Laboratories and fea-
tures a projection system that more than doubles
the brightness and clarity of the picture seen in
the viewing auditorium.
The three-day, four and one-half hour pro-
gram consisting of six clinics and two operations
will originate from Grace Hospital. From here it
will be beamed via microwaves to the Ballroom
of the Sheraton-Cadillac Hotel where a projection-
type receiver equipped with a 4y2x6-foot screen
will be installed.
Increased picture quality will be complemented
by a new programming technique for surgical
procedures. The two operations to be televised
will employ a three-way conversational hook-up
between the operating surgeon, a panel of dis-
tinguished specialists and a moderator at the audi-
torium.
Veteran M.C.I. televiewers will notice no radi-
cal change in the amount of equipment installed
in the television auditorium. The big difference
appears on the screen itself. The picture, while
the same size as in years past, is thrown on the
screen with double the former light intensity by
the new compatible projectors. In others words,
to a physician seated in the usual viewing area,
the picture is twice as clear and sharp. Then, too,
the increased brightness extends the viewing area,
permitting many more persons to view each pro-
cedure. Since the operative fields are pictured in
close-ups varying from three to seven inches in
width, the images shown on the giant screen rep-
resent a range of magnification of from 100 to
600 times actual sizes.
There is a radical change, however, in the ap-
pearance of the SKF Color Unit’s facilities at the
hospital end of the colorcasts. In the operating
room, the first color camera of them all, affec-
tionately called “Clarabelle” by the Color Unit,
has given way to a camera with a special lens
arrangement that will focus on a mirror directly
above the operative site. While Clarabelle never
obstructed the operating surgeon in any way, the
new positioning removes the camera still farther
from the operating table and potential inter-
ference. Another advantage brought by the new
camera is a revolving lens turret. Now three dif-
ferent close-up views of the same operative field
are available to the audience in place of the
former fixed view.
In the studio, panelists and clinic participants
are no longer to be confronted by two cameras
of standard black-and-white size, adapted for
color. In their stead, two cameras of somewhat
awesome dimensions are trained on the doctors.
Almost five feet long from Zoomar lens to control
rods, each camera is an example of the engineering
know-how that assures the Color TV Unit — and
postgraduate teaching — of the finest in technical
equipment for years to come.
Finally, the control room or “brain center” of
the colorcasts will not be found on the same floor
as the studio or even within the hospital. Cables
leading from the cameras within the hospital run
through windows and down the outside wall of
the hospital to a huge truck parked close to the
building. The truck is, in effect, a control-room-
on-wheels, containing all control equipment nec-
essary for a three-camera program. Via headsets,
two men seated at the truck control panels take
instructions from the director’s booth located in-
side the studio and maintain the technical quality
of the picture, while far from the actual television
scene.
Altogether, the versatility of the new equipment,
the “know-how” of the SKF crew and, perhaps
most important, the extensive TV experience of
most of the participants in the M.C.I. colorcasts
assures a program of excellent picture quality.
As to information content, viewers of past pro-
grams know there is no assurance needed on this
score.
234
TMSMS
Michigan Clinical Institute
Technical Exhibits-1957
Abbott Laboratories Booth No. 10
North Chicago, 111.
The new sedative, tranquilizer and antihypertensive,
NEMBU-SERPIN® Filmtabs® will be among new
products exhibited by Abbott Laboratories. Also shown
will be the new non-barbiturate hypnotic, PLACI-
DYL®; DESBUTAL®; ERYTHROCIN® Filmtabs;
IBEROL® Filmtabs; OPTILETS® Filmtabs; VI-
DAYLIN®; SELSUN®; PENTOTHAL® SODIUM;
and Abbott’s complete line of intravenous solutions
and equipment.
A. S. Aloe Company Booth No. 62
St. Louis, Mo.
Visit Space No. 62 where the A. S. Aloe Company
will have on display a cross-section of their most
complete line of physicians’ equipment and supplies.
Tom and Wallie Boufford will be on hand to greet
you and they will certainly appreciate the opportunity
of discussing mutual items of interest with you.
American Cyanamid Company Booth No. 63
Surgical Products Division
Danbury, Conn.
American Cyanamid Company Surgical Products
Division, manufacturers of Davis & Geek brand sutures
and other surgical specialties, will feature new suture
packaging, Surgilar and Surgilope R, designed to
eliminate broken glass from the operating room. All
the popular atraumatic R needle-suture combinations
are included in the Surgilar product line. Other
products of interest include Aureomycin R surgical
dressings and Melacast orthopedic bandages.
American Ferment Company, Inc. Booth No. 73
New York, N. Y.
Stop at Booth No. 73 for your personal supply of
Falgos. the buffered compound analgesic that acts
quickly and without gastric upset. Let us also ex-
plain the advantages of Caroid & Bile Salts Tablets,
Alcaroid Antacid, and Supligol, the whole bile-keto-
cholanic acid compound.
Ames Company, Inc. Booth No. 9
Elkhart, Indiana
The Ames exhibit will introduce a new and unique
concept in sedation — a new calmative drug — NOS-
TYN. NOSTYN is chemically and physiologically
unrelated to any available compound. NOSTYN al-
lays anxiety and tension with the power of gentleness;
possessing a wide margin of safety, NOSTYN avoids
depression or drowsiness.
Audio-Digest Foundation Booth No. 75
Glendale, Calif.
Audio-Digest Foundation — a subsidiary of the Cali-
fornia Medical Association — gives the busy physician
an effortless tour through the best of current medical
literature each week. This medical tape-recorded
“newscast” — compiled and reviewed by a professional
Board of Editors — may be heard in the physician’s
automobile, home or office. The Foundation also offers
medical lectures by nationally-recognized authorities.
Audograph Company Booth Nos. 16, 17
Detroit, Mich.
The sales booth is a series of panels of alternating
color in the form of a screen 20 feet wide. Four
large panels of dark blue bear the name GRAY. The
other panels are composed of shades complimentary
to this basic color and carry at the top of the panel
the various Gray systems. Four tables with con-
cealed wiring, blond finished with appropriate decals
and standing on wrought-iron legs bear the equip-
ment to be displayed.
Ayerst Laboratories Booth No. 7
Chicago, 111.
The Ayerst Laboratories exhibit features “Premarin”
Intravenous, for the rapid control of various types
of hemorrhages. Physicians are cordially invited to
visit Booth No. 7 for information on “Premarin”
Intravenous and other Ayerst specialties.
Baby Development Clinic Booth No. 33
Chicago, 111.
BABY DEVELOPMENT CLINIC, Booth No. 33, in-
vites doctors to visit its space and become familiar
with the NEW LIFEBUOY with TMTD to protect
and prevent odor of perspiration. Literature avail-
able, as well as samples for personal use and clinical
testing. ALSO REGISTER for sample jars of TUCKS
for comfort and care of patients who have had episiot-
omies, hemorrhoids, or anorectal surgery.
Baker Laboratories, Inc. Booth No. 50
Cleveland, Ohio
You are invited to visit our booth where Baker’s
Modified Milk and Varamel, two successful products
for infant feeding, are on display.
Baker representatives will be glad to discuss the prac-
tical application of Grade A milk, adjusted fat com-
position, zero curd tension, synthetic vitamins and
other important factors which help to eliminate many
of the problems in modern infant feeding.
Bristol-Myers Products Division Booth No. 57
New York, N. Y.
Please stop by for information on BIOGELS, an
original and unique development for effective control
of constipation. A personal supply of BUFFERIN,
the faster acting, better tolerated salicylate; and
AMMENS Medicated Powder, a dispersion of talc
in cornstarch, is also available.
Ciba Pharmaceutical Products, Inc. Booth No. 11
Summit, N. J.
CIBA is featuring two prescription specialties —
RITALIN, a new mild stimulant-antidepressent and
DORIDEN, a nonbarbiturate hypnotic-sedative. RI-
TALIN raises depressed patients to normal levels of
psychomotor activity without amphetamine-like over-
stimulation or depressive rebound. Nonhabit-forming
DORIDEN is already being widely used as a safe,
baribiturate replacement. Representatives will be
present to answer queries on these very effective
agents.
Coca-Cola Company Booth Nos. 65, 66
Atlanta, Ga.
Ice-cold Coca-Cola served through the courtesy and
co-operation of the Detroit Coca-Cola Bottling Com-
pany and The Coca-Cola Company.
February. 1957
235
MCI— TECHNICAL EXHIBITS
Cunningham Drug Stores, Inc. Booth No. 42
Detroit, Mich.
We cordially invite you to visit our exhibit showing
some of the services offered to you and your patients
by “your friendly Cunningham Drug Stores.”
Desitin Chemical Company Booth No. 22
Providence, R. I.
DESITIN OINTMENT : the pioneer in external cod
liver oil therapy.
Indications: diaper rash, slow healing wounds, burns
of all degrees, lacerations, hemorrhoids and fissures.
DESITIN POWDER: a unique, dainty medicinal
powder saturated with cod liver oil.
DESITIN HEMORRHOIDAL SUPPOSITORIES
with COD LIVER OIL: coats ano-rectal area
with soothing, lubricating cod liver oil, gives
prompt relief of pain, allays itching.
DESITIN LOTION: the original cod liver oil lo-
tion, soothing, protective, mildly astrigent and heal-
ing, in non-specific dermatitis, pruritus, poison ivy,
etc.
RECTAL DESITIN OINTMENT: A unique formu-
la, providing rapid and effective relief in simple
hemorrhoids, pruritus ani, fissures, etc. Does not
contain narcotics, local anesthetics, styptics to mask
any serious symptoms.
Detroit Creamery Company Booth No. 14
Detroit, Mich.
The Detroit
C r eamery
C o m p a n y,
local distrib-
utors of Seal-
t e s t Milk
and Dairy
Products, in-
vite you to
stop at the Sealtest booth and enjoy a complimentary
bottle of Sealtest Milk.
Detroit X-Ray Sales Company Booths Nos. 40, 41
Detroit, Mich.
We take pleasure in having the opportunity of ex-
hibiting our latest developments in diagnostic x-ray
equipment, and an additional line of Grenz Ray
Therapy apparatus.
We extend a cordial invitation to visit our booth
and discuss your radiological problems with our staff.
Dietene Company Booth No. 60
Minneapolis, Minn.
Have YOLT tasted MERITENE . . . the whole pro-
tein supplement that DOES taste good? Visit our
booth, enjoy a MERITENE Milk Shake with its
multiple nutritive values.
While you’re there, review the Dietene Diet based on
DIETENE Reducing Supplement. It provides the
rare combination of low calories (1000) with high
intake of protein and all essential vitamins and
minerals in an interesting, effective, SAFE weight
reducing diet.
Doho Chemical Corporation Booth No. 25
New York, N. Y.
AURALGAN, ear medication in Otitis Media and
removal of Cerumen;
OTOSMOSAN, effective, non-toxic Fungicidal and
Bactericidal (Gram negative-Gram positive) in the
suppurative and aural dermatomycotic ears;
RHINALGAN, nasal decongestant free from systemic
or circulatory effect and equally safe to use on
infants as well as the aged.
236
NEW LARYLGAN, soothing throat spray and gargle
for infectious and non-infectious sore throat in-
volvements.
Mallon Chemical Corporation, Subsidiary of the Doho
Chemical Corporation, is also featuring:
RECTALGAN, liquid topical anesthesia, for relief
of pain and discomfiture in hemorrhoids, pruritus
and perineal suturing.
DERMOPLAST, aerosol freon propellent spray for
fast relief of surface pain, itching, bums and abra-
sions. Also Obs. & Gyn. use.
Eaton Laboratories, Inc. Booth No. 38
Norwich, N. Y.
Published reports show that Furadantin® is one of
the most effective and rapidly acting agents avail-
able at this time for the treatment of prostatitis and
acute and chronic urinary tract infections.
Furadantin has specific affinity for the urinary tract,
producing antibacterial concentration in thirty min-
utes. Time-consuming trial and error with less effec-
tive agents is eliminated.
Ferndale Surgical, Inc. Booth No. 43
Ferndale, Mich.
Surgical instruments, diagnostic and examination
equipment. Pharmaceutical specialties of our own
manufacture. Inquiries on special formulas will be
welcomed.
Geigy Chemical Corporation Booth No. 5
Yonkers, N. Y.
The Geigy exhibit will feature PRELUDIN — the new
chemically different appetite suppressant noted for its
absence of side actions. Also on display will be
BUTAZOLIDIN — potent nonhormonal antiarthritic ;
new STEROSAN Hydrocortisone Ointment-anti-in-
flammatory, bacteriostat and fungistat. and other well
known Geigy products.
Gerber Products Company Booth No. 30
Fremont, Mich.
WHEN MILK IS CONTRAINDICATED as the
basic food for infants, Gerber “Meat Base Formula”
can provide a nutritionally adequate replacement. It
is well accepted and tolerated by infants of all ages.
Your Gerber detailman invites you to evaluate “Meat
Base Formula” and the complete line of supplementary
baby foods.
Hack Shoe Company Booth No. 3
Detroit, Mich.
Entering “Our 42nd Year of Service to the Profession”
Showing
(a) RIPPLE SOLES. “The Shoes that Walk for
You”
Styles for Men, Women and Children
Try them on at the meeting.
(b) SUPPORTIVE SHOES for men, women and
children
(c) Hack Pigeon Toe Shoes
(d) Hygienic shoes — of regular construction — for
children’s normal feet.
G. A. Ingram Company Booth Nos. 67, 68
Detroit, Mich.
Instant Sanka Coffee Booth No. 1
White Plains, N. Y.
Are you familiar with INSTANT SANKA COFFEE?
Your coffee-loving patients will love it. Designed not
to make people nervous or jumpy, Instant Sanka is
100 per cent pure coffee with 97 per cent of the
caffein removed. Stop by for a cup often during
your meeting . . . the proof is in the testing. And
be sure to register for professional samples and book-
lets.
A. Kuhlman & Company Booth No. 32
Detroit, Mich.
A. Kuhlman & Company invites you to see Castle’s
new No. 999 Autoclave in operation. This large
JMSMS
MCI— TECHNICAL EXHIBITS
capacity double-shell office autoclave offers unmatched
simplicity, safety, and style. We shall also display
the latest diagnostic and surgical instruments as well
as physicians examining room furniture.
Lea & Febiger Booth No. 70
Philadelphia, Pa.
Be sure to see these new books and new editions:
Blinick and Kaufman — Modern Office Gynecology;
Zimmerman, Netsky and Davidoff — Atlas of Tumors
of the Nervous System ; Stimson and Hodes — Common
Contagious Diseases; Wintrobe — Clinical Hematology;
Stimson — Manual of Fractures and Dislocations; Cush-
man— Strabismus; Bell — Pathology; Epstein — Skin
Surgery; Katz and Pick — Clinical Electrocardiography;
Soffer — Diseases of the Endocrine Glands; Wohl and
Goodhart — Modern Nutrition in Health and Disease;
Lewin — The Back and Its Disk Syndromes; Holmes
and Robbins — Roentgen Interpretation; and many
other books of current medical interest.
Lederle Laboratories Booth No. 26
Pearl River, N. Y.
You are cordially invited to visit the Lederle Booth
where our Medical Representatives will be in attend-
ance to provide the latest information and literature
available on our line.
Featured will be Achromycin, Diamox, Vitamins,
Pathilon, Varidase, and many other of our depend-
able quality products.
Liebel-Flarsheim Company Booth No. 48
Cincinnati, Ohio
The Liebel-Flarsheim Company cordially invites you
to visit the booth in which their latest electromedical-
electrosurgical equipment will be exhibited. We ask
particularly that you stop and see the L-F Basal-
MeteR, the first automatic, self-calculating metabolism
unit ever offered. Capable representatives will be
on hand at all times.
Eli Lilly & Company Booth Nos. 54, 55
Indianapolis, Ind
You are cordially invited to visit the Lilly exhibit
located in space Nos. 54 and 55. The display will
contain information on recent therapeutic develop-
ments. Lilly sales people will be in attendance. They
welcome your questions about Lilly products.
Maico Detroit Company Booth No. 69
Detroit, Mich.
The new Maico Hearing Aid weighing less than one-
half ounce is so small that the entire unit consisting
of transmitter, microphone, receiver, battery and ear
mold is worn in the ear. A complete line of intru-
ments to take care of cases from the borderline to
the profoundly deaf.
90 per cent of all precision hearing test instruments
used in America by ear physicians are Maico.
Mead Johnson & Company Booths Nos. 71, 72
Evansville, Ind.
Medco Products Company Booth No. 20
Tulsa, Okla
Presenting the MEDCO-SONLATOR. Providing a
new concept in therapy by combining muscle stimu-
lation and ultra sound simultaneously through a
SINGLE Three-Way Sound Applicator.
The MEDCO-SONLATOR is a distinct advance in
the effectiveness of physical therapy in your office
or hospital. A few minutes spent in our booth should
prove of value to your practice.
Medical Aids, Inc. Booth No. 36
Park Ridge, III.
Medical Aids, Incorporated, will feature a complete
line of pressure bandages, including the well-known
February, 1957
DALZOFLEX and PRIMER Combination, recom-
mended in the treatment of leg ulcers, phlebitis, etc. ;
the NULAST Elastic Crepe bandage, constructed of
Viscolax rubber threads, DALMAS elastic strapping,
which is waterproof, oil and grease resistant. LITE-
NET and CLAYS elastic stockings.
Medical Protective Company Booth No. 34
Fort Wayne, Indiana
MALPRACTICE PROPHYLAXIS . . . Less Mal-
practice Publicity for public consumption, Individual
Insurance invulnerable to charges of a “doctors’ com-
bine,” Periodic Information to policyholders, Fight-
ing Defense, Insurance Diagnosis that eliminates con-
tribution, Avoidance of Insurance Over-dose that
bring litigation and large losses, plus the “Know-
how” of Specialized Service make Medical Protective
policyholders safer.
Merck Sharp & Dohme Booth No. 21
Philadelphia, Pa.
The Merck Sharp & Dohme exhibit presents high-
lights on steroid therapy featuring the newer adrenal
cortical steroid preparations in endocrine disorders,
collagen diseases, respiratory allergies, eye diseases
and skin conditions.
Research developments in the field of antibacterial
agents are of clinical significance.
Expertly trained personnel will be pleased to discuss
advanced clinical reports on a new therapeutic agent
which may be described as a “mood stabilizer.”
Meyer and Company Booth No. 15
St. Clair Shores, Mich.
ATHEMOL — A new compound which has been high-
ly successful in the management of arteriosclerosis
will be presented by Meyer and Company.
ATHEMOL REDUCES SERUM CHOLESTEROL
AND RELIEVES THE PATIENT’S SUBJEC-
TIVE COMPLAINTS.
ATHEMOL IS EASILY TOLERATED BY ALL
PATIENTS; NO SIDE EFECTS OR TOXICITY
HAVE BEEN REPORTED.
ATHEMOL IS AN INEXPENSIVE AND EFFEC-
TIVE TREATMENT FOR ARTERIOSCLERO-
SIS.
Michigan Medical Service Booth No. 4
Detroit, Mich.
You are cordially invited to visit our booth to obtain
current information regarding Michigan Medical
Service (Blue Shield). Our representatives will gladly
visit with you and answer any questions you may
have with regard to your Blue Shield Plan.
Milex Products Booth No. 52
Oak Park, Mich.
Featuring a complete line of unique GYNECIC
SPECIALTIES which include the Crescent Dia-
phragm with built-in-inserter. Oligospermia cups, pre-
coital douche, basal temperature thermometer, Tricho-
San, and a Cancer Detection Unit. Also a new
product for pre-menstrual tension and dysmenorrhea
and a “Doctor’s Marital Guide” for patients, in two
editions.
Miller Surgical Company Booth No. 61
Chicago, 111.
See the Miller Electro Surgical Units and accessories
such as Snares, Suction-Coagulation attachments. For-
ceps, etc. A complete line of Diagnostic Equipment
consisting of illuminated Otoscopes, Ophthalmoscopes,
Eyespud with Magnet, Transillumination Lamps, Mir-
ror Headlite, Vaginal Speculum with Smoke Ejector
and Gorsch Operating Scopes and Stainless Steel
Proctoscopes, all sizes, with magnification, will also
be on display.
237
MCI— TECHNICAL EXHIBITS
C. V. Mosby Company Booth No. 24
St. Louis, Mo.
The Mosby Company will exhibit its complete line
of medical books and journals at the Michigan Clini-
cal Institute. Included among the most recent re-
leases will be the following: Bard “Medical Physiol-
ogy,” Bray “Clinical Laboratory Methods," Anderson
“Synopsis of Pathology,” DeSanctis-Varga “Handbook
of Pediatric Medical Emergencies,” Forster “Modern
Therapy in Neurology," Gradwohl “Clinical Labora-
tory Methods and Diagnosis,” Haymaker “Bing s Local
Diagnosis in Neurological Diseases,’ Leider “Practical
Pediatric Dermatology,” Meakins “Practice of Medi-
cine,” Richards “Surgery for General Practice," Sodi-
Pallares “New Bases for Electrocardiography,” Sut-
ton “Diseases of the Skin” and Ulett-Goodrich “A
Synopsis of Contemporary Psychiatry.”
Parke, Davis & Company Booth No. 31
Detroit, Mich.
Medical service members of our staff will be in at-
tendance at our exhibit for consultation and dis-
cussion of various products. Important specialties,
such as Penicillin S-R, Benadryl, Ambodryl, Dilantin
Suspension, Vitamins, Eldec, Oxycel, Milontin, Am-
phedase, Chloromycetin, Thrombin Topical, etc., will
be featured. You are cordially invited to visit our
exhibit.
Pet Milk Company Booth No. 37
St. Louis, Mo.
We shall be pleased to have you stop and discuss
the variety of time-saving material available to busy
physicians. Our representatives will be on hand to
discuss the merits of “Pet” Evaporated Milk for in-
fant feeding and INSTANT “Pet” Nonfat Dry Milk
for special diets. A miniature “Pet” Evaporated
Milk can will be given to all visitors.
Purdue Frederick Company Booth No 47
New York, N. Y.
SENOKOT Tablets and Granules — new non-bulk,
non-irrating constipation corrective acting selectively
on the parasympathetic (Auerbach’s) plexus in the
large bowel, physiologically stimulating the neuro-
muscular defecatory reflex.
PRE-MENS — the multidimensional premenstrual ten-
sion therapy.
SOMATOVITE — clinically proven to promote weight
gain, increase appetite and reduce hyperactivity
and restlessness.
SIPPYPLEX — the modern comprehensive therapy for
peptic ulcer.
Randolph Surgical Supply Company Booth Nos. 12, 13
Detroit, Mich.
Randolph Surgical will again display the popular
Barron Food Pump, with an actual demonstration.
Also many other new items that will be of interest
to the Medical Profession. Our Booth will be staffed
by experienced personnel to assist our many friends.
R. J. Reynolds Tobacco Company Booth No. 44
Winston-Salem, N. C.
Welcome to the R. J. Reynolds Tobacco Company
Exhibit! You are cordially invited to receive a
cigarette case (monogrammed with your initials) con-
taining your choice of CAMEL, WINSTON Filter,
Menthol Fresh SALEM, or CAVALIER King Size
Cigarettes.
A. H. Robins Company, Inc. Booth No. 28
Richmond, Va.
Physicians attending the meeting of the Michigan
Clinical Institute are extended a cordial invitation
to visit the exhibit of the products of the A. H.
Robins Company.
Experienced medical representatives will be in attend-
ance to welcome you and answer inquiries relative
to any of Robins prescription specialties.
Ross Laboratories, Inc. Booth No. 29
Columbus, Ohio
ROSS LABORATORIES: CURRENT CONCEPTS
IN INFANT FEEDING, stressing the critical aspects
of preventive care. Your Similac Representative will
be happy to discuss the role of physiologic feeding in
providing good growth, sound development, and opti-
mum clinical benefits. Copies of the latest Ross Pedi-
atric Research Conference Reports are available.
Rupp & Bowman Company Booth No. 58
Berkley, Mich.
The Rupp and Bowman Company cordially invites
you to visit exhibit Booth No. 58. Our display will
feature diagnostic instruments, equipment and surgical
supplies.
Sanborn Company Booth No. 53
Cambridge, Mass.
Visitors at the Sanborn Company Booth No. 53 will
have full opportunity to see and have demonstrated
our clinical diagnostic instruments such as the pop-
ular Viso-Cardiette and Metabulator.
In addition, there will be demonstrations and/or
data available on the Vector System, Viso-Scope, and
Transducers for pickup of pressure and other physi-
ologic events; and on the Twin-Viso, Twin-Beam, and
the “150” (and other) series of single and multi-chan-
nel direct-wiring and photographic recording systems.
Sandoz Pharmaceuticals Booth No. 51
Hanover, N. J.
BELLERGAL Spacetabs assures around the clock con-
trol of functional complaints (example — menopause
symptoms) in the periphery where they originate.
CAFERGOT P.B. the most effective oral medication
for the relief of migraine headache with G. I. disturb-
ance accompanied by tension.
FIORINAL a new approach to therapy of tension
headaches and other head pain due to sinusitis and
myalgia.
Any of our representatives in attendance, will gladly
answer questions about these and other Sandoz prod-
ucts.
W. B. Saunders Company Booth No. 2
Philadelphia, Pa.
Harold Rozema will again be on hand with the com-
plete Saunders line.
Some new titles of special interest include: Tracy:
The Doctor as a Witness; Nadas: Pediatric Cardiol-
ogy; Cecil and Conn: Specialties in General Prac-
tice; Artz and Reiss: Burns; Campell: Urology;
Friedberg: Diseases of the Heart, 2nd edition; Zim-
merman and Levine: Surgical Physiology; Conn:
Current Therapy 1957; and a new edition of the
famous red Dictionary — Dorland.
Schering Corporation Booth No. 6
Bloomfield, N. J.
The Schering exhibit, Booth Space No. 6, presents
the Meti-steroid preparations METIMYD, METI-
DERM, METRETON, SIGMAGEN, METICOR-
TEN and METICORTELONE. Clinical and lab-
oratory data demonstrating the advantages of these
new steroids in topical and systemic therapy of al-
lergic and inflammatory diseases are offered. New
indications for the Meti-steroids are also presented.
G. D. Searle & Company Booth No. 74
Chicago, Illinois
Smith, Kline & French Laboratories Booth No. 19
Philadelphia, Pa.
Featured at the SKF Booth this year are three phar-
maceutical compounds — Compazine, Sul Spansion and
Ecotrin — each of which exemplifies at least one out-
standingly unique therapeutic advantage. Featured
also are Cytomel and Thorazine. Stop at the SKF
Booth; our representatives will be most willing to
give you literature and information.
238
JMSMS
MCI— TECHNICAL EXHIBITS
E. R. Squibb & Sons Booth No. 8
New York, N. Y.
E. R. Squibb & Sons has long been a leader in de-
velopment of new therapeutic agents for prevention
and treatment of disease. The results of our dili-
gent research are available to the Medical Profession
in new products or improvements in products already
marketed.
At Booth No. 8, we are pleased to present up-to-date
information on these ad%»ances for your consideration.
Stuart Company Booth No. 39
Pasadena, Calif.
Swift & Company Booth No. 46
Chicago, 111.
Strained Ham, a unique flavor addition to the va-
rieties of Meats for Babies, is announced by Swift &
Company. The sweet flavor goodness of Swift’s
Premium Ham, ground to a smooth, creamy texture,
is the newest variety of Strained Meats for infants.
See and taste it at the Swift exhibit. You are cor-
dially invited to examine the complete line of these
100 per cent meat products, as well as Swift’s
Strained Egg Yolks and Swift’s* * Strained Egg Yolks
& Bacon for Babies; to discuss with the representa-
tives, Swift’s clinical research program in connection
with meat in the infant diet.
Testagar & Company, Inc. Booth No. 23
Detroit, Mich.
You will be welcome at Testagar & Co., Inc., Booth
No. 23, to receive samples and literature on our new-
est product release, Ascorbacaine Capsules, for pru-
ritus. Ascorbacaine Capsules are a combination of
Oral Procaine, 250 mg., and Ascorbic Acid, 150
mg., per capsule. Several other brand new products
will be shown.
Thompson Recorder Company Booth No. 35
Detroit, Mich.
Peirce Magnetic Belt Dictating equipment is port-
able, the magnetic belt is mailable. Reproduction of
voice, by magnetic recording results in natural repro-
duction, and hence secretaries enjoy typing. Because
of the magnetic principle, men have availability to
rechoose and correct words and phrases and there-
fore send error free dictation to a secretary. Belts are
reusable, 10,000 times.
S. J. Tutag & Company Booth No. 56
Detroit, Mich.
S. J. TUTAG & COMPANY will present the new
Quadamine. Quadamine (Granucap*) is a “timed
disintegration” type capsule containing an appetite
depressant-mood elevator, a mild sedative to coun-
teract central nervous stimulation of amphetamine,
6 essential vitamins and 6 important minerals.
Quadamine is especially designed for use in ( 1 )
obesity, (2) anxiety states and (3) nervous or agi-
tated states.
*Tutag brand of timed disintegration capsule (Pat.
Pend.)
Upjohn Company Booth No. 18
Kalamazoo, Mich.
Members of the medical profession are invited to visit
the Upjohn bohth where members of The Upjohn
Company professional detail staff are prepared to dis-
cuss subjects of mutual interest.
U. S. Vitamin Corporation Booth No. 49
New York, N. Y.
Exhibit features PANTHO-F, a strikingly effective
combination of inflammatory-suppressive hydrocorti-
sone 1% with antipruritic, epithelizing pantothenylol
2% (Panthoderm) . For quick relief of pain, inflam-
mation and itch, and rapid healing of eczemas, der-
February, 1957
matoses, topical ulcers, pruritus, slow healing wounds,
bites, stings, burns, etc. Also available: Pantho-F
0.2% (hydrocortisone 0.2% with pantothenylol 2%).
Professional samples and literature distributed also
on our complete line of nutritional and pharmaceu-
tical specialties.
Wallace Laboratories Booth No. 59
New Brunswick, N. J.
MILTOWN, the original meprobamate, will be fea-
tured at the Wallace Laboratories’ exhibit, booth 59.
It is a type of tranquilizer with muscle relaxing ac-
tion. It is of value in treating anxiety-tension states,
muscle spasm, sleeplessness due to worry and certain
neurological disorders. It is of special interest that
MILTOWN does not have autonomic side effects,
is well tolerated and is essentially non-toxic.
Westwood Pharmaceuticals Booth No. 27
Buffalo, N. Y.
Fostex Cream and Fostex Cake are new, easy to use,
therapeutically effective cleansing-type medications for
the treatment of dandruff, acne vulgaris and sebor-
rheic dermatitis. They contain Sebulytic* a unique
combination of penetrating anionic soapless cleansers
and wetting agents which are highly antiseborrheic,
and exert antibacterial and keratolytic effects.
•Trademark.
Wyeth Laboratories Booth No. 64
Philadelphia, Pa.
Wyeth will feature:
EQUANIL® (meprobamate*), unique anti-anxiety
agent that relaxes mental tension and muscle spasm.
EQUANIL effectively tranquilizes anxious, tense or
psychoneurotic office patients as seen in everyday prac-
tice. It is relatively free from untoward side reactions,
and it is not habit-forming.
PEN. VEE. Oral® (penicillin V), Tablets, the new
acid- stable penicillin that resists destruction by acid
in the stomach. Absorption from the duodenum is
maximal, therefore, blood levels are high. For treat-
ment and prophylaxis of infections caused by penicil-
lin-sensitive organisms.
•Licensed Under U. S. Patent No. 2,724,720.
Zimmer Manufacturing Company Booth No. 45
Warsaw, Indiana
A complete line of Fracture Equipment and Ortho-
pedic Instruments will be on display. Items of spe-
cial interest, BADGLEY NAIL AND PLATE for in-
tracapsular fractures, SCHNEIDER SELF-BROACH-
ING INTRAMEDULLARY PINS, “UNDERWRIT-
ERS APPROVED” EXPLOSION PROOF LUCK
BONE SAW AND BROWN-ELECTRO DERMA-
TOME and STRONG TRACTION APPARATUS
for reduction of Colle’s fracture.
ZIMMER, your guarantee of quality and prompt
service.
Retroperitoneal tumors can attain an enormous size
without causing significant symptoms.
* * *
Troublesome enlarged hemorrhoids and rectal tenesmus
are prominent in patients with presacral neoplasms.
* * *
The ratio of malignant to benign retroperitoneal
tumors was 4 to 1 in a series of 156 such neoplasms.
* * *
Discovery of an abdominal non-tender mass is the
most frequent single sign of a retroperitoneal tumor.
* * -si-
More cancers will be discovered by the widespread
use of a minimum or standard type of examination than
by the restricted use of a more elaborate examination.
239
Michigan’s Department of Health
Albert E. Heustis, M.D., Commissioner
GROUPS MAKE HEALTH RECOMMENDATIONS
FOR 1957-58
Some of the Michigan Department of Health budget
requests for 1957-58 have been appraised by two health
study groups.
Appointed by Governor Williams, a twenty-five mem-
ber Public Health Study Commission has issued a
twenty-three-point report on health and welfare pro-
grams.
A more than 100-member Citizens Public Health Ad-
visory Committee, sponsored by the Michigan Public
Health Association, has evaluated and made recommen-
dations on seven proposals which were chosen by this
group for priority study.
Issues considered by both groups are :
State Aid for Local Health Departments. — Support
is given by both groups to requesting increased state aid
for local health departments from the current level of
$400,000 to $600,000. The $600,000 is cited as a
“basic minimum” needed. The Citizens Committee
urged that the amount requested should be further
increased at the discretion of the State Health Commis-
sioner. The Public Health Study Commission recom-
mended that studies be made of the fund distribution
formula governing state aid for local health departments,
and of the twelve Michigan counties without local health
departments.
Poliomyelitis Vaccine. — Both groups urge that the
Michigan Department of Health be granted funds to
purchase poliomyelitis vaccine for 400,000 persons, in-
cluding children reaching immunizable age, children one
through fourteen years of age who have not been im-
munized. and for persons in other age groups. The
Public Health Study Commission expressed belief that
the State Health Department should look forward to
handling poliomyelitis vaccine in a manner as similar as
possible to the handling given other biologies. Both
groups urged extensive publicity campaigns on polio-
myelitis immunization.
Tuberculosis Post-Sanatorium Care. — The groups sup-
port a proposal which would grant state financial assist-
ance to counties in providing supervised post-sanatorium
care for tuberculosis patients whose return home has
been approved.
Trial Mental Health Programs. — The Public Health
Study Commission recommends that an appropriation
be made for a program aimed toward prevention of
relapse in mental illness to be worked out jointly by
the Michigan Department of Mental Health and the
Michigan Department of Health. The Citizens Public
Health Advisory Committee recommends that funds be
provided through the Michigan Department of Health
for the first year of a three-year demonstration program
to show how public health nursing service can aid men-
tal patients discharged from hospitals to their homes
on a convalescent basis. The Citizens Committee also
urges that supplementary funds be sought from private
sources for this project.
Licensure of Nursing Homes and Homes for the
Aged. — Both groups recommend that funds requested
for this purpose by the Michigan Department of Health
be appropriated as necessary to carry out this service
which is required under law.
Consultant Team Approach in Long-Term Illness. —
As one of a series of recommendations related to long-
term illness, the Public Health Study Commission calls
for unequivocal support through the Michigan Depart-
ment of Health budget for regional traveling consultant
teams which would work with nursing homes to help
provide efficient and high grade care. The Citizens
Public Health Advisory Committee recommends that a
team of workers be provided on the Michigan Depart-
ment of Health staff to help communities and institu-
tions develop effective and co-ordinated programs against
long-term illness.
Air Pollution Control. — A recommendation supported
by both study groups appeals for legislative action to
officially place air pollution control under jurisdiction
of the Michigan Department of Health.
Other Proposals. — The Public Health Study Com-
mission has made recommendations pertaining to chron-
ic disease hospital facilities, training programs for
persons dealing with various aspects of care for the
aged, nursing home care programs, medical care for
the needy and low-income groups, mental health, crip-
pled children, fluoridation, home and traffic accidents,
migrant worker’s health, vocational rehabilitation and
expanded facilities for the training of doctors. Recom-
mendations also were made urging establishment of an
interdepartmental committee of heads of appropriate
state agencies and a task force on the shortage of pro-
fessional health personnel.
The gastric mucosal folds end at the rolled margin of
the carcinoma, while in gastric ulcer they fade out
gradually into the surrounding edematous area.
* * *
The symptoms of bladder involvement by endo-
metriosis are variable and hematuria may not be present.
* * *
Local fulguration or open operation for endometriosis
of the bladder are the treatments of choice. Treatment
must be individualized and planned to meet the patient’s
needs and interest.
240
J.MSMS
Illustration by Hans Elias
Rolicton Diuresis Maintains
Continuous Edema Control
The efficacy of Rolicton (brand of amiso-
metradine) in maintaining diuresis in the ede-
matous patient has been established on an
average dosage of one tablet b.i.d. Larger
doses may be given as initial therapy and as
maintenance therapy in edema difficult to
control. Many patients will respond to one
tablet daily.
“The margin of safety and the diuretic index is
certainly an improvement over the use of oral mer-
curial diuretics.”1
Avoiding “Peaks and Valleys ”
A highly desirable effect, and one which
has been made possible with Rolicton, is the
maintenance of continuous diuretic effective-
ness day after day over an extended period,
to avoid the up-and-down weight pattern
typical of other edema-control methods.
“There was an obvious stabilization of weight
in practically all of the patients under observation,
and previous wide fluctuations in poundage disap-
peared.”2
Mercury-Sparing
Typical of the Rolicton diuresis pattern is
the ability of the drug to reduce and, in a
large percentage of patients, to eliminate the
need for mercurials parenterally.
“. . . the drug represents a most useful addition
to our armamentarium in the treatment of edema,
not only because it can be given orally . . . but more
so because it permits [us] to replace or to spare the
. . . mercurials.”3
G. D. Searle & Co., Chicago 80, Illinois.
Research in the Service of Medicine.
1. Asher, G.: Personal communication, June 23, 1956.
2. Settel, E.: A Clinical Evaluation of a New Oral Diuretic,
Rolicton, Postgrad. Med., Feb. 1957, in press.
3. Goldner, M. G.: Personal communication, June 29, 1956.
SEARLE
February, 1957
Say you saw it in the Journal of the Michigan State Medical Society
241
Legal Opinions
PROVEN
PAIN CONTROL
set/a™
GRADATIONS OF ANALGESIA
with light sedation
‘EMPIRAL’®
Phenobarbital gr. lA
Acetophenetidin gr. 2Vz
Acetylsalicylic Acid gr. 3'/2
*
‘CODEMPIRAL’® No. 2""
n
0 f
Codeine Phosphate gr. ‘A
Phenobarbital gr. %
Acetophenetidin gr. 2V2
Acetylsalicylic Acid gr. 3%
tf
‘CODEMPIRAL’® No. 3
(N)
Codeine Phosphate
Phenobarbital
Acetophenetidin
Acetylsalicylic Acid
gr. Vz
gr. lA
gr. 2Vz
gr. 3^2
(N) subject to Federal Narcotic Law
BURROUGHS WELLCOME & CO. IU.S.A.) INC.
Tuckahoe, N. Y.
Dear Mr. Burns:
You submitted the following inquiry received from a
County Society:
1. “Where does a doctor stand when he makes one
charge for cash, and another for credit? The credit
charges are usually about double and the implication
is that the cash charge is a discount.”
From a legal standpoint, I find no problem. I know
of no legal restriction upon the right of a physician to
fix his charges for services and to give discounts for cash
payments. In the absence of an express agreement be-
tween the physician and patient his charges are subject
only to the test of “reasonableness.”
I assume that my opinion as to the propriety, good
taste or ethics of such practice is not sought and I
therefore express no opinion thereon.
The second inquiry is as follows:
2. “If we expel a man or deny him membership
for ethical reasons, are we liable if we tell the in-
quiring public that he applied for but was denied
membership?”
I assume that the purpose of this inquiry is to ascer-
tain the possible liability for damages for libel, slander
or defamation of character. It is dangerous to generalize
in this area but I think it may be said safely that the
mere statement in answer to an inquiry that “X” has
been denied membership in a voluntary medical society
or that he has been expelled therefrom is not actionable
if such statement is true, is not actuated by malice and
such denial of membership or expulsion has been accom-
plished legally under the by-laws of the society.
From this, however, it should not be implied that it
is safe practice to disclose any and all information upon
which action has been predicated by the society or to
express opinion or make statements with respect to the
reasons therefor. Many statements made within the or-
ganization during the course of proceedings under its
by-laws might have the protection of some degree of
privilege which they would not have if made elsewhere.
The circumstances under which statements that reflect
upon another are made are usually important in de-
termining legal liability therefor.
The law pertaining to libel, slander and defamation
is so complex and confusing that no useful purpose could
be served by attempting a general discussion of it here.
Suffice it to say, therefore, that although I have an-
swered the specific question asked, I recommend that
caution be exercised in applying it to any set of circum-
stances other than the specific circumstances outlined in
the question.
Very truly yours,
Lester P. Dodd,
Legal Counsel
November 6, 1956
* * *
Dear Mr. Burns:
You have referred to me for opinion an inquiry from
a member concerning the scope of the activities in which
the doctor’s receptionist and office assistant may proper-
ly engage in connection with dispensing medication.
Apparently the inquiry was prompted by statements
made to the doctor by an investigator of the State Board
of Pharmacy and concerns itself primarily with whether
or not acts of the employe might constitute violation of
the Pharmacy Act.
Section 14 of the Act (14.736 M.S.A.) makes it un-
lawful for anyone but a registered pharmacist to have
(Continued on Page 244)
242
Say you saw it in the Journal of the Michigan State Medical Society
JMSMS
PATRICIAN
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At a price competitive with low-power,
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full x-ray facilities offered by the General
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Resident Representatives:
FLINT — E. F. Patton, 1202 Milbourne
E. GRAND RAPIDS — J. E. Tipping, 1044 Keneberry Way, S.E.
For demonstration visit our booth at the Michigan State Medical Convention.
February, 1957
Say you saw it in the Journal of the Michigan State Medical Society
243
LEGAL OPINIONS
THE
VERSATILITY
YOU ASKED FOR
THE
ECONOMY
YOU WILL
APPRECIATE
The New BURDICK UT-4
ULTRASONIC
UNIT
The compact new Burdick ultrasonic
unit offers greater mobility and greater economy for
the exacting demands of contemporary practice. The
UT-4 model meets the highest standards of quality
and workmanship for which Burdick equipment is
noted, at a new low price of $395.
Single continuous power
control. Automatic timer
switch.
Receptor switch permits
pre-setting the dosage be-
fore treatment.
Double-Scale Meter regis-
ters both intensity and total
output.
Right-angle applicator for
convenience and efficiency.
Ask your Burdick dealer for demonstration
THE G. A. INGRAM COMPANY
4444 Woodward Avenue, Detroit 1, Michigan
(Continued from Page 242 )
charge of, engage in or carry on for himself or for an-
other, the dispensing, compounding or sale of drugs,
medicines or poisons.
Section 18 of the Act (M.S.A. 14.740) provides that
nothing in this Act shall apply to the practice of a
practitioner of medicine who is not the proprietor of a
drug store, and shall not prevent practitioners of medi-
cine from supplying their patients with such articles as
they may deem proper.
Section 30 of the Act (M.S.A. 14.752) provides that
nothing in this Act shall be construed to interfere with
or preclude any legally practicing physician from pre-
scribing, dispensing, compounding or giving any medi-
cines or poisons to his patients in the regular course of
his practice as such physician.
If I correctly understand the status of the employe
referred to the doctor, she is not a registered nurse, a
licensed practical nurse, or licensed trained attendant
and therefore occupies the status of a lay employe such
as is referred to in an opinion by Attorney General
John R. Dethmers (now Chief Justice of the Michigan
Supreme Court), No. 0-4669, July 1, 1946. In that
opinion, the Attorney General held that an office girl
may, on a physician’s orders and instructions, deliver
medicines or drugs to patients but may not dispense
drugs or fill prescriptions. I am in accord with this
opinion and believe that if the employe merely delivers
to the patient medicines or drugs out of the doctor’s
supply which have been ordered by the doctor, she has
not violated the provisions of the Pharmacy Act. In
short, I do not agree with the investigator’s quoted
statement that: “only a registered pharmacist can pour
medicine from a bottle into an envelope.”
Caution, however, should be observed in the applica-
tion of the aforegoing opinion to insure that it is not
extended to include acts of the employe beyond the
handing out of specific drugs or medicines on the specific
orders of the physician. For instance, as was pointed out
in the Attorney General’s opinion above referred to, if
the employe were to give a specific drug or medicine to
a patient upon the doctor’s order, and the patient were
to return later saying that he or she had exhausted the
supply, the employe would not be privileged to refill the
order as such would require the exercise of judgment as
to whether or not additional medication were necessary
or proper.
Similarly, I believe that it would be improper for the
employe to be entrusted with compounding drugs and
in effect filling a physician’s prescription. Such would
necessarily require a knowledge of and constitute the
practice of pharmacy. This is obviously prohibited by
the statute.
Very truly yours,
(signed) Lester P. Dodd
October 23, 1956
STERILIZATION OF URETERAL CATHETERS
(Continued from Page 195)
References
1. Queries and Minor Notes: Sterilization of cath-
eters. J.A.M.A., 144:211, 1950.
2. Kiefer, J. H,, and Mitch, M.: Sterilization and
storage of catheters. J. Urol., 57:945, 1947.
3. Queries and Minor Notes: Sterilization of cysto-
scopes and ureteral catheters. J.A.M.A., 74:1536,
1920.
4. Roth, R. B. ; Kaminsky, A. F. ; and Hess, E.: Bac-
teriacidal additive for pyelographic media. J. Urol.,
74:563-566, 1955.
100 Maple Street
Parchment, Michigan
Submitted for publication April 13, 1956.
244
Say you saw it in the Journal of the Michigan State Medical Society
JiMSMS
Cool comfort for hot itching dermatoses
[hydrocortisone-calamine lotion a cream)
There’s no waiting for relief when you prescribe
HYDROBALM for patients with inflammatory and
pruritic dermatoses. In a matter of seconds
HYDROBALM suppresses distressing symptoms,
hides unsightly lesions, and sets the stage for
healing. HYDRO BALM — Cream or Lotion — presents
in two convenient, delicately scented, water-
washable flesh-tone greaseless vehicles, A thera-
peutically proved agents : ‘Hydrocortone’ (Hydro-
cortisone, U.S.P.) — 0.5% — to suppress inflamma-
tion. Calamine— 8% — to soothe and protect inflamed
skin. Benzocaine — 3% — to relieve itching and pain.
Hexylated Metacresol — 0.05% — for antisepsis.
Supplied : Topical Lotion HYDROBALM — in 15-cc. and 30-cc. handy, purse-size, plastic squeeze
bottles. Topical Cream HYDROBALM— in 5-Gm.. 15-Gm. and 30-Gm. tubes.
MERCK SHARP & DOHME
DIVISION OF MERCK a CO., INC.. PHILADELPHIA 1. PA.
February, 1957
Say you saw it in the Journal of the Michigan State Medical Society
245
the
new
B I RTC H E R
cervix
conization
electrodes
designed to meet the
HAWKINS* technic
Built by Birtcher of the finest materials to ex-
actly meet the requirements of the technic of
M. C. Hawkins, Jr., M.D., of Searcy, Arkansas,
described in his paper "Re-Evaluation of Coniza-
tion of the Cervix," published in Southern Medi-
cal Journal.
* Described in his paper which will be sent on request
NOBLE-BLACKMER, INC.
267 W. Michigan 28148
Jackson, Michigan
Frederick B. Ashton, M.D., one of Highland Park's
first doctors died in early December after a long ill-
ness. A native of Ontario, he graduated from the
Detroit College of Medicine in 1908 and became a
member of Highland Park General Hospital staff.
Ruel N. Dunnington, M.D., of Benton Harbor, died
at the age of seventy-four of a heart attack as he pre-
pared to answer a patient’s call. A past president of the
Berrien County Medical Society, he had practiced in
Benton Harbor since 1919. shortly after his graduation
from Northwestern University School of Medicine. In
1933, he was appointed district governor of the affiliated
Exchange Clubs of Michigan and in 1942 was honored
by Northwestern University with an alumni sendee
award.
James Henry, M.D., Grand Rapids physician for
fifty-four years died Nov. 7, 1956, at the age of
ieventy-nine. A member of the Kent County Medical
Society and an emeritus member of MSMS, Dr. Henry
was a life resident of Grand Rapids and a graduate of
University of Michigan Medical School in 1900. He
practiced general medicine until his retirement two years
ago.
Robert E. Mills, M.D., a practicing physician in
Boon since 1902, died in October at Cadillac Mercy
Hospital following a long illness. He was eighty-two.
Dr. Mills retired in 1946 after practicing in Boon since
his graduation from Saginaw Medical School. He was
a member of AMA and MSMS and an active member
of the Boon Baptist Church.
Kenneth B. Moore, M.D., age fifty-one, died follow-
ing a heart attack at his home on November 3, 1956.
Dr. Moore was a former City Health Officer and der-
matologist following postgraduate work at his school of
graduation, University of . Michigan Medical School.
He was a native of Columbiaville and came to Flint
forty years ago.
Harry A. Sibley, M.D., seventy-four, of Pontiac,
died on July 10, 1956, following a long illness. At
time of retirement in 1953, he had been in active prac-
tice longer than any other living physician. A graduate
of University of Michigan Medical School in 1907, he
was a life member of AMA, MSMS and the Oakland
County Medical Society, of which he was past presi-
dent. He served on the Board of Education and was at
one time school physician.
(Continued on Page 248)
246
Say you saw it in the Journal of the Michigan State Medical Society
JMSMS
Now available ... a new manual . . .
“Vegetable Oils in Nutrition”
Timely, Comprehensive, Useful ... with special reference
to unsaturated fatty acids
TIMELY . . . a summary of the literature in
this important field
COMPREHENSIVE . . . a review of au-
thoritative experimental and clinical research
pertaining to the special metabolic roles of
polyunsaturated fats
USEFUL ... in a form suitable for continual
reference use. Valuable to clinician, nutritionist,
chemist. Bibliography listing all pertinent pub-
lications
The role of dietary lipids in health and disease
is universally assuming new importance. Evi-
dence is accumulating that quality of the dietary
fat may be more important than quantity.
This review provides a broad perspective on
current authoritative and clinical opinions
regarding the relative dietary characteristics of
saturated and unsaturated fats . . . and the
indispensable nutritional role of polyunsatu-
rated fatty acids.
Corn Products Refining Company, the man-
ufacturer of Mazola corn oil, will keep you
informed of significant new developments in
this rapidly expanding field.
Mazola is a vegetable oil
(not hydrogenated) made
from com. It is unsaturated
... a prime source of essen-
tial linoleic acid.
ORDER YOUR COPY NOW...
Medical Department
Corn Products Refining Co.
17 Battery Place, New York 4, New York
Please send me, postpaid, the new reference manual
and monograph on “Vegetable Oils in Nutrition.”
Name.
Address.
City-
State.
February, 1957
Say you saw it in the Journal of the Michigan State Medical Society
247
IN MEMORIAM
ACETYLCARBROMAL tablets
• Proved safe and effective by 6 years’
clinical use.
• Soothes the central nervous system,
produces calmness without hypnosis.
• Non-toxic, non-cumulative, non-addict-
ing, no known contraindications.
• Does not impair mental or physical
function.
® Orally effective within 30 minutes for
sustained action up to 6 hours.
• Economical.
Indications: Tension, nervousness,
anxiety and muscular spasm.
Supplied: White round tablets
Acetylcarbromal 5 gr. in bottles
of 100, 1000.
Write for samples and literature
There’s Always A Leader
MALLARD, inc
3021 WABASH, DETROIT 16, MICHIGAN
(Continued from Page 246)
Harvey Spencer, M.D., fifty-nine, associate psychi-
atrist at the University of Michigan Health Service,
died following surgery in Boston in early July. He re-
ceived his medical degree from Harvard in 1924 and
served on that faculty from 1927 to 1938 and later
on the staff of the Harvard School of Public Health.
He was a member of the Tufts Medical School staff
from 1941 to 1943. He was a member of the Ameri-
can Psychiatry Association and the Michigan Society
of Neurology and Psychiatry.
■* * *
Lewis R. Way, M.D., fifty-eight, prominent Traverse
City physician and member of Munson Hospital staff,
died on July 9, 1956. He had practiced in Traverse
City since 1922 and had been active in medical, social
and political circles. He served as county chairman
for the Republican party. Dr. Way attended the Uni-
versity of Michigan and received his medical degree
from Northwestern University. He was a veteran of
two wars, serving in the army medical corps in World
War II, accompanying the invasion forces into France.
* * *
Carl V. Weller, M.D., of Ann Arbor, a member of
the University of Michigan Medical School faculty
and a nationally known pathologist, died in early De-
cember of a heart attack at the age of sixty-nine. A
faculty member since 1911, Dr. Weller was chairman
of the Department of Pathology from 1931 to 1936.
He specialized in three fields of research- — -lung cancer,
mustard gas and the biologic aspects of aging. He
served as president of the American Association of
Pathologists and Bacteriologists, the American Society
for Experimental Pathology, the International Academy
of Pathology, and the Michigan Pathological Society.
Dr. Weller’s son, Thomas, received the Nobel Prize for
medicine in 1954.
Never give hormones before doing a D and C and
biopsy of the cervix in the presence of irregular bleed-
ing. For these simple procedures, there is no substitute.
By following this plan, the number of times one fails to
find cancer of the cervix will be reduced.
* * *
Every cervical or uterine polyp must be considered
malignant until proven benign.
* * *
The development of a general biochemical screening
test for cancer will not change the essential need for
the competent physician’s examination to locate and
treat the cancer indicated by the test.
* * *
The incidence of cancer in patients with chronic
cystic mastitis is ten to twelve times greater than in
those with normal breasts.
* * *
It is probably wise not to give estrogen in high dosage
to women of or above forty years of age if they have
a family history of breast cancer.
* ■* *
On physical examination of the breast, gentleness is
the keynote in all approaches.
* * *
Any breast mass in a mature woman calls for careful
appraisal by the family physician.
248
Say you saw it in the Journal of the Michigan State Medical Society
J.MSMS
new physiologic iron chelate lor
hematologic
maximum
JHP»j
zm
IMH
i
timil
m
HKHSMHI
A
response — avoids interruption of
therapy due to g. i, irritation
—guards against iron
poisoning from accidental overdosage
FERROLIP-
(Iron Choline Citrate*)
for the clinical and
experimental proof, write for
complete literature
chelated iron for effectiveness
plus “built-in” tolerance and safety
TABLETS— 3 tablets supply 120 mg. of iron DROPS-Each cc. provides 16 mg. of iron
and 360 mg. of choline base. Adults: 1 or 2 and 48 mg. of choline base. M.D.R. for in-
tablets t.i.d.: Children, 1 tablet t.i.d. fants and children up to 6 years is 0.5 cc.
SYRUP- 6 teaspoonfuls supply 120 mg. of Supplied: Tablets: Bottles of 100 and 1000;
iron and 360 mg. of choline base. Adults: 2 Syrup: Pints and gallons; Drops: 30-cc.
to 4 teaspoonfuls t.i.d.: Children, 2 tea- dropper bottles,
spoonfuls t.i.d.
EATON A COMPANY
*U. S. Pal. 2.575.61 1
February, 1957
Say you saw it in the journal of the Michigan State Medical Society
249
NEWS MEDICAL
MICHIGAN AUTHORS
Mathew Alpern, Ph.D. and J. Reimer Wolter, M.D.,
Ann Arbor, are the authors of an article entitled “The
Relation of Horizontal Saccadic and V Vergence Move-
ments,” published in A.M.A. Archives of O phthalmology
for November. 1956.
Alfred Jay Bollet, B.S., M.D., is the author of an
article entitled “Present Knowledge of Ground Sub-
stance and Its Relationship to the ‘Collagen Diseases,’ ”
published in the Wayne State University College of
Medicine Bulletin, Volume 3, Number 3.
C. Paul Hodgkinson, M.D., Detroit, is the author of
an article entitled “Hypofibrinogenemia and Obstetric
Hemorrhage,” published in the Journal of the Arkansas
Medical Society, December, 1956. This paper was de-
livered at the eightieth annual session of the Arkansas
Medical Society.
Vance Fentress, M.D., Paul Firnschild, M.D., and
William S. Reveno, M.D., Detroit, are the authors of
an article entitled “Perforated Duodenal Ulcer Com-
plicating Prednisone Therapy,” published in the New
England Journal of Medicine, and condensed in the
American Practitioner and Digest of Treatment, Decem-
ber, 1956.
Ivan B. Taylor, M.D. and Edward W. Crawford,
M.D., Detroit, are the authors of an article entitled
“Anesthetic Management of Patients in Poor Physical
Condition,” presented before the Thirtieth Congress of
Anesthetists, and the annual meeting of the members of
the International Anesthesia Research Society, Florida,
April, 1956, and published in Current Researches in
Anesthesia and Analgesia, November-December, 1956.
J. S. DeTar, M.D., Milan, is the author of an article
entitled “The Generalist, the Hospital and the A.M.A.,”
presented at the Eighty-sixth Annual Session of the
Colorado State Medical Society, September, 1956, and
published in the Rocky Mountain Medical Journal,
December, 1956.
Richard H. Meade, M.D., Grand Rapids, is the
author of an article entitled “Some of the Forgotten
Men in the Field of Thoracic Surgery,” published in
the Journal of Thoracic Surgery, August, 1956.
Richard H. Meade, M.D., Grand Rapids, is the
author of an article entitled “The Story of the Develop-
ment of Surgery for the Patent Ductus Arteriosus,”
published in Surgery, October, 1956.
* * *
The Academy of Medicine of Cincinnati cordially
invites all physicians, their families, and their patients
to its 100th Birthday Party, February 27 through March
5, 1957. In order to officially observe the occasion, a
Health Museum and Exposition will be established in
Cincinnati’s spacious and historic Music Hall. One
hundred and seventy-five health and scientific exhibits,
representing medicine, hospitals, research centers, public
health, nursing, pharmacy and industry will be displayed
in the north and south halls. Notable among these
exhibits and occupying some 4,000 square feet of space,
will be an atomic energy exhibit from the American
Museum of Atomic Energy entitled “Atoms for Peace.”
In the main foyer of the hall, “Juno,” a full-sized,
activated manikin, graciously loaned for the occasion
by the Dominican Republic, will be on display. Juno
is operated electrically, and with concurrent recorded
narration, will demonstrate blood vessels, bones and or-
gan structures of the body.
Dr. Paul D. White and Dr. Walter Alvarez, noted
medical scientists and authors, have accepted invitations
to be among the distinguished guest speakers.
* * *
Rehabilitation Institute of Metropolitan Detroit
Courtesy of Albert Kahn Associated Architects and
Engineers, Inc., Detroit, Michigan.
The formal ground-breaking ceremony for the Re-
habilitation Institute of Greater Detroit took place on
December 4. 1955, at Harper Hospital. Among the
distinguished persons present was Senator Charles E.
Potter, who was the guest speaker. The Senator ex-
pressed his sentiments: “This building symbolizes need
which lies deep in the heart of each one of us: to be
useful and to be recognized by our fellow human
beings as useful. No one, I believe, recognizes the im-
portance of this need more clearly than the President
when he said this about our Vocational Rehabilitation
Laws. ‘It re-emphasizes a great value which we in
America place upon the dignity and the worth of these
individual human beings. It is a humanitarian invest-
ment of great importance.’ And we in Detroit repeat
those words for all the world to hear.”
(Continued on Page 252)
250
JMSMS
©1930 Mead Johnson & Co.
Newest Pablum Cereal
is 35% Protein
Pablum High Protein Cereal is derived from soy beans,
oats, wheat and dried yeast. This new cereal food contains
a level of active assimilable protein, 35%, much higher than
that commonly present in cereal grains. It helps to keep
baby trim. It satisfies baby’s hunger over longer periods of
time than even foods rich in carbohydrate.
Like all Pablum Cereals, Pablum High Protein Cereal
is made by nutritional and pharmaceutical specialists.
You can specify
with confidence !
PaMwn/fWucIi
DIVISION OF MEAD JOHNSON & CO., EVANSVILLE, INO. • Manufacturers of Nutritional and Pharmaceutical Products
February, 1957
Say you saw it in the Journal of the Michigan State Medical Society
251
NEWS MEDICAL
for modern
control of
salt retention
edema
CUMERTIUN*
(Brand of Mercumatilin, Endo)
Tablets
• effective oral diuretic with no sig-
nificant gastrointestinal irritation1
• Suitable for long-term mainte-
nance therapy.
• eliminates need for injections ir
certain cases, lengthens interval
between injections in others
• basically different in chemical
structure, extending the therapeu-
tic choice in organic mercurials
DOSAGE: 1 to 3 tablets daily as required.
SUPPLIED: As orange tablets, in bottles
of 100 and 1000. Also available —
CUMERTIUN Sodium Injection, 1- and 2-cc.
ampuls, in boxes of 12, 25, and 100; and
10-cc. vials, individually and in boxes
of 10 and 100.
1. Pollock, B. E., and Pruitt, F. W.: Am. J M
Sc., 226:172, 1953.
THE G. A. INGRAM COMPANY
4444 Woodward Avenue, Detroit 1, Mich.
(Continued from Page 250)
Carl V. Weller, M.D., Chairman of the Department
of Pathology, University of Michigan, and Editor-in-
chief, American Journal of Pathology, on retirement
leave from the University, died December 19, 1956,
in Ann Arbor.
* * *
LAWRENCE REYNOLDS, M.D.,
DETROIT RADIOLOGIST,
AWARDED GOLD MEDAL
Lawrence Reynolds, M.D., Radiologist and Chief of
of the Department of Radiology. Harper Hospital, De-
troit, receives congratulations from Dr. Clarence R.
Hufford (right), Toledo, Ohio, President of the Radio-
logical Society of North America, following presenta-
tion of the Society’s Gold Medal to Dr. Reynolds.
Fellow Detroit radiological colleague, Howard P. Doub,
M.D. (left) assists in bestowal of the coveted medal,
awarded annually by the Society to outstanding mem-
bers of the radiological specialty. Dr. Reynolds and Dr.
Doub are both editors of the two leading scientific
journals in radiology. The Journal of Roentgenology,
Radium Therapy and Nuclear Medicine, is edited by
Dr. Reynolds; the Journal of Radiology by Dr. Doub.
* * *
The Board of Regents of the University of Michigan
on December 14 reported several grants for medical
research, mostly in the Public Health Department. The
National Advisory Council, Health Research Foundation
of the Department of Health, Education and Welfare,
announced the grant of three sums for construction and
equipment of facilities at the University of Michigan.
First was $605,000 on a matching fund basis to pro-
vide additional facilities of about 33,000 square feet
of new space for the School of Public Health.
The Kellogg Foundation the same day announced
a similar matching grant to complete the construction.
There will be 4,000 feet added to the Department of
Environmental Health, 10.000 to the Department of
Epidemiology, 2,000 to Public Health Statistics, 5,000
to the Department of Public Health Practice and 12,000
(Continued on Page 254)
252
Say you saw it in the Journal of the Michigan State Medical Society
JMSMS
Trasentine-
c I B A
Summit, N. J.
integrated relief . . .
mild sedation
visceral spasmolysis
mucosal analgesia
TABLETS (yellow, coated), each containing
50 mg. Trasentine ® hydrochloride (adiphenine
hydrochloride CIBA) and 20 mg. phenobarbitaU
2/2228M
February, 1957
Say you saw it in the Journal of the Michigan State Medical Society
253
NEWS MEDICAL
CAMBRIDGE
AUDIO-VISUAL "SIMPLI-SCRIBE"
HEART SOUND DIRECT WRITING
RECORDER ELECTROCARDIOGRAPH
A Logical Combination
The Cambridge Audio-Visual Heart Sound Recorder
is a radically new portable instrument which enables
the Doctor to HEAR, SEE and permanently RECORD
heart sounds — simultaneously.
Heart sounds, picked up by the microphone, are
amplified to any desired degree for auscultation. The
Physician hears the heart tones faithfully reproduced
through an electrical stethophone fitted with bin-
aural ear pieces similar to those he is accustomed
to using. The heart sounds being heard are simul-
taneously visible upon the long persistence screen of a
three inch cathode ray tube.
Any portion of the heart sounds may be permanently
recorded upon paper-thin magnetic discs that may be
filed with the patient's history or mailed to a consultant.
They may be “played-back” (both heard and viewed)
at any time for review, study or consultation.
The Cambridge “Simpli-Scribe” Model is a direct
writing, portable electrocardiograph. When used in
combination with the Audio-Visual Recorder, the
electrocardiogram from the “Simpli-Scribe” may be
viewed upon the cathode ray screen of the Recorder
while listening to the heart sounds, or the electro-
cardiogram may be superimposed upon the heart sound
trace for timing complex cases.
Now the Physician, Hospital or Clinic has available a
pair of complementary instruments making possible
more rapid, accurate and complete diagnosis of heart
disease.
Send for Bulletin 18S
CAMBRIDGE INSTRUMENT CO., Inc.
3732 Grand Central Terminal, New Yor!< 17, N. Y.
Chicago 39, 4000 West North Avenue
Philadelphia 4, 135 South 36th Street
Cleveland 15, 1720 Euclid Avenue
Detroit 2, 7410 Woodward Avenue
254
Say you saw it in the Journal of the
(Continued from Page 252)
to the Department of Research in Industrial Hygiene
and Safety, including toxicology and industrial waste.
$58,522 is provided to remodel the seventh floor of
the research building, and $600,000 for a new structure
for research laboratories.
* * *
The Public Health Service in Washington. D. C., on
Thursday, December 13, 1956, announced a grant of
$900,000 on a 50/50 matching basis to Wayne State
University to help build a new eight-story addition
to the present College of Medicine building for pur-
poses of research. These grants are all part of a $24,-
000,000 appropriation made by the last Congress.
* * *
Soviet Doctors. — An American correspondent in
Moscow reports the Russians are increasing the num-
ber of doctors they now graduate 23.000 per year. The
official count is 330,000, or one to every 600 people,
and they believe there should be one for every hundred.
The state pays for the education, provides meals in
huge dormitories, even in vacation t;me; also helps
in clothing and and quarters for most of the students.
Nearly ninety per cent of the doctors now are women,
mostly the products of wartime training; however, in
some of the medical institutes today women account
for only 60 per cent.
Russian doctors are all government employees. Pay
starts at 400 rubles a month ($100) and for a direc-
tor's position may be as high as 4800 rubles a month.
Most doctors, in addition, get free housing and other
items from the government.
* * *
Blue Cross is the subject of a new study. U nited
States Review (November 24, 1956) reports the forma-
tion of a special subcommittee by the National Associa-
tion of Life Underwriters. Its assignment will be to
study the need for more effective regulation of Blue
Cross-Blue Shield and similar plans by the insurance
departments of the state.
■* * *
The Air Force reports that since July 1, 1956, 191
of its officers have entered residencies in various special-
ties, all but twenty-six of them in civilian hospitals.
The Air Force has need of more doctors in the special-
ties.
* * *
Surgeon-General Leroy Burney of the U. S. Public
Health Service is making a fresh plea to all doctors to
increase the use of poliomyelitis vaccine. Only four
states used all their free allotment— Illinois. Kansas,
North Dakota, and Vermont. The vaccine is now ac-
cumulating and is in sufficient supply to care for nearly
all who may wish it.
*■•*■*•
Medical care costs up during third quarter of year.
Over-all medical care costs for U. S. families rose
1.5 per cent during the third quarter of 1956. according
to a U. S. Bureau of Labor Statistics study. But fees
charged by physicians in the three-month period ending
(Continued on Page 256)
JMSMS
Michigan State Medical Society
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February, 1957
Say you saw it in the Journal of the Michigan State Medical Society
255
NEWS MEDICAL
(Continued from Page 254)
in September increased only 0.8 per cent. The over-
all cost of living increased 0.7 per cent. Medical care
costs, when drug costs were excluded, increased 0.9
per cent. Other changes in the cost of living index in-
cluded: general practitioners’ fees, up 0.8 per cent:
obstetrical care, up 1.7 per cent; prescriptions and
drugs, up 0.7 per cent, and dentists fees, 0.16 per cent.
Important factors in the rise in medical care costs
were a 3.2 per cent increase in hospital rates and a
3.9 per cent rise in Blue Cross fees.
* * *
Councilor’s Letter. — Over a period of years, a gradu-
ally developing change has taken place in the jour-
nalism business which I think deserves some serious con-
sideration on the part of the medical profession. It
brings to mind an old adage, time-worn but true, “a
little knowledge is a dangerous thing.”
The general public is not too well trained medically
and cannot, therefore, interpret medical information
correctly, but in recent years the public press has carried
more and more stories of the results of medical research
which have been immaturely released. These stories
obviously, will do more harm than good. The lay press
dramatically develops the information to a point allow-
ing the public to assume that a miraculous cure has been
developed, only to find later that the “balloon exploded.”
One good example was the immature publicity given
the Salk vaccine. The Michigan State Medical Society
was severely criticized in the newspapers for attempting
to block the release of the vaccine before it had been
properly proven. Later facts justified our stand; ulti-
mately the vaccine was made safe and has now been
in use for some time.
Periodically, we are informed in the newspapers and
magazines of new cures for cancer which were later
found to be entirely ineffective. “Pills to replace insulin
in diabetes” was given great publicity about a year ago.
After from six to eight months of clinical trial, it can
now be shown that very little benefit can be derived
from these pills. Yet, the public was led to believe that
the mouth treatment of the disease had already been
discovered. We are all familiar with many other exam-
ples of this same bad publicity in the lay press.
In recent years much publicity has been given local-
ly to the fact that certain patients had received heart
and brain surgery with dramatic improvement. This
bad publicity has gone so far that the patient’s name
is even printed in the press. We all know that heart and
brain surgey of the types to which I am referring are
still in the experimental stage, yet they give false hopes
to many people.
In my opinion, this is very bad journalism and very
poor ethics on the part of the physicians who see to it
that the reporter gets the story. — William M. LeFevre,
M.D.. Councilor, 11th District. Muskegon County Medi-
cal Society Bulletin, December, 1956.
* * *
( Continued on Page 258)
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256
Say you saw it in the Journal of the Michigan State Medical Soci ,
ety
J.MSMS
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APPARATUS
February, 1957
Say you saw it in the Journal of the Michigan State Medical Society
257
NEWS MEDICAL
(Continued from Page 256)
The Air Force expects to award the first contract in
December for construction of a new Aero Medical
Center, an $8.8 million project scheduled for completion
at the end of 1958. The center will house the School
of Aviation Medicine which is now being operated at
Randolph Air Force Base in Texas and Gunter Air
Force Base in Alabama. The new facility will be located
at Brooks Air Force Base, San Antonio, Texas.
First construction contracts will provide for an aca-
demic building, flight medicine laboratory, research
laboratory shops and supporting facilities. Contracts for
an altitude building and research building will be
awarded early in 1957.
The Air Force comments: “Establishment of this
single areo medical center will allow the Air Force
to conduct more extensive research into the medical
aspects of supersonic flight problems, and to provide
greater aviation medicine teaching facilities than are
now available. Emphasis will be placed on develop-
ing means of protecting fliers at the high speeds and
altitudes which are now encountered or expected to be
in the future.”
•*■*■*■
Selective Service plans to call up 450 physicians next
February, 250 of them for the Army and 200 for the
Air Force. This is the largest single call since the
Army, Navy and Air Force took 1,275 men in March,
1955. The following month Congress started hearings
on the doctor draft extension bill. The act is scheduled
to expire next July 1, and the Defense Department has
indicated it would not ask for another extension. The
draft call prior to the latest one was for 300 men in
October. Other calls this year were 297 in February
and 380 in July.
In announcing the call, Selective Service directed
local boards to comb their files to make sure that
younger Priority 3 physicians in residency training who
have been deferred are really essential to the operation
of hospitals. Some of these, said Selective Service, are
not essential but are so classified. “It is hoped that
there is yet time to get a sufficient number of younger
men reclassified into class 1-A to satisfy these proposed
calls without going into the upper age bracket,” a mem-
orandum to boards stated. By younger men, Selective
Service means those under thirty-seven years of age.
Since the program went into effect in 1950 at the
time of the Korean War, the special draft has brought
10,337 physicians into the services.
* * *
The Eighth Annual Discussional was held on the
University campus at Ann Arbor, December 8, 1956.
The medical directors of forty of the largest industrial
organizations of the United States and Canada were
present. It is conducted by the University’s Institute
of Industrial Health and the School of Public Health.
The use of the tranquillizing drugs in industry brought
(Continued on Page 260)
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258
J.MSMS
TESTED
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No one understands
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in a chosen work. The unmatched
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There are many short periods of time
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and the minutes during which a patient consumes oxygen in
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with complete confidence, it is wise to consider another important
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Sanborn
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February, 1957
Say you saw it in the Journal of the Michigan State Medical Society
259
NEWS MEDICAL
(Continued from Page 258)
criticism, and is leading to extended research. Y\ hat
tranquillizers will do to initiative is of vast importance.
James G. Miller, M.D., Director of the Mental Health
Research Institute, warns that about one American out
of twenty has one of these drugs every month. They
are even being dispensed by druggists without a pre-
scription. John H. Sheldon, M.D., Chief of Allergy,
cautioned about indiscriminate use of penicillin and
the danger of establishing sensitivity with consequent
reactions and loss of time. He cautioned that aspirin
also may cause allergic reactions. Hypertensive persons
may experience dizzy spells as a result of control drugs
and should not be responsible for operating machinery
where other persons are involved, nor should they be
permitted to work at jobs where extreme heat or physi-
cal labor tend to bring on dizziness, according to Sibley
Hoobler, M.D., head of the Hypertensive Unit.
The 40 medical directors attending the Discussional
represented such firms as General Motors Corporation,
Ford Motor Company, Chrysler Corporation. United
States Steel Corporation, Lever Brothers Ltd. of Canada,
Aluminum Company of America, Tennessee Valley
Authority, United Mine Workers of America, Canadian
Medical Institute, Wyandotte Chemical Company. Pru-
dential Insurance Company, Standard Oil Company,
and Inland Steel Company.
Ciba Citation. — The American Medical Association
at its Tenth Annual Clinical Meeting in Seattle, Wash-
ington. cited CIBA Pharmaceutical Products, Inc., for
service to the medical profession through its presenta-
tion of the national television series, MEDICAL HORI-
ZONS.
* * *
The Sixth International Congress on Ophthalmology
will be held in Washington, D. C., May 5 to 10, 1957.
The Pan-American Association of Ophthalmology will
hold its Fourth Interim Session in New York in con-
junction with the National Association for the Preven-
tion of Blindness, April 7 to 10, 1957.
The American College of Surgeons will hold a sec-
tional meeting in Toronto, March 25 to 27, 1957.
The International College of Surgeons, United States
Section, will hold its Mid-Atlantic Division meeting
February 10 to 13, 1957, at White Sulphur Springs,
West Virginia.
* * *
A history of the Medical Society of the State of
New York is now being prepared for publication. Several
states have published such volumes — Michigan, Florida,
Illinois.
* * *
The National Foundation for Infantile Paralysis has
announced another post doctoral training program with
March 1. 1957. as the last day for registration. Those
( Continued on Page 262)
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Phone: BRoadway 3-5403
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260
Say you saw it in the Journal of
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JMSMS
Michigan State Medical Society
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February, 1957
Say you saw it in the Journal of the Michigan State Medical Society
261
NEWS MEDICAL
ST. JOSEPH’S RETREAT
Member: American Hospital Association
Catholic Hospital Association
National Association ol Private
Mental Hospitals
The Central Neuro-Psychiatric
Hospital Association
Under the direction of the
Daughters of Chanty of St. Vincent de Paul
Serving Metropolitan Detroit
and Michigan almost a century
Martin H. Hoffmann, M.D.
Medical Director
23200 West Michigan Avenue
Dearborn
Logan 1-1400
(Continued from Page 260)
interested should contact their professional educational
committee. Fellowships are available in rehabilitation,
psychiatry, orthopedics, management of poliomyelitis,
preventive medicine, research or academic medicine.
* * *
Roger W. Howell, M.D., has been appointed head
of the Division of Preventive Psychiatry at the Lafayette
Clinic. He will be responsible for investigating commu-
nity resources in the school, public health and indus-
trial areas for the prevention of emotional illnesses.
He will integrate these investigations with, and teach
and conduct research problems at the Lafayette Clinic
and the Wayne State University College of Medicine.
Dr. Howell was born and educated in Ann Arbor,
Michigan. He was certified by the American Board of
Neurology and Psychiatry in 1945.
* * *
Maternal Health. — The Council on Medical Service
of the AMA has published in The Journal of the Amer-
ican Medical Association a six-part report of a very
extensive study on maternal mortality, two sections of
the report being devoted to research in Michigan. In
the December 8, 1956, issue there were five pages detail-
ing information developed through the Michigan State
Medical Society’s committee in co-operation with the
State Department of Health and the Wayne County
Committee. In the issue of December 29, 1956, much
the same groups were represented in the study, but
this time the work in Wayne County received the
emphasis. This again was given five pages in the
J.A.M.A. These reports contain an enormous amount
of very interesting material, and are well worth careful
reading by all members interested in maternal health
problems.
■*■•*■*
Tuberculosis case rates in Mich-
igan point up the fact that the
disease continues to be a problem
in the heavily populated areas.
Figures taken from the new edi-
tion of Tuberculosis in Michigan
show that Wayne County with 37
per cent of Michigan’s population
concentrated in 1 per cent of the
state’s area reported 61 per cent
of all new TB cases in Michigan in 1955. All of
Michigan’s largest cities had higher rates than the
counties in which they are located.
High case rates, however, were not limited to the
population centers of the state. Alger with less than
10,000 residents had the highest county case rates.
Baraga County ranked a close third behind Wayne.
Luce County was fourth. But these three Northern
Peninsula counties reported a combined total of forty-
two new cases of tuberculosis in 1955, compared with
Wayne’s 3,375.
* * *
The Institute for Hospital Public Relations is being
conducted by the Michigan Hospital Association, The
University of Michigan, Michigan Hospital Service,
and Blue Cross. It met in Ann Arbor, December 14, 1956,
with forty-five administrators and public relations offi-
262
J.MSMS
NEWS MEDICAL
cials in attendance. John S. DeTar, M.D., immediate
past president of the American Academy of General
Practice, was a principal speaker. He stressed that the
most important unsolved problem in interrelations be-
tween hospitals and doctors, is proper integration, with
general practitioners being given better acceptance than
has prevailed in the past.
* * *
On March 15, 1957, at the University of Louisiana
auditorium there will be a Symposium on Human
Nutrition, sponsored by the AM A Council on Foods and
Nutrition. Speakers will include outstanding men in
nutrition, biochemistry, pediatrics, heart disease and
allied fields. No Michigan men are listed.
* * *
Approval of the two-year Residency Program in Gen-
eral Practice at the U. S. Army Hospital, Fort Knox,
Kentucky, has been given by the Council on Medical
Education, American Medical Association according to
information received by the Education and Training
Division, Office of the Surgeon General of the Army.
This is the only residency program of general practice
conducted by the Army Medical Service and has six-
teen participants. The first year of the program is de-
voted to medicine and medical sub-specialties, including
six months in pediatrics; the second, to surgery and
surgical sub-specialties, including six months in gyne-
cology and obstetrics.
* * *
The Fourth Interim Congress of the Pan-American
Association of Ophthalmology will be held jointly with
the annual meeting of the National Society for the
Prevention of Blindness at the Hotel Statler, April 7-10,
1957. The program committee has arranged three most
interesting symposia for Monday, Tuesday, and Wednes-
day mornings on fundus diseases, surgery, and thera-
peutics.
* * *
M. K. Newman, M.D., addressed the Eastern District
of the Michigan Chapter of the American Physical
Therapy Association on October 30, 1956, on the sub-
ject, “Medical Aspects in Geriatrics.”
* * *•
American Board of Obstetrics and Gynecology. — The
next scheduled examinations (Part II), oral and clini-
cal, for all candidates will be conducted at the Edge-
water Beach Hotel, Chicago, Illinois, by the entire
Board from May 16 through 25, 1957. Formal notice
of the exact time of each candidate’s examination will
be sent him in advance of the examination dates.
Candidates who participated in the Part I exami-
nations will be notified of their eligibility for the Part
II examinations as soon as possible.
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February, 1957
263
NEWS MEDICAL
The Third Annual Merrell Symposium on Construc-
tive Medicine in Aging: Cardiovascular Disorders in
the Aged, was held Thursday, January 17, 1957,
at the Netherland Hilton Hotel, Cincinnati, Ohio.
Johnson McGuire, M.D., Professor of Clinical Medicine
and Director of the Cardiac Laboratory, University of
Cincinnati College of Medicine, was moderator.
Reports were presented by the following: K. J.
Franklin, The Medical College of St. Bartholomew’s
Hospital, London: “Investigation of What Is Con-
sidered Normal for the Aging Cardiovascular System”;
J. Earle Estes, Jr., Mayo Clinic, Rochester, Minnesota:
“Venous Disorders in Older People”; Walter S. Priest,
Associate Professor of Medicine, Northwestern University
School of Medicine, Chicago: “Anticipation and Man-
agement of Cardiac Decompensation”; Jessie Marmors-
ton, Professor of Experimental Medicine, University of
Southern California, Los Angeles: “Hormonal Aspects
of Myocardial Infarction in Female and Male Subjects”;
Ancel Keys, Professor of Physiology and Director of
Laboratory of Physiological Hygiene, University of Min-
nesota, Minneapolis: “Calories and Cholesterol”; Rob-
ert W. Wilkins, Professor of Medicine, Boston University
School of Medicine, Boston: “Drug Therapy for Hyper-
tensive Vascular Disease in Patients Past Midlife”;
Robert A. BrUce, Associate Professor of Medicine, Uni-
versity of Washington School of Medicine, Seattle:
264
Say you saw it in the Journal of the
“Evaluation of Functional Capacity in Patients with
Cardiovascular Disease” ; and Edward J. Stieglitz, Con-
sultant in Geriatrics, Veterans Administration and St.
Elizabeth’s Hospital, Washington, D. C.: “Integrated
Unity of the Patient.”
* * *
The Fourth International Poliomyelitis Conference
will be held in Geneva, Switzerland, July 8-12, 1957,
under the auspices of the International Poliomyelitis
Congress. For information and reservation form, write
the Secretariat of the Conference, Hotel du Rhone,
Geneva, Switzerland.
* * *
“Grand Rounds” — the series of valuable closed-circuit
telecasts for physicians, will be continued in 1957 by
the Upjohn Company, sponsors. Thirty-three newly-
developed large-screen projection television systems have
been acquired. For copy of program and production
dates, write J. C. Gauntlett, The Upjohn Company,
Kalamazoo.
* * *
“Encourage your child to prepare for a career in
the nuclear science fields,” advised Lawrence R. Haf-
stad, Vice President in charge of the research staff of
General Motors Corporation (and 1956 MSMS Biddle
Lecturer). Dr. Hafstad urges parents of the youngster
with a “scientific gleam in his eye” to help such a
JMSMS
Michigan State Medical Society
NEWS MEDICAL
child find an outlet in the atomic arena. For reprint
of Dr. Hafstad’s article “Should Your Child Be an
Atomic Scientist?” write Dr. Hafstad at 51 Madison
Avenue, New York 10, New York.
* * *
Eleventh Annual Symposium on Fundamental Cancer
Research, sponsored by the University of Texas M.D.
Anderson Hospital and Tumor Institute will be held
at the Texas Medical Center, Houston, March 7-8-9,
1957. For a copy of program write Leon Emochowski,
M.D., Anderson Hospital, Houston 25, Texas.
* * *
Harry J. Loynd, President of Parke, Davis & Com-
pany of Detroit, has announced selection of a site in
Ann Arbor as location for the new PD $10,000,000
Medical Research Center, after a survey of thirty sites
in Michigan.
* * *
The American Trudeau Society will hold its 52nd
Annual Meeting in Kansas City, March 6-9, 1957.
For program write Edward J. Welch, Chairman, 1101
Beacon Street, Brookline 46, Massachusetts.
* * *
The Tercentenary of the death of William Harvey,
discoverer of the circulation of the blood, will be com-
memorated by the holding of an International Congress
on the Circulation from June 3-7, 1957, in the Royal
College of Surgeons, London. For information and
program write D. Geraint James, M.D., 1 1 Chandos
Street, Cavendish Square, London, W.l, England.
* * *
The Sixth International Congress of Otolaryngology
will be held at the Statler Hotel, Washington, D. C.,
May 5-10, 1957. For information and program write
Paul H. Holinger, M.D., Secretary, 700 N. Michigan
Avenue, Chicago 11.
* * *
Willard L. Quennell, M.D., former administrator of
of Highland Park General Hospital and subsequently
associated with Veterans Administration, has been trans-
ferred to the VA Regional Office at Detroit.
* * *
The First Postgraduate American Assembly in Fer-
tility and Sterility will be held at the New York Medical
College-Metropolitan Medical Center, May 18-31, 1957.
Information and program may be obtained from Ralph
E. Snyder, M.D., Dean, 1249 Fifth Avenue, New
York 29. Limited registration with $150.00 tuition.
* * *
A statewide Gerontology Society was officially organ-
ized at a founders day luncheon and program at Kel-
logg Center, East Lansing, on December 8, 1956. Dr.
Wilma Donahue, Ann Arbor, was elected the first Society
President, with A. Hazen Price, M.D., Chairman of the
MSMS Geriatrics Committee, as President-Elect. Fred-
erick C. Swartz, M.D., Lansing, was named to the
Society’s first Board of Directors.
* * *
J. S. DeTar, M.D., Milan, President of the American
Academy of General Practice, discussed “A Hospital
Is Only as Good as Its Medical Staff” at the Institute
for Hospital Public Relations sponsored by the Michi-
gan Hospital Association in Ann Arbor, December 13.
PHENAPHEM* PLUS
NOSE COLD
each coated tablet:
Phenacetin (3 gr.) 194.0 mg.
Acetyl8alicylic Acid (2V4 gr.) . 162.0 mg.
Phenobarbital {V* gr.) .... 16.2 mg.
Hyo8cyamine Sulfate .... 0.031 mg.
Prophenpyrldamine Maleate . . 12.6 mg.
Phenylephrine Hydroohlorlde . 10.0 mg.
Battle Creek Sanitarium
91st Tear of
Continuous Service
Ideal lor Executives. Rest combined with med-
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Diagnostic and therapeutic service. Special De-
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therapy, Radiotherapy and Massage.
Well suited for treatment of metabolic disorders,
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diseases generally. All Sanitarium care is under
the immediate guidance of qualified physicians.
For rates and further information,
address Box 40
THE BATTLE CREEK SANITARIUM
Battle Creek. Michigan
Not affiliated with any other Sanitarium
February, 1957
Say you saw it in the Journal of the Michigan State Medical Society
265
PERSPIRATION PROOF
Insoles do not crack or curl
from perspiration^
• Insole extension and wedge at inner corner of
heel where support is most needed.
• The patented arch support construction is guaran-
teed not to break down.
Innersoles guaranteed not to crack or collapse.
• Foot-so-Port lasts designed and the shoe construc-
tion engineered with orthopedic advice.
• Conductive Shoes for surgical and operating room
personnel. N.B.F.U. specifications.
• We are also the manufacturer of the Gear-Action
Shoe designed by noted orthopedic surgeon.
• We make more shoes for polio, club feet and dis-
abled feet than any other shoe manufacturer.
Send for free booklet, “The Preservation of the Function of the
Foot Balancing and Synchronizing the Shoe with the Foot."
Write for details or contact your local FOOT-SO-PORT
Shoe Agency. Refer to your Classified Directory
Foot-so-Port Shoe Company, Oconomowoc, Wis.
A Division of Musebeck Shoe Company
V J
All important laboratory exam-
inations; including — ■
Tissue Diagnosis
The Wassermann and Kahn Tests
Blood Chemistry
Bacteriology and Clinical Pathology
Basal Metabolism
Aschheim-Zondek Pregnancy Test
Intravenous Therapy with rest rooms for
Patients
Electrocardiograms
Central Laboratory
Oliver W. Lohr, M.D., Director
537 Millard St.
Saginaw
Phone. Dial 2-4100 — 2-4109
The pathologist in direction is recognized
by the Council on Medical Education
and Hospitals of the A.M.A.
Tom D. Spies, M.D., Birmingham, Alabama, guest
essayist on the 1956 MSMS Annual Session program,
has been elected President-Elect of the Interstate Post-
graduate Medical Association of North America. Con-
gratulations, Dr. Spies!
* * *
The Midwest Institute of Alcohol Studies will be held
at Western Michigan College at Kalamazoo on June
24-28. The Institute will aid those who wish to survey
aspects of alcohol-related problems. Deadline for appli-
cations for scholarships is April 15. For full informa-
tion write George Nimmo, 102 S. Walnut Street, Lan-
sing.
* * *
MSMS Executive Director William J. Burns was a
member of a panel “Stumping Experts” at the Blue
Shield Professional Relations Conference, Drake Hotel,
Chicago, February 11.
* * *
T. E. Schmidt, M.D., of Jackson is serving as a
member of the Club Service Consultative Group of
Rotary International. Dr. Schmidt is Past President
of the Jackson County Medical Society and a mem-
ber of the MSMS Emergency Medical Service Com-
mittee; he is also Past President of the Rotary Club
of Jackson.
* * *
The American College of Allergists announces its
Thirteenth Annual Congress and Graduate Instructional
Course in Allergy, Palmer House, Chicago, March 17-22,
1957. For program write Orval R. Withers, M.D.,
2049 Broadway, Boulder, Colorado.
BEAUMONT MEMORIAL
CONTRIBUTIONS
The response of the MSMS membership to
the November 30 appeal of the Beaumont Me-
morial Committee for additional contributions
to wipe off the deficit of the Beaumont Me-
morial was instant and generous. To January
15, 1957, donors sent in checks totaling $7,570,
which liquidated all of the debt except $1,530.
The Council and the Beaumont Memorial Com-
mittee extend sincere thanks to all MSMS mem-
bers who came to the rescue of the Beaumont
Memorial Restoration in such noble fashion.
The American Cancer Society is distributing nation-
ally to all AMA members a thirty-two-page booklet
titled “The Physician and the American Cancer Socie-
ty.” The brochure, with two-color cover, is generously
illustrated. It details the ACS program of research and
outlines services to patients, as well as its public and
professional education programs. It gives a capsule
history of the Society, its organizational philosophy, its
guiding principles. Also provided is a listing of ACS
publications and materials of special interest to doctors,
and the addresses of the sixty ACS Divisions where
they may be obtained.
266
Say you saw it in the Journal of the Michigan State Medical Society
J.MSMS
NEWS MEDICAL
. . I’m writing you in regard to one of the very
best doctors in the world.”
This is part of a letter written by Mrs. Bonnie Ty-
koski, Monroe, Michigan, to the American Medical
Association in November, 1956.
Following a five-week stay at the Monroe Hospital
recovering from critical injuries received in an auto-
mobile accident, Mrs. Tykoski wrote her note of
appreciation.
“ . . . I’ve been trying to think of some way in
which I could let Dr. know how very,
very thankful I am. . . . All too often, the people
through neglect, or just not thinking, don’t give the
doctors the proper credit due to them. . . So I am
writing to you ... to let the AMA know of our per-
sonal opinion . . .”
The AMA reports that letters such as this now far
outnumber the critical ones received in the Chicago
office.
* * *
Michigan doctors who attended the AMA session in
Seattle, November 28-29, 1956 included: H. Peter
Brachman, M.D., Allegan; *George W. Slagle, M.D.,
and Wilfrid Haughey, M.D., Battle Creek; L. Fernald
Foster, M.D., and *Orlen J. Johnson, M.D., Bay City;
*John R. Rodger, M.D., Bellaire; Edward L. Quinn,
M.D., Birmingham; William A. Maynard, M.D., Cole-
man; *Warren W. Babcock, M.D., * Wyman D. Barrett,
M.D., J. Edward Berk, M.D., Melvin A. Block, M.D.,
*William Bromme, M.D., J. M. Colville, M.D., H. G.
Kobrak, M.D., ^Robert L. Novy, M.D., ^Clarence I.
Owen, M.D., *Grover O. Penberthy, M.D., F. P. Rhoades,
M.D., John Sigler, M.D., William C. Strutz, M.D., and
*Arch Walls, M.D., Detroit; Milton D. Comfort, M.D.,
Flat Rock; Sydney N. Little, M.D., and Franklin V.
Wade, M.D., Flint; * William A. Hyland, M.D., and
J. D. Vyn, M.D., Grand Rapids; Willis H. Huron, Iron
Mountain; Hilda A. Habenicht, M.D., and Jerome J.
Van Gasse, M.D., Jackson; Reader J. Hubbell, M.D.,
Kalamazoo; Frederick Swartz, M.D., Lansing; Harold
H. Gay, M.D., Midland; J. S. DeTar, M.D., Milan; A.
Deane Hobbs, St. Louis; John T. Ferguson, M.D.,
Traverse City; and D. Bruce Wiley, M.D., Utica.
* * *
March of Medicine will repeat its hour-long documen-
tary on missionary medicine, Tuesday, March 5, at
9:30 p.m., EST over the NBC-TV network.
This latest in the prize-winning TV series, produced
and sponsored by Smith, Kline & French Laboratories
in co-operation with the American Medical Association,
is called “Monganga,” tribal dialect for “White Doc-
tor.” Originally televised November 27, it brought a
heavy flow of enthusiastic letters, telegrams, phone calls
and personal messages — many asking to see the program
again.
The show chronicles the daily labors of one mis-
sionary, John Ross, M.D., as an “illustration of the
work American doctors are doing for sick people all
over the world.”
In Doctor Ross’ clinic, surgery is always preceded by
a prayer. He is shown at his fourteen-hour-day — over-
seeing a nearby leprosarium, conducting a weekly pre-
HEAD COLD
each coated tablet:
Phenacetin (3 gr.) ...... 194.0 mg.
Acetylsalicylic Acid (2 V4 gr.) . 162.0 mg.
Phenobarbital (Va gr.) .... 16.2 mg.
Hyoscyamine Sulfate .... 0.031 mg.
Prophenpyridamlne Maleate . . 12.5 mg.
Phenylephrine Hydroohlorido • 10.0 mg.
Protection against loss of income from
accident and sickness as well as hospital
expense benefits for you and all your
eligible dependents.
60 TO
PHYSICIANS CASUALTY & HEALTH
ASSOCIATIONS
OMAHA 2, NEBRASKA
Since 1902
February. 1957
Say you saw it in the Journal of the Michigan State Medical Society
267
NEWS MEDICAL
DAY BOOKS
APPOINTMENT BOOKS
CASE RECORDS
PATIENTS' ACCOUNT CARDS
INCOME AND EXPENSE LEDGERS
D
All Adapted to YOUR Needs by Experienced PM Managers
WRITE OR CALL FOR INFORMATION
»PROFESSIOI1AL
* m a n a g e m e n t
Security Bank Building — Battle Creek
SAGINAW — GRAND RAPIDS — DETROIT
A COMPLETE BUSINESS SERVICE FOR THE 111 E D I CAL PROFESSION
Affiliated Offices in Other Cities
MEDICAL TELEVISION SHOWS
Produced by Michigan Health Council
Date
Station
Subject
Guests
Dec. 2
WJBK-TV, Detroit
Vision
Two Films — “Eyes for Tomorrow”
“Light is What You Make It”
and
Dec. 6
WKAR-TV , East Lansing
M.D. Placement
Film — “A Citizen Participates”
Dec. 9
WJBK-TV, Detroit
To Save Your Life
Film
Dec. 16
WJBK-TV, Detroit
Dental Health
Two Films — “Picture Your Teeth”
“Come Clean”
and
Dec. 20
WKAR-TV , East Lansing
To Save Your Life
Film
Dec. 23
WJBK-TV. Detroit
Rehabilitation
Film — “Man in the Window”
Dec. 30
WJBK-TV. Detroit
Secrets of the Heart
Film
natal clinic, traveling to distant “bush clinics.” His
days not only include the diagnosis and treatment of
diseases which face all physicians everywhere, but also
the very special challenge of tropical medicine. Lep-
rosy, yaws, elephantiasis and sleeping sickness are en-
countered daily. Primitive living and sanitary condi-
tions must be improved — and often Doctor Ross turns
field construction engineer.
This dedicated man is a Kansan by birth who, as a
minister, served congregations in California. At the age
of thirty-six — after the death of his first four children,
two of them within ten days — he decided to become a
medical missionary. He graduated from the Indiana
University School of Medicine and took graduate work
at Tulane University. In 1950 — by then he was forty-
three years old — he was assigned to the Disciples of
Christ mission in the village of Lotumbe.
March of Medicine was the first television series to
receive an Albert Lasker Award for Medical Journal-
ism. In the past, the series has focused on such topics
as mental health, cancer, heart disease, arthritis, and
new surgical techniques.
PHYSICIANS AND PSYCHIATRISTS FOR
CALIFORNIA STATE
STREAMLINED EMPLOYMENT PROCEDURE: By in-
terview only (no written examinations). Interviews
held periodically in California and nationwide. Wide
choice of positions in 15 large State hospitals, insti-
tutions, and veterans home. 40 hour week, liberal va-
cation, and other benefits including generous retire-
ment annuities. Annual salary increases. Three salary
groups: $10,860 to $12,000; $11,400 to $12,600; $12,-
600 to $13,800. Candidates must be U. S. citizens and
in possession of, or eligible for, California license. For
full information write to Miss Carmack, Supervisor,
Medical Recruiting, Box A, State Personnel Board, 801
Capitol Avenue, Sacramento, California.
MARY POGUE SCHOOL, Inc.
Complete facilities for training Retarded and Epi-
leptic children educationally and socially. Pupils
per teacher strictly limited. Excellent educational,
physical and occupational therapy programs.
Recreational facilities include riding, group games,
selected movies under competent supervision of
skilled personnel.
Catalogue on request.
G. H. Marquardt, M.D. Barclay J. MacGregor
Medical Director Registrar
26 GENEVA ROAD, WHEATON. ILL.
(Near Chicago)
268
Say you saw it in the Journal of the Michigan State Medical Society
JMSMS
THE DOCTOR’S LIBRARY
Acknowledgment of all books received will be made in this column,
and this will be deemed by us as full compensation to those
sending them. A selection will be made for review, as expedient.
METABOLISM, Clinical and Experimental. Volume
V, Number 6. New York: Grune & Stratton.
LAKESIDE LECTURE SERIES, Volume I, 1956.
Lectures I-V. Lakeside Laboratories, Inc., Milwaukee
1, Wisconsin.
BOOK OF HEALTH — An authoritative Family Guide.
By W. W. Bauer, M.D., editor. Official American
Medical Association book (an original, not a reprint).
Printed by the Publicity Department of Dell Books,
200 Fifth Avenue, New York 10. First edition —
35 cents per copy.
What is health? Dr. Bauer’s definition of health is
“a state of being in which the individual is capable of
doing his daily work, of meeting obligations as they
arise, and of having a reasonable amount of fun. with a
reserve of energy always available to meet unforseen
demands.”
A partial table of contents of the Book of Health
includes: “Taking the Worry Out of Heart Disease”;
“The Cured Cancer Club”; “The Causes and Cure of
Excess Weight”; “The Facts About Arthritis”; “High
Blood Pressure and What to Do About It.”
This family guide is a worthy publication that can
well be recommended by doctors to all their patients.
\
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ENAPHI
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each coated tablet:
Phenacetin (3 gr.) 194.0 mg.
Acetylsalicylic Acid (2% gr.) . 162.0 mg.
Phenobarbital (V4 gr.) .... 16.2 mg.
Hyoscyamine Sulfate .... 0.031 mg.
Prophenpyridamine Maleate . • 12.5 mg.
Phenylephrine Hydrochloride • 10.0 mg.
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George A. Triplett and Richard K. Wind
Representatives
2405 West McNichols Road
Telephone University 2-8064
February, 1957
Say you saw it in the Journal of the Michigan State Medical Society
269
AN EXPERIMENT IN MEDICAL NOMENCLATURE
INTRODUCING THE TERM:
The exfoliative cytological examination is called by some
doctors the cytologic cervical test— by others the “Pap” smear
test. In urging all women to have this test annually, we are
calling it the cell examination for uterine cancer.
“ cell examination
for uterine cancer”
Here are our reasons :
Cytologic cervical test is a term which seems complicated to
many women.
“Pap” smear test is simple, but women we have talked to
find the word “smear” unpleasant and disturbing, and it may
add to their anxieties about pelvic examinations.
Public relations advisors say that broadcasters and editors
will dislike “smear” — and TV, radio and the press will be essen-
tial to the success of this educational project.
We have considered other terms but have at last agreed on
cell examination for uterine cancer as the term which simply
and accurately describes the keystone of this vitally important
program.
This test can help save thousands of women each year. In
many parts of the country it is becoming widely accepted as a
part of a routine checkup. As fast as county medical societies
approve, our local Units will urge women to go to their physi-
cians annually for a cell examination for uterine cancer.
AMERICAN
CANCER
SOCIETY
Michigan Division, Inc.
21 Ottawa, N.W.
Grand Rapids, Michigan
American Cancer Society
Southeastern Michigan Division
48 1 I John R. Street
Detroit, Michigan
270
Say you saw it in the Journal of the Michigan State Medical Society
J.MSMS
THE JOURNAL
of the Michigan State Medical Society
DLUME 56
MARCH, 1957
NUMBER 3
Contributors to This Issue
R. T. Blackhurst, M.D.
E. S. Gurdjian, M.D.
T. R. Palaszek. M.D.
J. H. Reid, M.D.
C. S. Stevenson, M.D.
E. H. Watson, M.D.
J. E. Webster. M.D.
vRCH, 1957
J. L. Wilson, M.D.
Table of Contents
Perinatal Mortality Study in Wayne County
January, 1953, to July, 1954
Ruben Meyer, M.D., C. Dale Barrett, M.D.,
and James T. Oliver 321
Review of Immunization Programs Recommended
With Advent of Salk Vaccine
James L. Wilson, M.D 327
A Review of Pediatric Meningitis in a General
Hospital Over a Ten-Year Period
E. M. Jiichhorn, M.D., and ]. H. Reid, M.D 331
A Plea for Preschool Eye Care
R. T. Blackhurst, M.D 336
Rheumatic Fever Prophylaxis
Robert E. Fisher, M.D 339
Rubella in Pregnancy
Warren H. Fearse, M.D 340
The Physician and the Adoption of Children
Ernest H. Watson, M.D 342
Plyperextension of the Fetal Head in Breech
Presentation
Theresa R. Palaszek, M.D 345
Management of Breech Presentation and Delivery
Charles S. Stevenson, M.D 347
Shoulder-Hand Syndrome
E. S Gurdjian, M.D., and /. E. Webster, M.D. .. 353
President’s Message:
Kids are Important 357
Editorial :
Child Welfare Issue 356
Proposed National Legislation 356
Prepayment a 359
What Makes Blue Shield Different? 360
Deaths Balance Births 360
L. Fernald Foster, M.D. — Servant and Director
of Medicine 362
Michigan State Medical Society — Annual Session
of the Council 364
Michigan’s Department of Health 378
In Memoriam 380
Correspondence 383
News Medical 384
The Doctor’s Library 397
You and Your Business 278
Heart Beats 280
AMA Washington Letter 286
PR Report 288
AMA News Notes 292
© 1957 by Michigan State Medical Society
275
THE JOURNAL
of the Michigan State Medical Society
=VOLUME 56 MARCH, 1957 NUMBER 3=
PUBLICATION COMMITTEE
G. B. SALTON5TALL, M.D., Chairman Charlevoix
WILLIAM BROMME, M.D Detroit
B. M. HARRIS, M.D Ypsilanti
O. B. McGILLICUDDY, M.D Lansing
W. S. STINSON, M.D Bay City
T. P. WICKLIFFE, M.D Calumet
Office of Publication
2642 University Avenue
Saint Paul 14, Minnesota
Editor
WILFRID HAUGHEY, M.D.
610 Post Bldg., Battle Creek, Michigan
Secretary and Business Manager of THE JOURNAL
L. FERNALD FOSTER, M.D.
Thorne Bldg., 919 Washington Ave.
Bay City, Michigan
Executive Director
WM. J. BURNS, LL.B.
606 Townsend Street, Lansing 15, Michigan
All communications relative to exchanges, books for review, manu-
scripts, should be addressed to Wilfrid Haughey, M.D., 610 Post
Bldg,, Battle Creek, Michigan.
All communications regarding advertising and subscription should
be addressed to Wm. J. Burns, 2642 University Avenue, Saint
Paul 14, Minnesota, or 606 Townsend Street, Lansing 15, Michigan.
Telephone Ivanhoe 57125.
© 1957, by Michigan State Medical Society.
Published monthly by the Michigan State Medical Society as its
official journal at 2642 University Avenue, Saint Paul 14, Minnesota.
Entered at the post office at Saint Paul, Minnesota, as second
class matter. May 7, 1930, under the Act of March 3, 1879.
Acceptance for mailing at special rate of postage provided for
in Section 1103 Act of October 3, 1917, authorized August 7, 1918.
Yearly subscription rate, $6.00; single copies, 60 cents. Additional
postage; Canada, $1.00 per year; Pan-American Union, $2.50 per
year; Foreign, $2.50 per year.
PRINTED IN U.S.A.
OFFICERS OF THE SOCIETY
1956-1957
President ARCH WALLS, M.D Detro
President-Elect G. W. SLAGLE M.D Battle Cree
Secretary L. FERNALD FOSTER, M.D Bay Cit
Treasurer W. A. HYLAND, M.D Grand Rapic
Speaker K. H. JOHNSON, M.D Lansin
Vice Speaker J. J. LIGH 1 BODY, M.D Detro
Editor WILFRID HAUGHEY, M.D Battle Cree
THE COUNCIL
D. BRUCE WILEY, M.D., Chairman, Utica
W. B. HARM, M.D., Vice Chairman, Detroit
L. FERNALD FOSTER, M.D., Secretary, Bay City
Tern
District Expirt
A. E. SCHILLER, M.D 1st Detroit 19f
O. B. McGILLICUDDY, M.D 2nd Lansing 19f
H. J. MEIER, M.D 3rd Coldwater 19f
RALPH W. SHOOK, M.D 4th Kalamazoo 19f
C. ALLEN PAYNE, M.D 5th Grand Rapids 19f
H. H. HISCOCK, M.D 6th Flint 196
H. B. ZEMMER, M.D 7th Lapeer 191
L. C. HARVIE, M.D 8th Saginaw 19!
G. B. SALTONSTALL, M.D 9th Charlevoix 19!
W. S. STINSON, M.D 10th Bay City 19!
W. M. LeFEVRE. M.D 11th Muskegon 19!
B. T. MONTGOMERY, M.D 12th Sault Ste. Marie....l9!
T. P. WICKLIFFE, M.D 13th Calumet 19!
B. M. HARRIS, M.D 14th Ypsilanti 19!
D. BRUCE WILEY, M.D 15th Utica 191
G. THOMAS McKEAN. M.D 16th Detroit 191
W. B. HARM, M.D 17th Detroit 19!
WILLIAM BROMME, M.D 18th Detroit 19!
ARCH WALLS, M.D President Detrc
G. W. SLAGLE, M.D President-Elect Battle Cre.
K. H. JOHNSON, M.D Speaker Lansii
J. J. LIGHTBODY, M.D Vice Speaker Detrc
L. FERNALD FOSTER. M.D Secretary Bay Ci
W. A. HYLAND, M.D Treasurer Grand Rapi
W. S. JONES, M.D Past President Menomin
EXECUTIVE COMMITTEE OF THE COUNCI
D. BRUCE WILEY, M.D Chairmt
W. B. HARM, M.D Vice Chairm;
W. M. LeFEVRE, M.D Chairman. County Societies Committ
G. B. SALTONSTALL, M.D Chairman, Publication Committ
RALPH W. SHOOK, M.D Chairman, Finance Committ
K. H. JOHNSON. M.D Speaker, House of Delegat
J. J. LIGHTBODY, M.D Vice Speaker, House of Delegal
ARCH WALLS, M.D Preside
G. W. SLAGLE. M.D President-El<
L. FERNALD FOSTER, M.D Secreta
W. A. HYLAND, M.D Treasu:
SECTION OFFICERS
Dermatology and Syphilology
Wm. T. Kruse, M.D Grand Rapids
Chairman
Coleman Mopper, M.D Detroit
Secretary
Gastroenterology and Proctology
N. D. Nigro, M.D Detroit 1
Chairman
E. J. Tallant. M.D Detroit
Secretary
General Practice
F. P. Rhoades, M.D Detroit 2
Chairman
F. C. Brace, M.D Grand Rapids
Secretary
Gynecology and Obstetrics
J. H. Beaton, M.D Grand Rapids
Chairman
R. W. McClure, M.D Detroit 26
Secretary
Medicine
J. M. Kaufman, M.D Detroit 26
Chairman
J. W. Hall, M.D Traverse City
Secretary
Nervous and Mental Diseases
W. R. Slenger, M.D Ann Arbor
Chairman
S. C. Mason, M.D Ann Arbor
Secretary
Occupational Health
O. J. Johnson, M.D Bay City
Chairman
P. B. Rastello, M.D Detroit 9
Secretary
Ophthalmology and Otolaryngology
B. C. Wildgen, M.D Muskegon
Chairman (Ophth.)
W. K. Locklin, M.D Kalamazoo
Co-Chairman (Oto.)
H. A. Dunlap, M.D Detroit 14
Secretary (Ophth.)
H. L. LeVett, M.D Lansing
Co-Secretary (Oto.)
Pediatrics
C. E. Booher, M.D Grand Rapids
Chairman
A. M. Hill, M.D Grand Rapids
Secretary
DELEGATES TO A.M.A.
Public Health and Preventive
Medicine
J. D. Monroe, M.D Pont
Chairman
J. K. Altland, M.D Lansing
Secretary
Radiology, Pathology, Anesthesiolo
R. B. Sweet. M.D Ann Arl
Chairman (Anes.)
E. R. Jennings, M.D Detr
Vice-Chairman (Path.)
E. O. Pearson. M.D Kalama: |
Secretary (Rad.)
Surgery
E. T. Thieme, M.D Ann Arl
Chairman
H. M. Bishop, M.D Sagin j
Secretary
Urology
R. P. Lytle, M.D Detroi
Chairman
J. F. Harrold, M.D Lans
Secretary
Alternates
Delegates
W. A. Hyland, M.D., Grand Rapids, Chairman 1957
J. S. DeTar, M.D., Milan 1957
C. I. Owen, M.D., Detroit 1957
W. D. Barrett, M.D., Detroit 1958
W. H. Huron, M.D., Iron Mountain 1958
R. L. Novy, M.D., Detroit 1958
W. W. Babcock, M.D., Detroit 1- !
E. F. Sladek, M.D., Traverse City P
O. J. Johnson, M.D.. Bay City P j
William Bromme, M.D.. Detroit P
J. R. Rodger, M.D., Bellaire P
G. W. Slagle, M.D., Battle Creek P
276
Section Delegate
G. C. Penberthy, M.D. (Surgical Section) Detroit
JMSJ ,1
Achrocidin is indicated for prompt
control of undifferentiated upper res-
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questionable middle ear, pulmonary,
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respiratory epidemics; when bacterial
complications are observed or expected
from the patient’s history.
Early potent therapy'is provided
against such threatening complications
as sinusitis, adenitis, otitis, pneumon-
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matic states.
Included in this versatile formula are
recommended components for rapid
relief of debilitating and annoying cold
symptoms.
Adult dosage for achrocidin Tablets
and new, caffeine-free achrocidin
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Available on prescription only
symptomatic
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Tablets
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Each tablet contains:
Achromycin® Tetracycline
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Phenacetin
120 mg.
Caffeine
30 mg.
Salicylamide
150 mg.
Chlorothen Citrate
25 mg.
‘Trademark
LEDERLE LABORATORIES DIVISION, AMERICAN CYANAMID COMPANY, PEARL RIVER. NEW YORK
ARCH, 1957
Say you saw it in the Journal of the Michigan State Medical Society
277
You and Your Business
COMPREHENSIVE HOSPITAL
PUBLIC HEALTH PLAN
Lankenau Hospital in Philadelphia has an-
nounced plans for a $40,000,000 building project,
the building of the most completely integrated
medical center. The hospital of the future will
divide its attention and resources almost equally
between treating the sick in its great hospital
facilities and preventive medicine and clinical in-
struction. Lankanau claims to be the only hos-
pital in the United States with a comprehensive
public health education program for preventive
medicine; with an unusual health museum and
auditorium attracting 40,000 visitors annually.
These include medical and other professional
groups, educational films; lectures and open
forums on medical topics.
U. S. COMMISSION ON AGING
PROPOSED
Senator Potter of Michigan has introduced a
bill (S258) to set up a U. S. Commission on
Aging, ten members from the Senate and House,
the executive branch and the public. It will study
aged persons’ problems employment, income
maintainance, health and physical care, housing
living arrangements and recreation. The com-
mission’s recommendations are to be made to
Congress before Tuly 1. 1958, at which time the
commission automatically dissolves.
CARE FOR AGED COSTLY
“Unless more economical and effective methods
are found and widely applied, the growing popu-
lation of elderly persons and disabled people of
all ages requiring prolonged (medical and hos-
pital) care will continue to bankrupt themselves,
and ultimately bankrupt many local governments
and voluntary health insurance plans,” Dr. LeRoy
E. Burney, surgeon general of the U. S. Public
Health Service, declared at the University of
Michigan, on January 23, 1957, speaking to local
health department officials at the first Institute on
Public Health Administration conducted by the
U-M School of Public Health and the Michigan
Department of Health.
SCHERING AWARD CHEMOTHERAPY
OF MENTAL ILLNESS
New areas of research opened up by the de-
velopment of the tranquilizing drugs have had a
marked impact on the interest of the doctors of
tomorrow, according to Dr. R. Richard McCor-
mick, Chairman of the Committee on the Schering
Award.
278
The Schering Award is an annual competition
among medical students in the United States and
Canada, with prize-winning papers being given
national recognition. The competition has been
sponsored by Schering Corporation, pharmaceut-
ical manufacturers of Bloomfield. N. T., annually
since 1939. Dr. McCormick reported that medical
students submitting papers for the pharmaceutical
manufacturing firm’s annual competition have
shown a clear preference for the topic, “Recent
Advances in the Biochemical Aspects and Treat-
ment of Mental Disease.” To date, the papers
dealing with this subject are almost double those
submitted on both cardiology and eye disorders,
the other two subjects for the 1957 competition.
Dr. McCormick attributed the growing interest
of medical students in this topic to the recent
flood of publicity about tranquilizing agents, and
about the problem of mental illness.
He announced that the deadline date for entry
forms for the contest has been extended to March
15, 1957, but warned that all manuscripts must
be submitted by June 30, 1957.
Cash awards have been doubled to $4,500 this
year, he added, bringing the first prize in each of
the three categories to $1,000, and the second
prize in each to $500. Other outstanding papers
will be awarded professionally useful gifts.
The contest is open to all medical students in
the United States and Canada. Information may
be obtained by writing the Schering Award Com-
mittee, 60 Orange Street, Bloomfield, N. J.
DIABETES HISTORY
In 1947, through the efforts of Dr. Elliott P.
Joslin, The Diabetic Fund was created. One ol
its functions was to supervise the awarding of the
Quarter Century Victory Medal, to those diabetics
who have been controlled on a diet and insulin foi
twenty-five years without developing any compli-
cations. The idea behind the creation was two-
fold. first, “to encourage diabetic patients to per-
severe in the careful control of their disease b}
proving through living examples that such con-
trol was worth while,” and secondly, “to lean j
from those who earned the award the method:
they had followed to attain it.”
Up to September 1956 only sixty-eight sue!
medals had been given out, including one to : i
diabetic in Ann Arbor. To meet the require
ments the patient’s condition must be excellent
as shown by a complete physical examination. Ai
accredited ophthalmologist must certify that tb
eyes are free from complications. X-rays of th
(Continued on Page 312)
JMSM
Rauwiloid'
A Dependable Antihypertensive
“...by far the most effective
and useful orally administered agent for reducing blood
pressure . . . fully worthy of a trial in every case of
essential hypertension in which treatment is thought
necessary. The severe cases, which always need treat-
ment, are as likely to respond as the mild.”1
1. Locket. S.: Brit. M.J.
2:809 (Apr. 2) 1955.
An Effective Tranquilizer, too
“ . . . relief from anxiety resulted in generally in-
creased intellectual and psychomotor efficiency with
a few exceptions.”2 Rauwiloid is outstanding for its
nonsoporific sedative action in a long list of diseases
burdened by psychic overlay.
2. Wright, W.T., Jr., et al.: J. Kansas
M. Soc. 57:410 (July) 1956.
Dosage: Merely two 2 mg. tablets at bedtime.
After full effect one tablet suffices.
A logical first step when more potent drugs are needed
Rauwiloid is recognized as basal
medication in all grades and types
of hypertension. In combination with
more potent agents it proves syner-
gistic or potentiating, making
smaller dosage effective and freer
from side actions.
Rauwiloid +Veriloid&
In moderate to severe hyperten-
sion this single-tablet combination
permits long-term therapy with de-
pendably stable response. Each tablet
contains 1 mg. Rauwiloid (alseroxy-
lon) and 3 mg. Veriloid (alkavervir).
Initial dose, 1 tablet t.i.d., p.c.
Rauwiloid +
Hexamethonium
In severe, otherwise intractable hy-
pertension this single-tablet com-
bination provides smoother, less
erratic response to hexamethonium.
Each tablet contains 1 mg. Rauwi-
loid and 250 mg. hexamethonium
chloride dihydrate. Initial dose, ^2
tablet q.i.d.
Riker
LOS ANGELES
[arch, 1957
Say you saw it in the Journal of the Michigan State Medical Society
279
Heart Beats
THE RESEARCH PROGRAM OF THE AMERICAN HEART ASSOCIATION,
ITS AFFILIATES AND CHAPTERS
Charles D. Marple, M.D., Medical Director
The necessity for expanding the scientific re-
search effort of the nation is clearly evident and
generally understood, but public recognition of
this fact is of relatively recent origin.
Industry has provided much of the impetus to
the twentieth century renaissance of research. No
literate adult can fail to note the regular appear-
ance in the press of advertisements by which
industry solicits the services of men with scientific
training and skills, and entices the youth of our
country into scientific careers — for industry’s sake.
For the most part, these appeals have been made
to recruit men in the physical sciences: engineer-
ing, physics and electronics. Recently, the press-
ing need for biological scientists has been em-
phasized, principally by educators and the scient-
ists themselves. It is now obvious that what
America needs most is not the traditional '‘good
five-cent cigar,” but more high-grade scientific
manpower.
Since World War II, both Federal and private
agencies have instituted programs of research sup-
port in a wide variety of scientific fields, physical,
biological and sociological. While these programs
have much in common, each has its own individu-
ality. Several organizations, including the Life In-
surance Medical Research Fund, the National
Heart Institute of the National Institutes of
Health, and the American Heart Association, are
concerned primarily with the cardiovascular field.
The growth of the American Heart Association’s
program of research support has been dramatic.
The first awards were made in 1948, and the first
appointees began their work under Association
auspices during the fiscal year, 1949-1950. In that
year, there were twenty-four Research Fellows, two
Established Investigators, and nineteen Grants-in-
aid; no Career Investigators were appointed at
that time. I he total amount of money invested
by the Association in research during the year was
$222,433.
Today, in the eighth year of the program, there
are sixty Research Fellows, sixty-four Established
Investigators, and 180 Grants-in-aid; in addition,
three Career Investigators have been selected for
lifelong support by the Association. The total sum
invested in research during the year exceeds
280
$1,850,000. The day when the staff could be per-
sonally familiar with the life story of each inves-
tigator— in effect, know “the name, number and
batting average of each player,” is now but a
memory.
In numbers of individuals supported and in
amounts of money spent, the research program of
the Association is unquestionably successful. But
what of its quality, which, in the final analysis,
is the most vital consideration?
The research program of the American Heart
Association rests upon two fundamental concepts:
( 1 ) that support should be given to individual in-
vestigators rather than to projects per se, and (2)
that the research activities selected for support
should cover a wide range of scientific disciplines,
with emphasis on basic research.
Accordingly, through the Research Fellowship,
the Association attempts to attract promising
young scientists, provide them with an opportunity
of obtaining training and experience, of develop-
ing the necessary knowledge and skills, and of
acquiring the spirit of dedication which is essen-
tial to the maximum productivity in investigation.
The Established Investigatorship goes a step fur-
ther and gives the scientist an opportunity to
establish himself as an independent worker. There
is no waste in this program. The tyro who leaves
research for academic medicine or for clinical
practice is the better physician for his research
experience. For the exceptional individual, there
is the possibility of lifelong support as a Career
Investigator, a unique opportunity which reflects
the vision of the Association’s early leadership.
No one can foretell where the next important
scientific discovery will be made ; no one can guess
what esoteric research will lead to a practical
cardiovascular advance. What we do know is that
basic studies in physiology, chemistry and physics
produce fundamental knowledge from which comf
all practical medical developments. It is only b) '
pursuing every possible hypothesis that significan
discoveries are brought to fruition.
This attitude has permitted wide latitude in th<
types of investigation supported. Much of thi
work relates directly to arteriosclerosis, hyperten
(Continued on Page 282)
JMSM U
for anxiety
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# no blood dyscrasias, liver toxicity, Parkinson-like syndrome
or nasal stuffiness
© chemically unrelated to chlorpromazine or reserpine
Cl does not produce significant depression
© orally effective within 30 minutes for a period of 6 hours
Indicat: anxiety and tension states, muscle spasm.
THE ORIGINAL MEPROBAMATE
DISCOVERED AND INTRODUCED
BY WALLACE LABORATORIES, New Bruntwick.N.J,
2-methyl-2-n-p ropy l-l 3-propanediol dicarbamate — U. S. Patent 2,724t720
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Literature and Samples Available on Request
CM-3706-R3
THE MILTOWN ®
MEPROBAMATE MOLECULE
Iarch, 1957
281
Say you saw it in the Journal of the Michigan State Medical Society
HEART BEATS
RESEARCH PROGRAM
(Continued from Page 280)
sion, rheumatic fever and other specific cardio-
vascular conditions, but, on the other hand, many
research projects are selected which can only be
classified as basic physiology, chemistry and bio-
logy.
As the national program has grown, the increase
in the number of applications submitted and in the
total funds requested each year has kept pace with
the increase in available funds. A certain loss of
flexibility has ensued as a natural consequence of
this growth. Of the many proposals made for in-
troducing new forms of research support, only a
few can be adopted. Artificial limitations are im-
posed by necessity, on the types of awards offered,
on the sums awarded, and on the length of time
for which awards are made.
Affiliates and Their Chapters
The growth of the affiliated heart associations
and their chapters has provided an unexcelled op-
portunity for diversification of research support.
Although these local heart associations are bound
by the general research policies of the national
organization, they are in most respects free to
spend their funds as they deem advisable. As funds
for research have increased on the local level, from
a nation-wide total of $477,500 in 1949 to more
than $2,900,000 in 1956, heart associations have
been enabled to support research in more effec-
tive ways. They have instituted forms of research
support hitherto not offered by the national agen-
cies, e.g., chairs of cardiovascular teaching and
research, student fellowships, block and fluid
grants, and so forth.
Here, then, is a highly imaginative and practi-
cally unrestricted research program which has
utilized national and local resources to support a
broad spectrum of scientific research in a variety
of ways, designed in many instances to fit a par-
ticular need. As more funds are collected, addi-
tional investigators and projects can be supported
and additional types of assistance can be offered to
meet the demands of the everchanging research
picture. An evaluation of these programs will
demonstrate eventually the merit in each indi-
vidual approach.
The essential point, however, is that a program
of research support, like any other scientific en-
deavor, requires vision, imagination, specialized
knowledge and good judgment. It is necessarily
experimental, but in creating new frontiers of
knowledge, there is a high degree of promise and
satisfaction.
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282
JMSMf
Say you saw it in the Journal of the Michigan State Medical Society
'OR MOST INFECTIONS
(NOVOBIOCIN-PENICILLIN G. MERCK)
THE ANTIBIOTIC PRODUCT
IOST LIKELY TO BE EFFECTIVE
M PARE THESE ADVANTAGES:
Proved effectiveness in the largest num-
of clinically important infections in-
ding those caused by antibiotic-resistant
bhylococci and proteus.
rherapeutic, bactericidal blood levels are
mptly achieved.
exceptionally well tolerated; patient sen-
vity reactions are rare at recommended
age.
^o yeast or fungal super-infections nor
r antibiotic-induced enteritis, vaginitis or
ctitis have been reported following
rHOCILLIN.
'fo problems of cross-resistance have been
ountered with Cathocillin.
rhe normal intestinal flora is not dis-
hed by Cathocillin.
AGE: for adults — two capsules q.i.d.; for children
er too lbs. — dosage in proportion to weight (e.g. one
■ule q.i.d.Jor a child weighing 50 lbs.).
one prescription the one antibiotic product most likely to be effective
MERCK SHARP 8c DOHME
DIVISION OF MERCK ft CO.. INC.. PHILADELPHIA I, PA.
CONSIDER CATHOCILLIN FIRST
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erysipelas.
SUPPLIED -.Blue and white capsules of ‘Cathocillin’
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[arch, 195?
Say you saw it in the Journal of the Michigan State Medical Society
205
AMA Washington Letter
THE MONTH IN WASHINGTON
With Congress now well along in its session, the
list of health and medical bills totals several hun-
dred. Some are minor — and few persons will be
affected regardess what happens. Others just
don’t make much sense — and the committees, re-
gardless of politics, can be trusted to let these
measures die a peaceful death.
But there are scores of others — all important
bills — that have some chance of passage, their
prospects ranging from an outside possibility to a
strong probability. At this stage they can be re-
garded as the raw material out of which will
come the studies, the debates and the arguments
in the months ahead.
One of the major health-medical issues is fed-
eral aid to medical, dental and osteopathy schools.
On this the administration wants grants for con-
struction and equipment only; some of the Demo-
crats want to include money for operating ex-
penses as well.
In number of bills introduced, the general sub-
ject of problems of the aging probably tops the
list. And that is no surprise. For several years
welfare workers, housing experts and recreational
leaders, as well as physicians, have been looking
for ways to help the retirement age population.
Recently a special center was set up within the
Institutes of Health to devote its time exclusively
to the aged. Outside government, voluntary
groups have also been at work on the same sub-
ject.
Now the ideas developed by the years of discus-
sion are coming to the surface in the form of
legislation. Several of the bills would set up com-
missions, appointed either by the President or
Congress. Another recommends that an existing
House Committee make a study of the aging,
similar to that suggested for the various commis-
sions.
The commissions and committees would have
one thing in common : They would further study
and investigate in a field that many persons be-
lieve already has been plowed and replowed by
investigators.
Several lawmakers want to get going right
away. They would set up within the Department
of Health, Education, and Welfare a new Bureau
of Older Persons, which immediately would start
out to solve some of the problems through grants,
demonstrations and more research.
Most controversial of the “help the aged” bills
is one originally proposed by the then Social Se-
curity Administrator, Oscar Ewing, in 1951. It
286
would allow 60 days a year of govemment-paic
hospitalization every year for persons covered b'
OASI after they reach age 65. They could hav<
this free service whether or not they were on re
tirement.
As in most Congresses, those who want to ge
the veterans more benefits and those who thin!
they are getting too much already are coming t<
grips over new bills. Important in this group i
a measure proposed by Chairman Teague (D.
Texas) of the House Veterans Affairs Committei
that would tighten up procedures under whicl
veterans with non-service-connected conditions re
ceive hospitalization. But at the same time then
is pressure from other quarters for a lengthening
of the “presumptive periods” for various diseases
Where the law now states that a certain diseasi
or condition will be considered service-connectec
if diagnosed within one year after the veteran’
discharge, these bills would make the period tw<
or three years.
Many other bills aimed at liberalizing veterans
benefits in various ways also are awaiting com
mittee action.
Social security and taxes are other popula
fields for the legislators. As expected, several bill
call for lowering the age at which a disabled per
son can start receiving his social security pension
now set at 50. Many measures would change th
income tax laws to allow more credit for medica
expenses, and one proposes allowing the taxpaye
to deduct premiums for health insurance fror
his income tax itself.
Of major interest to physicians and most sell
employed is the Jenkins-Keogh legislation, whic
would allow deferment of taxes on a portion c
income put into retirement plans.
Again, a number of lawmakers want the fee
eral government to take a more active part i
control of narcotics, barbiturates and amphett
mines and treatment of addicts. One suggestion
to consider any shipment of barbiturates or an
phetamines as a part of interstate commerce, o
the theory that intrastate control is essential t
interstate control. This and other bills also ca
for strict record-keeping and registration (phys
cians excepted from these provisions).
A plan introduced in the last session and offere
again would give the President the right to a
sume control over the production distribution an
use of any drugs or biologicals “for use in tl
prevention and treatment of disease.”
Other medical bills will of course be introduce
as the session moves on; those discussed here a
ready are assured of considerable attention.
.TMS1V
■Su*~gr.
MriBAcrsh
soap of h^'HecI o
PR REPORT
NEW FILMS ADDED TO
MSMS FILM LIBRARY
Doctors who anticipate giving court testimony
on a traffic accident or other personal injury cases
will be relieved to know that the MSMS Film
Library has three new films that will help them
prepare for their coming ordeal. Truly, ALL
doctors w'ill find these films valuable. In fact, they
are highly recommended for showing at county
medical society meetings.
Medical Witness is the first of new AMA series
on doctor-lawyer relations, having been produced
in co-operation with the American Bar Association.
The film depicts right and wrong methods of pres-
enting medical testimony by re-enacting the trial
of a personal injury case. Medical Witness is a
30-minute, black and white, 16 mm. sound film.
On Impact, a behind-the-scenes documentary
film, shows an entirely new approach to automo-
bile safety that can save a half-million persons
annually from highway injuries. Included are
scenes of actual automobile test crashes staged to
test new safety developments. The 14-minute,
black and white sound film was produced for the
AMA by the Ford Motor Company.
The Case of the Doubting Doctor is a dramatic
film which gets right to the heart of some of the
misunderstandings about medical societies — yet
brings home positively the tremendous values of
medical organizations from the county society
right on to the national level. Produced by the
AMA, the 30-minute color sound motion picture
is designed to stimulate greater member participa-
tion, create a better informed membership and
enhance appreciation of society services.
LT ANTIDOTE FOR TL
There’s nothing like a Locum Tenens as an
antidote for Tense Living.
Need a vacation? Want some temporary help
in your office during the summer resort rush? Or
would you just like a breather from a heavy pa-
tient load? Maybe a Locum Tenens is the answer.
The M.D. Placement Service of the Michigan
Health Council maintains a list of young doctors
of medicine who are seeking temporary positions.
Some of these M.D.s want openings right now.
Others will be ready this summer. And the time
they can spend as a Locum Tenens ranges from
six weeks to a year.
A letter or telephone call to the Michigan
Health Council, M.D. Placement Service, 706
North Washington Avenue, Lansing 6, Michigan,
will put you in touch with the practitioner you
might need to give you a hand for a short time.
So take advantage of this free service if you nee
assistance on a temporary basis.
Rather than wait until the last minute to find
Locum Tenens, however, the M.D. Placemei
Service recommends this procedure. As soon as yc
know the approximate dates you might need shor
term help in your practice, list your opening wit
the Service. This allows plenty of time for mal
ing the necessary arrangements with an M.D. seel
ing such a position as you offer.
SPEAKERS ON PLASTIC SURGERY
County medical societies may arrange for sc
entific speakers on the subject of plastic surgery I
contacting the Michigan Academy of Plastic Su
geons, according to an announcement by Robe
J. Meade, M.D., Lansing, Secretary of the new’
formed organization.
Doctor Meade said that members had offered 1
speak to medical societies and other groups in a
effort to relate new developments in plastic su:
gery to practicing doctors of medicine. TI
Academy asks that requests be made eight weel
in advance if possible. Write Robert J. Meadi
M.D., Secretary, Michigan Academy of Plasti
Surgeons, 1023 East Michigan, Lansing 12, Mich
gan.
IT’S STEADY WORK
BUT NOT MUCH ELSE
With eight years of socialized medicine exper
ence, some 40,000 British doctors are talking <
going on what amounts to a strike. Their incom
have been frozen since 1951. and they want a $
per cent pay boost to keep them abreast •
Britain’s inflated living costs.
This state of affairs presents the best argumei
against socialized medicine we’ve encountere
With the individual’s personal ability of su<
small account, and with no incentive to be s'
perior, we can’t see much future for Briti:
medicine’s ability to attract men who arer
mediocre.
And it’s highly alarming to think of the si
and the hurt having to put their faith in prac
tioners who went into medicine because it offe
steady work (even if the pay is poor) and a whi
collar. In light of what’s happened to Britaii
40,000 unhappy doctors, that appears to be abo
the most that can be said for the professi(
under socialized medicine.
We can’t imagine that many people would
happy over calling in a doctor who assessed 1
profession that way. — Detroit Free Press, Wedn<
day, January 16, 1957.
288
JMSI
EFFECTIVE in respiratory infections
ding the 25% due to resistant
ylococci.1-3
FFECTIVE in dermatologic and mixed
;issue infections including the 22%
ant to one or more antibiotics.3 6
effective in genitourinary infec-
including the 61% resistant to other
iotic therapy.2-5
IFFECTIVE in diverse infections includ-
le 21% due to resistant pathogens.1-5
EFFECTIVE in tropical infections in-
lg those complicated by heavy bacte-
mtamination or multiple parasitisms.7
1. Carter, C. H., and Maley, M. C. : Antibiotics Annual 1956-
1957, New York, Medical Encyclopedia, Inc., 1957, p. 51.
2. Shalowitz, M., and Sarnoff, H. S. : Personal communication.
3. Shubin, M.: Personal communication. 4. La Caille, R. A.,
and Prigot, A. : Antibiotics Annual 1956-1957, New York,
Medical Encyclopedia, Inc., 1957, p. 67. 5. Winton, S. S., and
Cheserow, E.: Antibiotics Annual 1956-1957, New York, Medi-
cal Encyclopedia, Inc., 1957, p. 55. 6. Cornbleet, T. : Personal
communication. 7. Loughlin, E. II.: Mullin, W. G.; Alcinder, L.,
and Joseph, A. A. : Antibiotics Annual 1956-1957, New York,
Medical Encyclopedia, Inc., 1957, p. 63.
tthe antimicrobial spectrum of tetracycline
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83 mg.) 2 oz. bottle.
■X-TRAOEMARK
Pfizer Laboratories, Division, Chas. Pfizer & Co., Inc., Brooklyn 6, N. Y
World leader in antibiotic development and production
AMA News Notes
AMA SPONSORS DOCTOR-LAWYER
MEETINGS
More than 300 doctors and lawyers in Atlanta,
Denver and Philadelphia will get together this month
(March) at the invitation of the American Medical
Association to discuss mutual problems of the two
professions. The day-and-a-half meetings have been
scheduled as a follow-up to three similar sessions held
in other cities in the fall of 1955. Dates and locations
for the Friday and Saturday symposiums are: March
15-16 at the Atlanta-Biltmore Hotel, Atlanta; March
22-23 at the Cosmopolitan Hotel, Denver, and March
29-30 at the Benjamin Franklin Hotel, Philadelphia.
Topics to be discussed include trauma and disease,
medical expert testimony and the medical witness. On
Friday afternoon, Dr. Herman A. Heise of Milwaukee
will speak on the use and background of scientific tests
for intoxication to be followed by a mock trial demon-
stration. Participants in the mock trial include AMA
staff personnel and Lt. Robert Borkenstein, inventor
of the testing device known as “Breathalyzer.”
On Saturday morning, a doctor-lawyer panel will
discuss trauma and cancer followed by a question and
answer period. After luncheon, Irving Goldstein, a
Chicago attorney, author of “Trial Technique, Medical
Trial Technique” and editor of Medical Trial Technique
Quarterly , will speak on the medical witness and expert
medical testimony. Winding up the program will be a
showing of the movie, “The Medical Witness,” and a
question period.
American Medical Association and American Bar As-
sociation representatives will be at each meeting. AMA
spokesmen in Atlanta and Philadelphia will be Dr.
David B. Allman, president-elect, and in Denver, Dr.
George F. Lull, secretary-general manager. ABA repre-
sentatives include — in Philadelphia, David Maxwell,
president; Atlanta, E. Smythe Gambrell, immediate past
president, and Denver, Thomas M. Burgess, member,
board of governors.
Registration fee for each symposium will be $5.00 to
cover the cost of the luncheon and any published pro-
ceedings. Advance registrations should be sent im-
mediately to the AMA Law Department.
NEW SLIDEFILM PINPOINTS
QUACK DEVICES
More than a dozen mechanical quack devices and
gadgets play the villain in a color slidefilm with sound
just released by the AMA Bureau of Investigation. The
15-minute filmstrip, “Mechanical Quackery,” is supple-
mented by narrative description of the devices and the
fraudulent uses to which they have been put. It is
available — on loan — to medical societies, service and
fraternal groups and schools.
Oliver Field, Bureau director, describes the film as a
public education experiment. “The slidefilm is a flexible
and effective medium to use in exposing some of the
quacks to the public,” he said. “It may be used by
medical societies or individual doctors as a tool in a
concerted program to fight quackery. It is valuable, too,
when used by lay or professional groups to alert their
members or the community to the harm caused by
quacks who use these worthless machines and devices as
cure-alls.”
Twenty-five sets of the film and record are in the
Bureau of Investigation’s lending library. Requests
should be addressed to the Bureau. (Note: Equipment
needed to show “Mechanical Quackery:” A sound
slidefilm projector — or a filmstrip projector with a 3354
RPM turntable. Strip has 60 frames. Record is 12-
inch.)
NEW MEDICOLEGAL FILM
A new medicolegal film on professional liability will
be premiered Wednesday evening, June 5, during the
AMA’s Annual Meeting in New York City. This film,
second in a series of six on various medicolegal prob-
lems, is being produced by the Wm. S. Merrill phar-
maceutical company in cooperation with the American
Medical Association and the American Bar Association.
C. Joseph Stetler, director, AMA Law Department, re-
ports a tremendous interest among both doctors and
lawyers in the first film, “The Medical Witness,” which
was first shown at the 1956 Clinical Session in Seattle.
COLD WEATHER DAMAGES EXHIBIT
Even babies embedded in solid blocks of plastic have
to be sheltered from the cold. Five of the twelve
fetuses embedded in plastic blocks for the AMA exhibit,
“Life Begins,” were damaged recently by exposure to
below freezing temperatures while enroute to Spring-
field. Illinois, for showings by the Illinois State De-
partment of Public Health. Preservatives inside ex-
panded, splitting the plastic blocks. The AMA Bureau
of Exhibits reports that the five fetuses are being reset
at the University of Illinois.
AREA MEDICAL SERVICE MEETINGS
A number of regional meetings have been scheduled
this spring by committees of the AMA Council on
Medical Service. Representatives of similar state com-
mittees will be invited to each session.
Committee on Maternal and Child Care. — March 30-
31 in Philadelphia for the New England and Middle
Atlantic states. Group will consider proposed guides
for perinatal death studies similar to those prepared for
maternal death studies.
Committee on Federal Medical Services. — March 16
in Reno, Nevada, for the Rocky Mountain and Pacific
Coast states; April 6 in New York City for the New
England and Middle Atlantic area. Principal discussion
topic will be the AMA policy on care for veterans with
(Continued on Page 298)
292
.TMSMS
NO OTHER
ANTIRHEUMATIC
PRODUCT
PROVIDES AS MANY
BENEFITS AS
1
MEPROl BAM ATE
predniso | LONE 'buffered
THE ONLY
ANTIRHEUMATIC,
ANTI ARTHRITIC
THAT SIMULTANEOUSLY
RELIEVES:
1. MUSCLE SPASM
3. JOINT INFLAMMATION
3. ANXIETY AND TENSION
4. DISCOMFORT
AND DISABILITY
MERCK SHARP Sc DOHME
DIVISION OF MERCK a CO.. INC. PHILADELPHIA I, PA,
MEPROLONE is the trade-mark of Merck & Ca. lac.
Say you saw it in the Journal of the Michigan State Medical Society
AMA NEWS NOTES
AREA MEDICAL SERVICE MEETINGS
(Continued from Page 292)
non-service-connected disabilities in Veterans Adminis-
tration hospitals.
Committee on Aging. — April 27-28 in Dallas, Texas,
for the Southwestern states. Over-all problems in the
field of aging and the role of medicine and medical
societies in meeting these problems will be discussed.
“MARCH OF MEDICINE” PROGRAM
ON MISSIONARY MEDICINE REPEATED
Overwhelming response from physicians, churchmen,
television writers and viewers has prompted March of
Medicine to repeat its hour-long documentary on mis-
sionary medicine Tuesday, March 5. at 9:30 p.m. EST
over the NBC-TV network. This latest in the prize-
winning TV series, produced and sponsored by Smith,
Kline and French Laboratories in cooperation with the
American Medical Association, is called “Monganga,”
tribal dialect for “white doctor.” Originally televised
November 27, it brought a heavy flow of enthusiastic
letters, telegrams, phone calls and personal messages —
many asking to see the program again.
The show chronicles the daily labors of a medical
missionary, Dr. John Ross, as an “illustration of the
work American doctors are doing for sick people all
over the world.” Doctor Ross is shown at his 14-hour
day — overseeing his clinic and a nearby leprosarium,
conducting a weekly pre-natal clinic, traveling to dis-
tant “bush clinics.”
“NOMENCLATURE” INSTITUTE
IN INDIANAPOLIS
The American Medical Association recently an-
nounced that a short course on the use of the Standard
Nomenclature of Diseases and Operations in the doctor’s
office, clinic or hospital will be held June 17-19 at the
Indiana University Medical Center, Indianapolis. Two
other "Institutes” have been scheduled in 1957: March
11-13 in Roanoke, Virginia, and August 5-7 in San
Francisco. These three-day meetings are conducted by
the AMA as a special service to medical record
librarians and others using the Nomenclature in their
work. Tuition is free. Applications should be sent to
Mrs. Adaline C. Hayden, C.R.L., associate editor of the
Nomenclature, at AMA Headquarters, Chicago.
FILM ON HEREDITY AVAILABLE
The basic story of heredity, sex determination, sex
roles and attitudes within the framework of heredity
and environment is dramatically told in a new color
film which has recently been added to the AMA Film
Library. The 18-minute sound film, “Human Heredity,”
was designed primarily for junior high students al-
though older persons also will find it informative. One
of the primary purposes of this 16mm film is to stim-
ulate group discussion on this extremely important
health subject. Medical societies may book the film
through AMA’s Council on Scientific Assembly Motion
Pictures and Medical Television.
NEWSCOPES
The American Medical Education Foundation wound
up its fifth year of operation with a record total of
$1,072,717 in contributions for the country’s 83 med-
ical schools. This represents a 41 per cent increase
over the previous year. . . . The Committee on Rela-
tionships Between Medicine and Allied Health Agencies
- — a committee of the AMA Board of Trustees — recently
developed a brief statement designed to assist medical
societies in this activity. Copies are available to phy-
sicians from the Council on Medical Service. . . .
Limited supplies of the booklet, “Fitness of American
Youth — A Report to the President of the U. S. on the
Annapolis Conference,” are available to physicians from
the AMA Bureau of Health Education. This sum-
marizes the findings and recommendations of the 149
national leaders in government, medicine, education,
recreation, public health, sports, civic and youth pro-
grams who met last June to consider the problems of
physical activity for young people. AMA representa-
tives included Dr. Elmer Hess, immediate past president,
and Dr. W. W. Bauer, director, Bureau of Health Edu-
cation.
THE EARLY BIRD CATCHES THE WORM
The Sears-Roebuck Foundation announces that ap-
plications for financial assistance to physicians desiring
to enter private practice are currently being processed
for the first half of 1957. The deadline for receiving
applications is April 1, with final determination on who
will receive assistance no later than June 15. All ap-
plications are reviewed by a 17-member Medical Ad-
visory Board who use as the sole criteria for loan evalu-
ation the medical need of the community and the
financial, need of the physician.
The Foundation makes an annual grant of $125,000
to a revolving assistance fund for the purpose of making
supplemental, 10 year, unsecured loans to physicians
interested in establishing or improving facilities in sub-
urban, rural or small town communities. These loans
can be used for new building construction, remodeling,
purchase of equipment, and for supplemental expenses
connected with establishing a practice. The interest
rate of these loans ranges from zero to six per cent de-
pending on the rapidity of repayment.
This is an ideal time for graduating internes and
residents who are interested in entering private practice
but lack the necessary funds to apply since, if chosen,
the funds will be available upon graduation in July. A
Foundation spokesman urged all interested physicians
to apply immediately and not wait for the April 1
deadline to insure proper processing of applications.
Applications may be obtained from county or state
medical societies, AMA’s Council on Medical Service, or
from the Sears-Roebuck Foundation, 3333 W. Arthing-
ton, Chicago, Illinois.
There is no single therapy which can be applied with
universal success at any time in the development of
bone cancer.
298
JMSMS (L
clinical evidence1 ^indicates that to augment the
therapeutic advantages of the “predni- steroids”
antacids should be routinely co-administered
to minimize gastric distress
ROUTINE
CO-ADMIN IS TRA TION
MEANS
All the benefits of the
“predni-steroids” plus
positive antacid action to
minimize gastric distress.
Riferences: 1. Boland. E. \V.,
J .A.M.A. 160:613 (February
25) 1956. 2. Margolis, H. M.
cl al, J. A.M.A. 158:454 (June
11) 1955. 3. Bollet, A. J. el al.,
.1. A.M.A. 158:459 (June 11)
1955.
(Prednisone Buffered)
2.5 mg. or 5 mg.
prednisone or
prednisolone with
50 mg. magnesium
trisilicate and
300 mg. aluminum
hydroxide gel.
MERCK SHARP & DOHME
DIVISION OF MERCK & CO INC.
PHILADELPHIA 1. PA
Say you saw it in the Journal of the Michigan State Medical Society
March, 1957
311
YOU AND YOUR BUSINESS
DIABETES HISTORY
(Continued from Page 278)
complete body must be free from evidence of cal-
cification in the arteries. The electrocardiogram
must be normal.
The first such medal to be awarded in Western
Michigan was given to Miss Janet Witteveen of
Holland at the February 15 meeting of the Muske-
gon County Medical Society.
Miss Witteveen developed the usual symptoms
of diabetes in January, 1930. She was examined
by Dr. Wm. C. Kools of Holland who found
sugar in the urine. He attempted control of the
disease by diet alone but found it necessary to
start insulin in November. 1930. In 1933, she
was admitted to Presbyterian Hospital in Chicago
under the late Dr. R. T. Woodyatt, who readjust-
ed the insulin dosage. In 1940, she was under the
care of Dr. Merrill Wells of Grand Rapids with
the complaint of numerous insulin shocks. She
was brought under better control at that time by
a combination of P.Z.I. and unmodified insulin.
In March, 1954, at the age of thirty-six, she
again was experiencing numerous shocks alternat-
ing with spells of hyperglycemia. She had an en-
larged thyroid, nervousness, palmar perspiration,
and other hyperthyroid symptoms. An isotope
tracer study indicated hyperactivity of the thyroid
and a therapeutic dose of I131 resulted in marked
diminution of these symptoms.
During her first year on insulin, she required
from thirty to forty units daily. In 1940, she was
controlled on 44 units, and at the present time is
well controlled on N.P.H. alone, two doses totaling
23 units. She was used in the experimental study
of “Orinase” for a time, which made no difference
in the degree of control or insulin requirement.
In November, 1955, she completed twenty-five
years on insulin. A complete physical examination,
x-rays, electrocardiogram and a thorough eye ex-
amination were done and forwarded to the Ad-
visory Committee in Boston. Word has just been
received that she has been awarded the medal
and it was presented to her officially on Feb-
ruary 15, 1957.
William M. LeFevre, M.D.
Councilor, 11th District
NEW \
1
A.
r
P.C.Demerol
ToM
312
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Phenacetin 150 mg. (2V2 grains)
olmlrol hydrochloride 30 mil (1/1 jjra!S) Narco,lc bla"k
Potentiated Pain Relief
WINTHROP LABORATORIES
New York 18, N. Y. • Windsor, Ont.
Demerol (brand of meperidine), trademark reg. U.S. Pat. Off.
Say you saw it in the Journal of the Michigan State Medical Society
JMSMS
nv JOU R N A L
of the Michigan State Medical Society
Issued Monthly Under the Direction of The Council
VOLUME 56 MARCH, 1957 NUMBER 3
Perinatal Mortality Study in Wayne County
January , 1953, to July, 1954
By Ruben Meyer, M.D.
C. Dale Barrett, M.D.
James T. Oliver
Detroit, Michigan
'T' HE REALIZATION that neonatal mortality
statistics have become fairly stable at levels
of about 20 per 1,000 livebirths in the last ten
years has stimulated a number of communities
to organize surveys of the problem. In June, 1956,
the Association of Maternal and Child Health
Directors counted twenty-six states engaged in the
study. The Wayne County Medical Society in
collaboration with the Detroit and Michigan De-
partments of Health established its Perinatal Mor-
tality Committee in 1952. A questionnaire type
of report form was developed by a group of ob-
stetricians, pediatricians, public health officers and
pathologists. Approximately forty hospitals in
Wayne County were asked to cooperate in com-
pleting a questionnaire for every stillbirth over
2,000 grams and all neonatal deaths. Nineteen
agreed to do so.
Each cooperating hospital appointed a commit-
tee to review the reports, compiled by a resident
or intern. The cause of death was to be verified
and preventability assessed. These reports were
then transmitted to the County Society Commit-
tee for further study. Ultimately all but nine hos-
pitals discontinued this work. Preventability was
too infrequently evaluated to analyze. No hospital
reported one hundred per cent of eligible still-
Dr. Meyer is Chairman, Perinatal Mortality Commit-
tee, Wayne County Medical Society.
Dr. Barrett is Director of Maternal and Child Health,
Detroit Department of Health.
Mr. Oliver is Biostatistician, Detroit Department of
Health.
births and neonatal deaths as revealed by a check
against death certificates. The average was 70
per cent with a range from 20 per cent to 88
per cent.
TABLE I. SUMMARY OF PERINATAL DEATHS
ACCEPTED FOR ANALYSIS
Total Cases Studied
1,456
Cases Excluded — Stillbirths under 2,000 grams
87
— No data
1
Total Cases Accepted
1,368
Neonatal Deaths
943
Stillbirths
425
The pertinent maternal history, both medical
and surgical, the history of the pregnancy, the la-
bor and delivery, and the neonatal history were all
to be covered in detail. The disease or condition
leading directly to the infant's death as well as oth-
er antecedent causes and significant contributory
conditions were reported with a reasonable degree
of accuracy. However, at the time of statistical an-
alysis, it became evident that there was frequent
omission of other data, and numerous items had
to be eliminated. Other items were loaded with
nonpertinent information and also had to be
discarded. For example, past medical history in-
cluded tonsillectomy and nonrelated childhood
diseases. This was a deficiency in editing by the
central committee which must be corrected in
future studies. Items regarding maternal anemia,
abnormal vomiting, bleeding, and physiologic ab-
normalities were all inadequately recorded and
specified.
March, 1957
321
PERINATAL MORTALITY STUDY— MEYER ET AL
The number of cases studied as seen in Table
I totaled 1,456, of which eight-eight were exclud-
ed, leaving 1,368. There were 943 neonatal deaths
and 425 stillbirths. It is not our intention to prove
There was good matching in all cause groups listed
in Table II except “maternal chronic disease”
and “other.” It is possible that the heavy weight-
ing of the study group by Herman Kiefer Hospital
TABLE II. COMPARISON OF STILLBIRTHS ACCEPTED FOR STUDY WITH TOTAL
STILLBIRTHS OCCURRING IN DETROIT DURING 1954-1955 CAUSES
OF STILLBIRTH. (EXCLUDING ALL STILLBIRTHS UNDER 2,000 GRAMS)
Causes of Stillbirth
Detroit,
1954-1955
Perinatal Death Study
Number
% of Total
Number
% of Total
Maternal diabetes
37
2.4
21
5.0**
Other chronic disease in the mother
19
1.2
7
1.6
Acute infection in mother
5
0.3
4
1.0
Toxemia
97
6.2
30
7.1
Ante-and intra-partum infection, etc.
10
0.6
6
1.4
CPD, dystocia, and malposition
Cord and placental conditions
95
6.1
22
5.2
Cord
309
19.7
69
16.2
Placental conditions
301
19.3
86
20.2
Birth injuries
27
1.7
11
2.6
Congenital malformation
112
7.2
32
7.5
Asphvxia; immaturitv; unknown
391
25.0
94
22.1
Erythroblastosis
87
5.6
34
8 0
Other
73
4.7
9
2.1*
♦Significant at 5% level.
♦♦Significant at 1% level.
A greater proportion of women having some chronic disease as a cause of stillbirth exists in the study
Soup in the city stillbirth occurrence. This may be due to the large proportion of cases selected from
erman Kiefer Hospital. Many problem cases are referred to Herman Kiefer Hospital for obstetrical
care and follow-up.
TABLE III. COMPARISON OF NEONATAL DEATHS ACCEPTED FOR STUDY
WITH TOTAL NEONATAL DEATHS OCCURRING IN DETROIT DURING
1953-1955 — causes of death
Cause of Death
Detroit, 1953-1955
Perinatal Death Study
Number
% of Total
Number
% of Total
Congenital malformations — CNS
40
1.2
13
1.3
Congenital malformations — Circul. Svst.
135
4.2
37
3.9
Other congenital malformations
171
5.3
71
7.5**
Birth injuries
244
7.6
83
8.8
Postnatal asph. and atelectasis
890
27.5
328
34.8**
Infections of newborn and other infections
105
3.2
20
2.1
Hemolytic disease of newborn
120
3.7
17
1.8**
Immaturity
1451
44.8
342
36.4**
Other
80
2 . 5
32
3.4
Total
3236
943
♦♦Significant at the 1 % level.
1. Greater proportion of congenital malformations in study group than for city.
2. Greater proportion of asphyxia and smaller proportion of immaturity as cause of death in study group
than for city as a whole. This is due to greater care in certifying other than immaturity as a cause of
neonatal death. Unfortunately, asphyxia and atelectasis is, in itself, as great a wastebasket cause as
is immaturity. It is more descriptive of the mode of dying than a cause of death. This points out the
need for establishing a new series of death cause classes pointing out abnormalities in delivery,
pathology in the mother leading to abnormal gestation and delivery, etc.
• A lower proportion of deaths due to erythroblastosis exists in the study group than in the deaths
occurring in the city. This may be due to the heavy weighting of cases from Herman Kiefer Hospital,
where the majority of the patients are drawm from the Negro race. The incidence of Rh negative
individuals is extremely small in the Negro.
any particular thesis in the study of these cases,
but simply to subject these two groups, neonatal
deaths and stillbirth, to statistical analysis, in
order to document certain characteristics of peri-
natal mortality in association with maternal con-
ditions.
A comparison was made of occurrence rate by
cause to total stillbirths between stillbirths re-
ported as occurring in the city of Detroit in 1954
and 1955 and the Perinatal Mortality Study.
cases has unduly influenced this group. Compli-
cated maternity cases from the low income groups
are generally routed through Kiefer Hospital.
Otherwise, the comparison shows that the study
group is a fair sampling of all stillbirths occurring
in Detroit.
Another matching test was made for birth
weight distribution of stillbirths as shown in Table
IV. The two groups do not appear to be well
matched. Discrepancies exist in three out of the
322
JMSMS
PERINATAL MORTALITY STUDY— MEYER ET AL
seven groups: 2,521 to 2,725 grams, 3,626 to
4,080 grams, and 4081 plus. There are a large
number of stillbirths reported to the Bureau
of Vital Statistics where weight is not stated. This
Table V shows better sampling as evidenced by
birth weight distribution in neonatal deaths when
the study group is compared with death cer-
tificates for the city at large. There is significant
TABLE IV. COMPARISON OF STILLBIRTHS ACCEPTED FOR STUDY WITH
TOTAL STILLBIRTHS OCCURRING IN DETROIT DURING 1954-1955
BIRTH WEIGHTS
(EXCLUDING ALL STILLBIRTHS UNDER 2,000 grams)
lirth We
ights in
Grams
2071-
2300
2301-
2520
2521-
2725
2726-
3175
3176-
3625
3626-
4080
4081+
Not Stated
or Unknown
Detroit perinatal death study
8.2
9.4
10.1**
24.3
16.2
11.5**
11.3**
9.0
Detroit occurrence 1954, 1955
10.5
10.6
5.2
22.4
19.5
16.4
6.7
12.5
♦♦Significant at 1 % level
TABLE V. COMPARISON OF NEONATAL DEATHS ACCEPTED FOR STUDY WITH
TOTAL NEONATAL DEATHS OCCURRING IN DETROIT DURING 1953-1955
BIRTH WEIGHTS
B
rth Wt
fights i
n Grarr
is
Under
1390
1390-
1615
1616-
1840
1841-
2070
2071-
2300
2301-
2520
2521-
2725
2726-
3175
3176-
3625
3626-
4080
4081 +
Not Stated
or Unknown
Detroit
perinatal
death study
53.3**
6.2
6.0
4.1
3.8
3.1
3.4
6.7
6.2
2.5
1.8
2.9**
Detroit
occurrence
1954, 1955
43.1
5.9
5.3
3.9
3.7
3.6
2.4
7.3
6.2
2.7
1.7
14.2
♦♦Significant at 1% level.
Many infants were not weighed at birth. Birth weight was estimated for study or obtained from autopsy
report after birth certificates (from which weight data were transcribed to death certificates) were turned
in to Registrar. The differences seen here, then, have no real meaning.
TABLE VI. COMPARISON OF CONDITIONS IN MOTHER AND INFANT FOR
LIVEBORN INFANTS DYING IN THE NEONATAL PERIOD AND FOR
STILLBORN INFANTS
Mat
ernal and Infant Pathology Present
Live
Neonata
3orn-
1 Death
Stillbirth
Number
Percent
Number
Percent
Total studied
943
100.0
425
100.0
Pelvic or abdominal surgery
182
19.3
83
19.5 Surgery recorded which was not
pertinent
Abnormal vomiting
109
11.6
32
7.5*
Bleeding
275
29.2
68
16.0**
Hypertension
74
7.9
60
14.1**
Albuminuria
67
7.1
56
13.2**
Infections
27
2.9
12
2.8
German measles or other virus
12
1.3
4
0.9
Medical or surgerical complications
106
11.3
72
17.0 Many conditions, not appropri-
ate, included
Anemia
94
10.0
49
11.5
Multiple pregnancy
126
13.4
11
2 6**
Premature rupture of the membrane
102
10.8
32
7.5
Analgesia
496
52.7
311
73.2**
Pituitrin
59
6.3
64
15.1**
Jaundice
43
4.6
4
0.9
A greater number of women having liveborn infants: Fewer women having liveborn infants:
1 — had a history of abnormal vomiting 1 — had hypertension or albuminuria
2 — had a history of bleeding during pregnancy 2 — received analgesia or pituitrin
3 — had a multiple pregnancy
♦Significant at 5% level.
♦♦Significant at 1 % level.
is a deficiency in hospital reporting of stillbirths
and points out the need for further education of
delivery room personnel to weigh all stillbirths.
difference only in infants less than 1390 grams
and weights not stated. The failure to weigh in-
fants is greater in the city as a whole than in the
March, 1957
323
PERINATAL MORTALITY STUDY— MEYER ET AL
study group. This indicates that case reviews re-
sult in greater attention to detail in hospitals and
are beneficial for that reason if for no other.
as they appear in stillbirth and neonatal death
records. Table VI lists the number and per-
centage of each group which shows the condition
TABLE VII. CAUSE OF STILLBIRTH AND GRAVIDA (EXCLUDING GRAVIDA
UNKNOWN OR NOT STATED)
Gravida
Median
1
2
3
4
5
6
7
8
9
10+
Total
Chronic disease in mother
4.38
6
2
3
2
4
4
2
1
1
3
28
Maternal toxemia
3.62
10
6
3
4
5
1
1
3
2
1
30
Dystocia and birth injury
1.92
11
6
5
2
6
0
1
0
1
0
32
Cord condition
2.14
22
11
7
11
7
2
2
1
0
4
67
Placental condition
2.35
21
17
13
16
9
3
2
1
1
1
84
Congenital malformation
1.83
9
9
7
5
0
1
0
0
1
0
32
Erythroblastosis
3.36
2
4
9
7
4
3
1
4
0
0
34
Immaturity and asphyxia
2.32
22
19
19
13
7
7
1
1
2
2
93
Other
3.33
5
1
3
3
3
2
0
0
0
2
19
Total
2.48
108
69
69
63
45
23
10
11
8
13
419
Percent
25.8
16.5
16.5
15.0
10.7
5.5
2.4
2.6
1.0
3.1
Accumulated percent
42.3
58.8
73.8
84.5
90.0
92.4
95.0
96.9
Women delivering stillbirths have* a history of a greater number of pregnancies than women delivering
liveborn infants who die during the neonatal period. Comparing gravidity and parity, a greater fetal
loss per number of pregnancies is seen for the following causes of stillbirth:
Dystocia and birth injury
Cord conditions
Immaturity and asphyxia
TABLE VIII. CAUSE OF STILLBIRTH AND PARITY (EXCLUDING PARITY
UNKNOWN OR NOT STATED)
Cause
Para
Median
0
1
2
3
4
5
6
7
8
9
10+
Total
Chronic disease in mother
3.08
5
5
3
1
6
3
1
1
2
1
0
28
Maternal toxemia
2.50
10
2
2
3
4
1
4
2
1
0
1
30
Dystocia and birth injury
0.33
16
3
5
2
4
1
1
0
1
0
0
33
Cord condition
0.88
19
17
7
10
7
1
2
1
1
0
2
67
Placental condition
1.26
23
15
17
16
8
3
6
1
1
0
0
84
Congenital malformation
0.68
9
ii
7
2
2
0
0
1
0
0
0
32
Erythroblastosis
2.25
2
4
10
6
8
0
3
1
0
0
0
34
Immaturity and asphyxia
0.93
21
28
17
12
6
3
1
1
2
0
2
93
Other
2.20
5
2
2
5
2
1
0
0
0
2
0
19
Total
1.19
110
87
70
57
47
13
12
8
8
3
5
420
Percent
26.2
20.7
16.7
13.6
11.2
3.1
2.8
1.9
1.9
0.7
1.2
Accumulated percent
46.9
63.6
77.2
88.4
91.5
94.3
96.2
98.1
98.8
Women delivering stillbirths have a history of a greater number of previous deliveries than women delivering
liveborn infants who die during the neonatal period.
TABLE IX. NEONATAL DEATH CAUSE AND GRAVIDA (EXCLUDING GRAVIDA
UNKNOWN OR NOT STATED)
Cause
Gray
ida
Median
1
2
3
4
5
6
7
8
9
10+
Total
Congenital malformation
1.94
27
34
27
17
6
3
1
2
0
0
117
Birth injury
1.64
28
21
11
5
8
3
4
1
0
1
82
Asphyxia
2.13
71
82
61
45
21
16
4
10
4
7
321
Infection
1.80
6
5
2
2
0
0
2
0
0
2
19
Hemolytic disease of newborn
3.50
3
2
3
2
2
3
1
1
0
0
17
Immaturity
2.11
87
75
70
42
28
18
8
4
4
3
339
Other
1.67
10
9
3
5
1
1
1
1
0
0
31
Total
2.01
232
230
176
118
67
44
21
19
8
13
928
Percent
25.0
24.8
18.9
12.7
7.2
4.7
2.3
2.1
0.9
1.4
Accumulated percent
49.8
68.7
81.4
88.6
93.3
95.6
97.7
98.6
Comparing gravidity and parity, a greater fetal loss per number of pregnancies is seen for the following
causes of death:
Asphyxia
Immaturity
The table shows that the study cases represent a
fair sample of the universe of neonatal deaths in
the city of Detroit.
A comparison was made of maternal conditions
under study. It appears that a greater number
of women having liveborn infants had a history
of abnormal vomiting, bleeding during pregnancy
and multiple pregnancies. We have no interp re-
324
JMSMS
PERINATAL MORTALITY STUDY— MEYER ET AL
tation for the abnormal vomiting and bleeding,
but it is not difficult to see that the product of
multiple pregnancies, while often low in weight,
dystocia and birth injuiy stillbirths indicates that
women delivering stillbirths due to that cause had
a history of greater fetal loss than mothers of other
TABLE X. NEONATAL DEATH CAUSE AND PARITY (EXCLUDING PARITY
UNKNOWN OR NOT STATED)
Para
Cause
Median
0
1
2
3
4
5
6
7
8
9
10+
Total
Congenital malformation
0.99
18
42
32
11
9
1
3
1
1
0
0
118
Birth injury
0.70
26
22
16
5
6
4
3
0
0
0
0
82
Asphyxia
0.76
91
92
52
35
23
10
11
4
0
0
2
320
Infection
0.75
7
4
3
2
0
2
0
0
0
0
I
19
Hemolytic diesease of
newborn
2.5
2
3
3
2
3
3
1
0
0
0
0
17
Immaturity
0.71
110
83
72
30
17
15
2
5
1
2
0
337
Other
0.64
9
11
4
5
0
0
1
i
0
0
0
31
T otal
0.78
263
257
182
90
58
35
21
11
2
2
3
924
Percent
28.4
27.8
19.7
9.8
6.3
3.8
2.3
1.2
0.2
0.2
0.3
Accumulated percent
56.2
75.9
85.7
92.0
95.8
98.1
99.3
99.5
99.7
TABLE XI. HISTORY OF PREVIOUS ABORTIONS, IMMATURES, OR OTHER
ABNORMAL PREGNANCIES FOR WOMEN DELIVERING STILLBORN
AND LIVEBORN INFANTS AS PERCENT OF TOTAL CASES*
Previous
Abortions
None
i
2
3
4
5
6+
Total
Stillborn
Liveborn-neonatal death
75.3
86.0
17.7
11.1
3.9
1.8
1.9
1 . 1
1.0
0.0
0.2
0.0
0.0
0.0
413
280
The two groups differ significantly. Women delivering stillbirths have a history of a greater number of
abortions.
Previous Immatures
None
1
2
3
4
5
6+
Total
Stillborn
90.4
7.4
1.5
0.0
0.5
0.2
0.0
404
Liveborn-neonatal death
90.3
8.5
0.4
0.4
0.0
0.0
0.4
282
The two groups do not differ materially regarding number of previous immatures.
Previous Other Abnormal Pregnancies
None
1
2
3
4
5
6+
Total
Stillborn
85.4
11.7
2 2
0 . 5
0.0
0.2
410
Liveborn-neonatal death
86.1
113
2.1
0.5
278
The two groups do not differ materially regarding number of previous abnormal pregnancies.
*Unknown or not recorded cases excluded; Liveborn 2,000 grams and under excluded, to match groups.
are quite apt to be born alive, albeit with a poor
:hance for survival.
Fewer women having liveborn infants had hy-
pertension or albuminuria and fewer received
analgesia or pituitrin. The possible effects of toxe-
mic factors or depressing agents in producing still-
oirth reveals itself here.
Tables VII through XI relate stillbirths to grav-
idity, parity and previous abnormal pregnancies.
Women delivering stillbirths have a history of a
greater number of pregnancies than those deliver-
ing livebirths who die in the neonatal period. The
difference between parity and gravidity in the
stillbirths. Wffimen delivering stillbirths have a
history of a greater number of births than do
those delivering liveborn infants dying during the
neonatal period. In the neonatal death group
the differences between parity and gravidity in
the asphyxia and immaturity deaths indicates that
women delivering infants who die of these causes
had a history of greater fetal loss than mothers
of infants dying of any other cause.
Table XII shows the incidence of various forms
of anesthesia related to stillbirths and neonatal
deaths. There was less pudendal usage in the
stillbirth class than in the neonatal deaths. Here,
March, 1957
325
PERINATAL MORTALITY STUDY— MEYER ET AL
TABLE XII. ANESTHESIA USED FOR DELIVERY —
COMPARING STILLBIRTHS AND NEONATAL DEATHS
Anesthesia
Pudendal
Saddle
Spinal
Inha-
lation
Other
None
Total
Stillbirths
— number
30
14
55
237
12
77
425
— percent
7 i**
3.3
12.9
55.8**
2.8
18. 1**
Neonatal
Deaths
— number
105
55
142
350
20
271
943
— percent
11.1
5.8
15. 1
37.1
2.1
28.8
♦♦Significant at 1% Level
Fewer women delivering stillbirths had pudendal or no anesthesia.
More women delivering stillbirths had inhalation anesthesia.
especially, a group of controls of survivors would
have been valuable to see if this is a trend in the
direction of survival with this form of anesthesia.
The opposite situation is seen under inhalation
anesthesia, where there are more stillbirths under
that class. With no anesthesia the apparent trend
is similar to pudendal. A control group of sur-
vivals is necessary for verification of these dif-
ferences.
Table XIII shows a comparison of analgesia
and anesthesia in varying combinations between
stillbirths and neonatal deaths. In order to mini-
mize the effects of other factors, we eliminated
infants or stillbirths who had conditions which
might be considered incompatible with life such
as congenital anomalies and erythroblastosis. To
match the two groups we eliminated neonatal
deaths under 2000 grams. We included only non-
macerated stillbirths known to have been alive
until shortly before birth. Also eliminated were
those infants with serious maternal or birth com-
plications such as toxemia, diabetes, cardiovascu-
lar disease, placental or cord problems, difficult
labor, presentation or inertia.
Analgesia, both with and without anesthesia,
shows a significant difference between the still-
births and neonatal deaths. There is a greater
usage of analgesia, proportionately, in the still-
births than in the neonatal deaths. Here, too, a
control group would have strengthened the validity
of this observation.
Conclusions
1. A second Perinatal Mortality Study should
be instituted with a new approach, using a check
sheet report of the type devised by the North Caro-
lina State Board of Health and other groups.
2. A research staff is needed with a substantial
part of its time available for supervision, comple-
TABLE XIII. ANALGESIA AND ANESTHESIA USEI
FOR DELIVERY. STUDY OF A SELECTED
GROUP OF CASES
Stillbi
rths
Neonatal
Deaths
No Analgesia or Anesthesia
5
8.8%
32
19.9%
Analgesia alone
3
5.3%
3
0.9%
Analgesia — total
47**
82.5%
92
57.2%
— with barbiturates
7
25
— without barbiturates
40
67
Analgesia and Anesthesia
44**
77.3%
89
55.4%
Analgesia and Inhalation
Anesthesia
23
46
Analgesia and Conduction
Anesthesia
21
43
Anesthesia Alone — Total
5
8.8%
37
23.0%
Anesthesia Alone —
Inhalation
4
15
Anesthesia Alone —
Conduction
i
22
Ether
27a
54.0%
54a
42.5%
No Ether
23
46.0%
73
Total cases includedb in
Anesthesia and
Analgesia Study
57
161
**Significant at 1 % level
(a) One in each group was recorded as “ether analgesia”
(b) Infants or stillbirths were included in this phase of the study
who :
1. Had no conditions which might be considered incompatib]'
with life. These include congenital anomalies, erythroblastosis
or who to match the stillbirths, were under 2,000 grams.
2. Were not macerated stillbirths and were known to have be'e'
alive until shortly before birth.
3. Did not have serious maternal or birth complications. Exclude :
were deaths occurring because of: a) Toxemia, diabetes, or C\
disease; b) Placental or cord problem; c) Difficult labor
presentation or inertia.
tion and editing, to produce reliable data. This
staff should also be available to participating hos-
pitals in organizing their programs. It should
co-ordinate the efforts of the hospital committees
with the Wayne County Medical Society Perinatal
Mortality Committee. In order to resume this
study in keeping with these recommendations, it
will be necessary to provide a research grant for
the purpose of financing the special staff needed
to do the work. The nucleus of this staff might
be composed of an obstetrician-pediatrician team;
clerical, nursing and statistical services co-ordi-
nated by an epidemiologist who would serve as
the research director.
3. A random selection of surviving infants
should be made to serve as a control against the
perinatal deaths.
4. Regular review of all perinatal deaths in all
hospitals in Wayne County should be established
procedure for accreditation. Without any deli-
berate evaluation it is evident from this study
that the examination of perinatal deaths resulted
in more careful attention to certain details. The
educational results should produce at least some
beneficial effect on fetal and neonatal salvage.
5. An evaluation of factors of preventability
should be part of future study.
(Continued on Page 330)
«
326
TMSMS
Review of Immunization Programs Recommended
With Advent of Salk Vaccine
TT is clear that immunization against polio-
myelitis should now be routine and must be
integrated with other immunization procedures.
Now, therefore, is a good time to review our
present habits of immunization in this part of the
country, and to consider why we have arrived at
our present generally accepted program.
Immunization is routine against diphtheria,
whooping cough, tetanus, and smallpox in Michi-
gan, and now poliomyelitis must be attacked. We
may hope that in a few years other diseases can
ne prevented; for instance, measles.
Our present programs, like many other things
in medicine, are a result of multiple compromises.
In considering the acceptance of any immunizing
agent, the factors to be weighed are the effective-
ness of the immunizing agent balanced against
the risk of the procedure, and all considered in
balance with the risk of the disease itself. The
risk of the disease itself may change over the
years as is true to these common diseases which
are being considered. The risk is influenced by
the frequency of the disease and, of course, by
the effectiveness of available treatment.
The timing of the procedure is first determined
by the danger period in life of the disease con-
sidered, but our whole program is of course great-
ly influenced by matters of convenience and cost.
There has been in the last decade a marked trend
towards early immunization so that most routines
are initiated in very young children, at two or
three months of age or even earlier. This tendency
las developed because of the convenience of im-
munizing small infants, the short memory of a
three-month-old infant, the few reactions, but
most importantly the desire to develop, early in
ife, protective antibody levels against whooping
;ough.
The first disease against which general im-
munization was successful was, of course, small-
iox. Here in Michigan, and at this time, we can
Dr. Wilson is in the Department of Pediatrics, Uni-
versity Hospital, Ann Arbor, Michigan.
VIarch, 1957
By James L. Wilson. M.D.
Ann Arbor, Michigan
consider that we are carrying out smallpox vac-
cination on an individual as a matter of general
duty to the public. The risk of exposure to small-
pox itself is almost negligible. The risk of serious
complications from the vaccination is very small
indeed, but even local reactions are a nuisance so
that we can consider that a person living in
Michigan at present is making some sacrifice for
the good of general public health by having his
infant or himself vaccinated. We realize, how-
ever, that if this procedure were dropped, we
probably would be in trouble again in a very
few years and no one questions the advisability of
continuing smallpox vaccination. The age of vac-
cination becomes then surely a matter of con-
venience since the risk of exposure at any age is
small. It is obvious that the risk of the vaccina-
tion procedure itself becomes somewhat less in
the small infant than the child of two or three,
since he is less likely to contaminate the vaccina-
tion wound with his fingers when he is an infant.
He is more protected and there is less chance for
secondary infection. Another argument for early
immunization is that the infant is much more
under our control; we have him in our hands, as
it were, and early vaccinati@n can be combined
with vaccination for other diseases for which the
urgency is somewhat greater. Most physicians,
therefore, are combining the vaccination with the
other immunizations and a convenient time is in
the middle of the first year. Some physicians are
recommending smallpox vaccination in the new-
born period. It is true that almost every baby is
then completely under control since he is in the
hospital and vaccination can be recommended
then with certainty that it is going to be accom-
plished. The disadvantage is worth considering.
There probably are a greater number of failures
of “takes” in the newborn period. There seems
to be some lessening of ability to develop vaccinia
and, of course, many physicians dislike complicat-
ing this very confused period of life with some
other illness. However, it is clear that the de-
cision as to when to vaccinate can be made on the
327
IMMUNIZATION PROGRAMS— WILSON
basis of convenience rather than on immunological
data.
It was early believed that a very young baby
developed antibodies against pertussis very poorly,
so in the early days of pertussis immunization the
procedure was not initiated until the child was
six, seven, or even eight months of age. In the
case -of pertussis this delayed immunization car-
ried a very great disadvantage since the mortality
from whooping cough is far greater in early in-
fancy than it is later. It was a great step ahead
when Sako* showed that a small baby could in-
deed make antibodies to pertussis, even though
not as effectively. There was an immediate trend
towards earlier immunization against pertussis to
gain some protection as soon as possible against
higher mortality in early infancy. This was very
reasonable, even though the antibody level result-
ing might not be as great. Whether this should be
initiated at one month, two months, or three
months, is still a matter of opinion but that it
should be early seems definitely accepted by every-
one. It is interesting that soon after we began the
early immunization against whooping cough for
the advantage it gave us in the prevention of early
and highly fatal disease in small infants, our anti-
biotics began to appear and the risk of whooping
cough itself in early life became less if medical
care was sought since our treatment became im-
mediately more effective. Nevertheless, there
seems no reason at all to return to the late date
of immunization simply because we have these
broad spectrum antibiotics.
About the time when the effectiveness of early
initiation of whooping cough vaccination became
evident the combinations of antigens such as
whooping cough and diphtheria were shown to be
effective. We feel, however, no urgency to im-
munize the small infant against diphtheria.
Maternal antibodies are carried through the
placenta and this passive immunity protects the
baby pretty effectively for six months or so. How-
ever, the advantage of the combination of diph-
theria toxoid and pertussis vaccine made it prac-
tical and sensible to give the diphtheria toxoid
early simply because we needed to get pertussis
immunity early.
Immunization against tetanus has almost al-
ways been a “free rider” in the pediatric age
group. The risk of tetanus in infancy is practical-
*The Journal of the American Medical Association
Vol. 127, No. 7, February 17, 1945, page 379.
328
ly negligible. We immunize our infants against
tetanus not so much because of the risk from
tetanus as that it can be done “for nothing” since
it can be combined very effectively with diph-
theria and whooping cough with some synergistic
advantage and no added risk of reaction.
In our more sophisticated populations the ad-
vantage of immunization against tetanus is as
much to prevent the later need for decision about
giving horse serum with its risks in case of an ac-
cident as it is simply to prevent tetanus. Im-
munization against tetanus had never been proved
by clinical data to be effective in infants or young
children. However, the determination of anti-
body level showed, without any question, that im-
munization was theoretically effective. It re-
mained for war experience in adults, however, to
prove from a clinical point of view that tetanus
immunization with the use of toxoid actually was
effective, and no one questions the advisability of
combining it, therefore, with the other agents in
the now common triple vaccine, whooping cough
and diphtheria, all at an early age as a matter of
convenience rather than because the risks in these
early months of life calls for such protection.
Now, the new agent, the Salk vaccine, comes
in for consideration. There is no need in this note
to attempt to summarize the results of the nation-
wide experiment which was necessary to determine
the effectiveness of the Salk vaccine. We can ac-
cept it as being highly effective even though we
are not yet quite certain as to how frequently
booster shots have to be given. In the great ex-
periment, the shortage of the material available
made it practical to limit the immunization to
the children in the age group where the greatest
poliomyelitis incidence occurred, and where the
children were available for controlled experiment,
that is, in the first, second, and third grade chil-
dren. After the vaccine was shown to be effective,
there was still a great shortage of the vaccine
which only recently has been relieved, so that im-
munization continued for some time to be re-
stricted to the most susceptible age groups, ex-
cluding infants.
As with all immunization procedures, again the
question arose as to the ability of a small infant to
develop antibodies under the stimulus of an
antigen. This was questioned in regard to polio-
myelitis as it had been in regard to whooping
cough and other diseases, but particularly because
of the known passive immunity which the mother
JMSMS
IMMUNIZATION PROGRAMS— WILSON
transmitted to the baby, as in diphtheria, which
protected the baby for a considerable extent,
though not absolutely, for the first early months
of life. The question was whether the passive im-
munity of early life might prevent the develop-
ment of active immunity, and whether the small
infant’s capacity to develop antibodies was too
immature anyway. It was a big step ahead there-
fore, when it became pretty evident that the
presence of passive antibodies did not prevent the
development of active antibodies, but this did
not prove still that young babies could, in fact,
develop antibodies. At this moment, only a few
studies have been carried out on this point. The
one from the Well Baby Clinic of the Michigan
School of Public Health and Department of
Pediatrics has seemed to us adequate, however, to
establish the fact that a useful level of antibodies
can be produced in this age group. It seems cer-
tain, at this writing, that immunization can be ini-
tiated at three or four months of age or even
earlier without the antigen’s being wasted.
Now, although the risk of poliomyelitis is very-
much less in small infants than in older children,
the convenience of injecting a small infant versus
an older child, again adds its weight to the ar-
gument for early immunization. The fact that the
babies are being routinely brought by their moth-
ers to physicians for such procedures, gives another
reason for initiating the immunization then
rather than waiting for the age group where the
risk of poliomyelitis is greater.
There seems at present to be no reason for not
| giving the Salk vaccine at the same time we in-
t itiate the so-called triple vaccine injections. A
question still at issue is whether the mixing of the
Salk vaccine and the standard triple vaccine in
the same syringe results in any less effectiveness of
the two agents. The fact that the State furnishes
free one material, and the other must be pur-
chased, also may pose a small problem. It seems
best to give the two products separately in two
syringes until further data are available, though
probably the mixture would be both safe and ef-
fective.
There has been much public discussion of the
j idvantage of an oral vaccine against poliomyelitis.
Phis procedure is indeed tempting to consider. It
seems highly probable that such a vaccine can be
developed and may be available in a few years,
and it appeals to us because the oral route is the
way that nature itself produces natural im-
munizations, and because it could be given with-
out the pain and the bother associated with a
needle. However, the advantage of an oral vac-
cine, if available, over our injected vaccine may
not be very great from a practical point of view
if the vaccine can be combined with the present
triple vaccine into a quadruple vaccine. Can such
a package be made of the four vaccines? I think
there is little doubt that it can be and that we
can expect soon such product to be on the mar-
ket, but possibly not approved for one or two
years, though very active work is being carried
on in this field. When this takes place, the ad-
vantage of an oral vaccine in infants will then
become negligible since we have to give a “shot”
anyway for the routine immunization against our
other diseases, and the combination of the Salk
vaccine, like that of tetanus, can be a “free rider”
with the other necessary immunization procedures.
But without waiting for an oral vaccine or a
quadruple vaccine, and with the availability of
an adequate supply of Salk vaccine, it seems de-
sirable that immunization with the Salk vaccine
in infancy should be immediately carried out as a
routine. The administration of two shots at the
same time is very convenient indeed. A small
baby hardly begins to cry from his first shot be-
fore the second one is injected, and the total
trauma to be remembered, therefore, seems to be
actually about the same as if the product were
mixed.
The timing of the procedure again seems to be
a matter of convenience. The baby is brought to
most physicians at two or three months of age
for initiation of the triple vaccine. A very prac-
tical procedure, therefore, is to begin now to give
two shots at three months (or if one prefers at
two months), one of the triple vaccine, which is
now traditional and free, and one of the Salk
vaccine that must be purchased; on the fourth
month of life, or one month after the first shot, to
give again the triple vaccine; on the fifth month
to give the third shot of the triple vaccine, as we
now do, and the second shot of the Salk vaccine,
and finally the third shot of the Salk vaccine with
the routine booster shot of the triple vaccine at
the end of the first year or some few months later.
The reactions to Salk vaccine have been so smalt
that the fear of a double reaction, therefore, seems
no longer an adequate reason for wanting to give
March, 1957
329
IMMUNIZATION PROGRAMS— WILSON
the two shots at different times. The total amount
of work involved for the physician is hardly in-
creased. Since the total amount of work for the
mother to bring her child to a physician for this
procedure is not increased, she is likely, therefore,
to adhere to the program.
The booster shot is now routine and is wisely
based upon the fact that although immunization
when it is started as early as three months, may
result in somewhat less effective production of
antibodies, that a booster shot will bring on a
marked recall reaction and give us a total im-
munity far better than if we had started it later
with only three injections. One must not con-
sider the proposed program as necessarily to be
rigidly followed because great variations of it
might well be made without theoretical dis-
advantage.
There is some question whether the initiation
of Salk vaccine immunization should ever be co-
incidental with a booster shot to other agents.
The journal of Immunology* has published some
data that would indicate that there may be a poor
response to the first injection of one antigen if, at
the same time there is being stimulated a recall
reaction by a “booster shot” of some other antigen.
In other words, a recall reaction to tetanus, per-
tussis, and diphtheria by a booster shot being
given, let us say at fifteen months, might be a poor
time to give the first shot of the Salk vaccine.
This is another reason, therefore, to initiate them
all simultaneously.
*The Journal of Immunology — Volume 77, Number
3, September, 1956. Studies on Diphtheria-Pertussis-
Tetanus Combined Immunization in Children. I.
Heterologous Interference of Pertussis Agglutinin and
Tetanus Antitoxin Response by Pre-existing Latent
Diphtheria Immunity.
The infant immunization program has been
carried out by pediatricians with such enormous
success that the vast majority of people, taught to
expect this program, are cooperating to have their
infants so protected, but this interest in little
babies does not seem to be carried on to the
school age group. The lack of interest in main-
taining protection of older children against diph-
theria, for instance, has been emphasized recent-
ly by the increase of diphtheria cases in Detroit.
It is rather disturbing that now that there is an
abundance of Salk vaccine, the demand by the
public for it has become less. We shall have to
“sell” this protection to the people now, just as
we have less dramatized procedures in the past.
The problem of getting adults immunized, and
older children who are already past the childhood
age in which immunization procedures is asso-
ciated in the public mind, is a very difficult one.
The initiation of a Salk vaccine procedure in an
infant, however, makes a very good time to sug-
gest to young parents that they themselves could
profit from this protection as the data year by
year show more and more the increased age in-
cidence of poliomyelitis.
The following is a suggested program to be
followed now until a quadruple vaccine is avail-
able. It should be emphasized that theory would
permit wide variations in any program and that
practical considerations of convenience, cost, and
of the public interest, play a bigger part of estab-
lishing the details than do immunization prin-
ciples.
3rd month — triple vaccine and 1st Salk dose
4th month — triple vaccine
5th month — triple vaccine and 2nd Salk dose
1 5- 1 8th month — triple vaccine and 3rd Salk dose
PERINATAL MORTALITY STUDY IN WAYNE COUNTY
( Continued from Page 326)
6. An “alerter” system might be efficiently used
to investigate current perinatal mortality rates in
hospitals where they deviate from the expected
mean. This need not be so elaborate as the Chi-
cago system.
7. The Association of Obstetricians and Gyne-
cologists, the American Academy of Pediatrics
and other interested organizations should meet
with representatives of the statistical division of
the World Health Organization to revise the sec-
tion of the international lists of Diseases and
Causes of Death which pertain to perinatal mor-
tality. In coding stillbirths, there is too much
overlapping of asphyxia and immaturity. On the
other hand, there is inadequate coding of mater-
nal complications in neonatal deaths.
330
.TMSMS
A Review of Pediatric Meningitis in a General
Hospital Over a Ten-Year Period
By E. M. Eichhom, M.D.
J. H. Reid, M.D.
Flint, Michigan
VER THE past two decades the outlook for
^ the meningitis patient has changed from one
of almost complete hopelessness to that of fairly
good chance for complete cure. However, deaths
and disabling complications irom meningitis still
occur, and the disease remains a sufficiently for-
midible emergency to warrant serious study for
the purpose of improving our understanding of
the disease and thereby utilize our diagnostic and
therapeutic weapons to best advantage.
Of the many advances in clinical medicine dur-
ing recent decades, none surpass antimicrobial
therapy in usefulness to the practitioner of medi-
cine in his efforts to control disease. Nowhere is
the importance of antimicrobial agents more
dramatically portrayed than in the therapy of
meningitis. Now that most of the commonly used
antimicrobials have been available for several
years, it is possible to study the results of their use.
The purpose of this study is to determine how
effective their use has been in the past, and to
find if previous experience offers information en-
abling us to utilize them more effectively.
The material for this study was provided by
reviewing the case records of pediatric meningitis
cases from 1945 through 1954 at Hurley Hos-
pital. We feel that Hurley Hospital, a general
hospital with an open staff, offers an excellent
opportunity to examine the care of a serious infec-
tious disease by a presumably average cross section
of medical practitioners.
Over the ten-year-period there were 151 cases
with thirty-four deaths, for a gross mortality rate
of 22.5 per cent. When the statistics are examined
for individual years (Fig. 1), it is found that there
is a gradual increase in the number of cases, while
the death rate follows a downward trend. The
mortality for recent years approaches the 10 per
cent rate which should be obtainable, according
to recent articles.1,2
Of the patients who survived their illness, six-
teen (14 per cent) were noted to have definite
neurologic residuals. These included mental re-
tardation, paralysis, spasticity, convulsions, hydro-
cephalus and blindness. One can assume that
not all residuals became fully documented on the
total no. of cases 151
total no. of deaths 3u
Fig. 1. Pediatric meningitis cases during a ten-year
period.
charts. Subtle damage resulting in personality
changes, behavior problems, mild retardation, and
mild spasticity could easily be overlooked in an
infant. In addition, there were twenty-two cases
with periods of hospitalization over three weeks.
Such prolonged courses would imply late control
of the disease and a high incidence of residual
brain damage.
Figure 2 demonstrates the age incidence and the
death rate according to age. Of the nine infants
less than one month old, eight died. Of the twenty-
nine infants one to six months old, seven died.
It is obvious that meningitis is primarily a disease
of infancy and that mortality is higher in the
very young.
March, 1957
331
PEDIATRIC MENINGITIS— EICHHORN AND REID
Clinical Manifestations
To prevent mortality and to keep residual cen-
tral nervous system damage at a minimum, early
recognition is essential. In an effort to become
3&
Fig. 2. Age incidence of meningitis.
familiar with the clinical findings seen most fre-
quently, the observations on the patients reviewed
were listed in Table I. This tabulation consists of
the signs and symptoms noted on the 115 cases
with an acceptable history and physical examina-
tion. All age groups were included. It is inter-
esting that in twenty-six cases no mention was
made of the presence of the findings usually asso-
ciated with meningeal irritation. These cases were
reported as having the findings shown in Table II.
As might be expected, most of these patients were
in the younger age groups, however; the oldest
was twelve years old. It is noteworthy that ten
of the twenty-six patients expired. Frequently,
diagnosis was not suspected early and proper
therapy was delayed.
It is only reasonable to assume that if those who
examined these patients had been more familiar
with the less well known manifestations of
meningitis in infancy, the tabulation would have
been higher for these findings. An excellent re-
view article published recently1 listed the more
common findings seen in meningitis at different
stages of infancy. These are presented in Table III.
In reviewing the clinical picture of meningitis,
it is useful to remember that most cases are hema-
TABLE I. SYMPTOMS AND SIGNS OF MENINGITIS
(FROM 115 CASES WITH ADEQUATE WORK-UP)
FEVER 85
STIFF NECK 77
VOMITING 70
DROWSINESS 49
RASH-PETECHIA 28
CONVULSIONS 26
STIFF BACK 23
UPPER RESPIRATORY INFECTION 21
HEADACHE 18
COMA 15
IRRITABLE 14
BULGING FONTANELLE 10
OCULAR SIGNS 7
NECK PAIN 7
KIR MG. BRUDZINSKI 4
LEG PAIN 3
BACK PAIN 2
ABDOMINAL PAIN 2
TABLE II. SIGNS AND SYMPTOMS IN 26 CASES
WITHOUT MENINGEAL IRRITATION
FEVER 19
VOMITING 15
DROWSINESS 14
CONVULSIONS 7
BULGING FONTANELLE 6
RASH OR PETECHIA 6
COMA 4
UPPER RESPIRATORY INFECTION.. 4
IRRITABILITY 3
HEADACHE 2
OCULAR SIGNS 2
togenous in origin.3 If the septicemia can be
recognized and treated before meningitis appears,
the prognosis becomes much better. In septi-
cemia, as well as in meningitis, clinical manifesta-
tions in the newborn and younger infant are not
as striking as in older children, and valid infor-
mation regarding these manifestations is valuable.
Table IV contains manifestations listed in a report
recently published.4 The authors reported that
enteric organisms were found in 80 per cent of
cases in recent years, with Escherichia coli the
most frequently encountered organism.
Laboratory Diagnosis
Once meningitis (or septicemia in infants) is
suspected, the spinal fluid should be examined as
soon as possible. By personally examining spinal
fluid stained with Methylene blue and with Gram
stain, the physician may be able to plan a more ef-
fective therapeutic program. The diagnostic pro-
gram should include blood culture as well; occa-
sionally this will produce the causative organism
when spinal fluid culture fails. Petechiae also
should be scraped for smear and culture. The
role of the laboratory in diagnosis is a vital one
and good bacteriologic technique should be active-
ly encouraged.
332
.TMSMS
PEDIATRIC MENINGITIS— EICHHORN AND REID
Causative Organisms
Our experience regarding causative organisms
is seen in Figure 3.
In forty-six cases (30.5 per cent), no organism
Gram negative diplococci were seen in thirteen
instances, or 8.5 per cent. There was one death,
for a rate of 7.7 per cent. These cases were scat-
tered throughout infancy and childhood.
ORGANISTS ENCOUNTERED
figures in parentheses represent fatalities
UNKNOWN
H. INFLUENZAE
N. MENINGITIDIS
331 (U)
3 28 (3)
ORA.: NEG. RODS
GRAM NEG. DIPLOCOCCUS
PNEUMOCOCCUS
GRAM POS. DIPLOCOCCUS
M. TUBERCULOSIS
PSEUDOMONAS
STAPH. ALBUS
ESCHE:lICHIA COLI
STREPTOCOCCUS
33 1U (U)
3 13 (1)
Fig. 3. Organisms encountered. Figures in paren-
theses represent fatalities.
31*6(111)
TABLE III. MENINGITIS MANIFESTATIONS
(From Pediatrics, Vol. 17, February 1956.)
IN THE NEWBORN
CYANOSIS
FEVER
VOMITING
JAUNDICE
JITTERYNESS OR DROWSINESS
IN OLDER INFANTS
FEVER
VOMITING
JITTERYNESS OR DROWSINESS
CONVULSIONS
BULGING FONTANELLE
was found. This group had fourteen deaths, for a
mortality rate of thirty per cent.
Hemophilus influenzae was seen in thirty-one
cases, or 20.5 per cent of the total number. There
were four deaths for a mortality rate of 13 per
cent. The ages ranged from two months to six
years, with all but five in the first two years.
Neisseria meningitis was seen in twenty-eight,
or 18.5 per cent of the cases, with three deaths,
for an eleven per cent mortality rate. Ages ranged
from two months to thirteen years, with all but
eight between five months and three years.
Organisms identified only as Gram negative
rods were seen from fourteen patients, or 9 per
cent. Four of these died, for a mortality rate of
29 per cent. Three of this group were less than
one month old, the rest were scattered throughout
infancy and childhood.
TABLE IV. NEWBORN SEPTICEMIA
(From Pediatrics, Vol. 17, April 1956.)
EARLY CLINICAL FINDINGS
FEVER OVER 101 47%
GASTROINTESTINAL 30%
JAUNDICE 29%
SKIN LESIONS 24%
CENTRAL NERVOUS SYSTEM. .. 15%
OMPHALITIS 9%
LATER CLINICAL FINDINGS
FEVER OVER 101 51%
HEPATOMEGALLY 33%
ICTERUS 32%
MENINGITIS 26%
SKIN LESIONS 21%
CENTRAL NERVOUS SYSTEM. .. 13%
Pneumococcus was identified seven times, or
4.6 per cent. The mortality numbered two, or a
rate of 28 per cent. The ages ranged from one
month to six years, but all except one were in
the first thirteen months.
Gram positive diplococci were seen four times,
or in 2.6 per cent. There was one death.
Tuberculous meningitis was proven in three
patients, with one survival. A tremendous de-
crease in incidence compared to earlier studies
that found tuberculous meningitis to he one of
the most common types.3
Pseudomonas was found twice, fatal on both
occasions. The ages were newborn and seven
years.
Staphlococcus albus was present twice, fatal
once.
Escherichia coli and streptococcus were each
identified once. Both patients recovered.
March, 1957
333
PEDIATRIC MENINGITIS— EICHHORN AND REID
Effect of Treatment Prior to Diagnosis
It is well known that previous antibiotic ther-
apy often makes identification of the causative or-
ganism difficult or impossible. When this occurs,
precise antimicrobial planning is usually impossi-
ble.
Our experience in this regard revealed that, of
the fifty-two patients known to have had anti-
microbial therapy prior to diagnosis, organisms
were observed in twenty-three cases. In the ninety-
nine patients not known to have had antimi-
crobial therapy before diagnosis, eighty-two had
organisms observed. For the two groups the
fatality rate did not differ significantly. Of the
fifty-two receiving prior treatment, ten died. Of
the ninety-nine not known to have had prior treat-
ment, twenty-four died. This last group includes
most of those having a rapid fulminating course
who died a few hours after being first seen and
admitted to the hospital.
Of the sixteen patients known to have residual
central nervous system damage, seven were known
to have had antibiotics prior to diagnosis. Seven-
teen of the twenty-nine patients with a hospital
stay of over three weeks had also received anti-
biotics before spinal fluid examination.
Therapy
Once the diagnosis of meningitis is established,
treatment should not be delayed. Effective blood
and tissue levels of antimicrobial agents are most
rapidly obtained by intravenous administration.
Frequently, it is possible to do this at the same
time veneclysis is performed for the blood culture.
With the large number of physicians composing
the attending staff, one would expect to see a
large number of therapeutic programs. However,
in recent years the tendency has been for the man-
agement to become quite similar, with most pa-
tients being placed on programs closely resembling
those advocated in recent articles on the sub-
ject.1’2’5
When the organism is unknown, most patients
receive sodium sulfadiazine, Chloromycetin, and
crystalline penicillin all in large dosage. Some
authorities 2,5 feel that all patients should be start-
ed on multiple antibiotics in this manner, drop-
ping the less effective agents when the culture and
sensitivity studies become available. However,
others1 feel that more accurate treatment is often
possible.
In H. influenza infections, Chloromycetin is
usually the most effective antibiotic. Dosage
ranges from 75 to 100 mg/k. Other broad spec-
trum agents and sulfadiazine are useful with this
organism. H. influenza type B antiserum was
felt to have speeded improvement noticeably in
several of our own cases.
For meningococcus infections, sulfadiazine is
the therapy of choice. Penicillin is often used
with the sulfa.
In pneumococcus meningitis, it is generally
agreed that penicillin is the most effective agent
and should be administered in frequent large
doses, 1,000,000 units every four hours.
Pseudomonas aeruginosa meningitis has a bet-
ter prognosis now that polymixin B is available.
Tuberculous meningitis therapy is outside the
scope of this discussion. The reader is referred
to an excellent report.6
Complications
Of the early complications of meningitis, periph-
eral vascular collapse is the most dangerous. It
must be watched for carefully and treated vig-
orously. The picture of acute adrenal insuffici-
ency encountered in the Waterhouse-Friderichsen
syndrome is well known and in this emergency
hydrocortisone is useful. Whole blood, intraven-
ous fluids, and levarterenol may be required as
well in order to bring the patient out of the peri-
pheral collapse.
In addition to the shock produced by acute
adrenal insufficiency, it is recognized that septice-
mia can cause peripheral vascular collapse.7,8
Shock of this etiology is treated much like that
of adrenal collapse with more emphasis on the use
of levarterenol.
Of the thirty-four deaths in our series, post-
mortem examinations were performed on twenty.
Of these, only two had hemorrhagic destruction of
the adrenals. One of the two produced a growth
of meningococcus and the other had a rash typical
of meningococcemia. Meningococcus was cul-
tured from two additional cases, and one other
with a hemorrhagic rash. However, these had no
anatomic adrenal abnormality. A suprisingly fre-
quent postmortem finding was degenerative
changes of the renal tubular epithelium. This
was seen in fourteen of the twenty postmortem
examinations. Experimental work on the effects
334
TMSMS
PEDIATRIC MENINGITIS— EICHHORN AND REID
of hypotension on the kidneys of dogs9 may explain
this finding.
Subdural fluid formation is another complica-
tion deserving mention. This well-described en-
tity10 is responsible for many of the postmeningitis
central nervous system defects, but is easily diag-
nosed and not too difficult to treat, with gratify-
fying results when recognized early and treated
properly. Diagnosis is made by subdural tap. In-
dications for subdural tap are: Failure of tem-
perature curve to show a progressive decline,
positive spinal fluid culture after forty-eight hours
of adequate therapy, convulsions during the con-
valescent period, gross neurologic abnormality,
clinical impression that the course was unsatis-
factory, and enlargement of the head circum-
ference.
Summary
The pediatric meningitis cases of Hurley Hos-
pital were reviewed, and the survival rate was
found to be improving.
Clinical and laboratory findings were tabulated
and discussed.
The difficulty in recognition and changing
physical manifestations at early age groups are
discussed, and the importance of early diagnosis
and early intelligent therapy is stressed.
Peripheral vascular collapse and subdural fluid
complicating meningitis are discussed briefly.
References
1. Smith, Margaret H. D.: Pediatrics, 17:258 (Feb.)
1956.
2. Carson, M. J., and Koch, R. : Pediat. Clin., North
America: May, 1956, p. 377.
3. Levinson, Abraham: Brennemann’s Practice of Pedi-
atrics, Vol. 4, Chapt. VIII, p. 1.
4. Smith, Richard T.: Pediatrics, 17:549 (Apr.) 1956.
5. Etteldorf, S. N.: J.A.M.A., 159:746 (Oct. 22)
1955.
6. Jones, E. M.. and Howard, W. L.: Michigan M.
Soc. 54:1315 (Nov.) 1955.
7. Martin, W. J., and Nichols, Donald R. : Proc.
Staff Meet., Mayo Clin., 31:333 (May) 1956.
8. Hall, Wendell H., and Gold, David: Arch. Int.
Med., 96:403 (Sept.) 1955.
9. VanSlyke, D. D.: Ann. Int. Med., 41:709 (Oct.)
1954.
10. Matson, D. D.; Ingraham, F. D.; and McVay,
J: J.A.M.A., 152:387 (May 30) 1953.
“THE MEDICAL WITNESS”
The American doctor, increasingly on call as a court-
room witness, is about to receive expert help in pre-
senting his testimony.
The American Medical Association and the Ameri-
can Bar Association have joined forces for the first time
to present a series of educational films dealing with
the professional relationships of doctors and lawyers,
according to announcement by Dr. George F. Lull,
secretary and general manager of the AMA.
The first film in the series, “The Medical Witness,”
had its premiere showing at the AMA’s clinical meet-
ing in Seattle, Washington, November 27. The film
is now available for showings before medical societies,
bar associations, and other professional groups through-
out the country.
“The Medical Witness,” a thirty-minute black and
white 16 mm. film, depicts right and wrong methods
of presenting medical testimony by re-enacting the
trial of a personal injury case. The series is being
produced by The William S. Merrell Company of Cin-
cinnati, ethical pharmaceutical manufacturer, as a
service to the medical and legal professions.
Stressing the “vital importance of these films to all
doctors and lawyers,” C. Joseph Stetler, head of the
AMA’s law department, said:
“Medical testimony is required today in from 60 to
85 per cent of all cases litigated.
“The taking of medical testimony is at the core of
court operations in personal injury cases. Medical
societies and bar associations are increasingly concerned
about the problems which arise in the practice of
presenting medical evidence through partisan experts
hired by parties to law suits.
“ ‘The Medical Witness,’ the lead-off film in this
series, shows doctors and lawyers how to develop
expert testimony that is truly objective and scientific
and in the best interests of the plaintiff, the judge and
the jury.
“Our central purpose in all these films is to acquaint
doctors and lawyers with each other’s professional,
procedural and ethical problems in litigation and other
areas where two professions come into contact.”
“The Medical Witness,” Mr. Stetler said, deals spe-
cifically with questions that concern both professions,
such as the following:
1. What is and should be the relationship between
the medical witness and the lawyer?
2. What is the most effective way to examine and
cross-examine the medical witness?
3. How does the medical witness support his opinion?
4. How does a jury react to the testimony?
Medical societies wishing to arrange for showings of
“The Medical Witness” and later films in the series, may
write to the Film Library, American MedicaJ
Association, 535 North Dearborn Street, Chicago 10,
Illinois. Bar associations should write to the National
Legal Audio-Visual Center, Indiana University, Bloom-
ington, Indiana.
March, 1957
335
A Plea for Preschool Eye Care
'“P HOSE of you who have two good eyes may
regard this brief article with little interest,
and many of you will retain none of its content.
Those of you who have but one good eye may
momentarily reflect back on your childhood and
wonder what, through the span of years, that tre-
mendous handicap has meant to you. Such reflec-
tion may bring forth a question. What are we as
physicians doing for today’s children with similar
visual defects? The answer may bring surprise and
disillusion! There are more one-eyed children of
school age being seen by ophthalmologists today
than ever before.
The school health program is a huge success
and a growing tribute to the general practitioner
and pediatrician. In contrast, the school vision
screening program is sending us an alarming num-
ber of partially blind “healthy” young Americans.
In most cases this partial blindness could have
been prevented.
It would seem that the problem is one of ignor-
ance— ignorance of the growth and development
of vision. If we as physicians have been negligent
or lethargic, certainly parents must be excused.
All of us have been taught the fundamentals of
child development. Even the most conscientious
parent, however, can be expected to have only the
most meager knowledge of vision. Most of them
honestly feel secure in waiting until the child
reaches first grade before having that initial eye
examination. Currently many parents even wait
for the results of the first school screening of the
child’s eyes. For many years parents have under-
stood that dental health is best assured if the teeth
are checked by age three, and yet there is almost
universal ignorance as regards the more important
topic of how eyesight develops.
The problem is twofold. It involves the early
detection (and treatment) of: first, eyes which
are poorly aligned, and, second, eyes which have
an optical defect (hyperopia, myopia or astigma-
tism), particularly when only one of the eyes is
involved. When left undiscovered and untreated,
the end result in either case is often the same —
336
By R. T. Blackhurst, M.D.
Midland, Michigan
permanent loss of all useful central vision in one
eye (amblyopia).
Each of us has two separate and distinct types
of vision — one peripheral and one central. Peri-
pheral vision is present at birth or develops shortly
thereafter. It is this function which permits an
infant to follow lights and moving objects and
which later permits him to walk without bumping
into things. The peripheral fields of the two
eyes partly overlap and are therefore part of the
binocular pattern, although they alone cannot
maintain useful binocular vision.
Central vision on the other hand develops slow-
ly and gradually throughout the first six years of
life. A small infant has no ability to fixate — no
critical or sharp vision. This process so important
for reading, driving, watching “TV,” et cetera,
consists of only a few degrees in the central portion
of the visual field. It is the essential backbone of
binocular vision and stereopsis. Without it there
can be no guarantee of parallel or straight eyes.
The visual mechanism cannot be expected to main-
tain permanent alignment in the absence of two
sharp, identical pictures which may be fused into
a single perception. Young eyes develop by doing.
Only by constant repetition of the process of ob-
serving, studying and concentrating on small
objects, shapes and outlines does central vision
develop in the eyes.
Amblyopia affects only central vision. It is
actually “an island of blindness in a sea of vision.”
This is true because the brain must ignore only
that portion of a picture which is sharp enough to
be objectionable.
This central “island” can easily be demon-
strated. Hold a cigarette between the thumb and
forefinger of your left hand extended directly
away from the shoulder. Now concentrate on the
thumbnail of the right hand held fourteen to six-
teen inches in front of your face. If you slowly
move the cigarette toward your extended right
thumb you will find that it cannot be recognized
as a cigarette until it is within fourteen to six-
teen inches of the thumb. The presence of a filter
TMSMS
PRESCHOOL EYE CARE— BLACKHURST
cannot be determined until the cigarette is within
five or six inches, and the brand name cannot be
read until it is directly in line with the thumb.
This small area where the name can actually be
read represents central vision, and it alone is
involved in amblyopia.
Normally each eye receives a picture — two pic-
tures reach the brain and are blended into one — a
single binocular perception resulting in stereopsis.
If the eyes are not absolutely straight, two differ-
ent pictures are presented to the brain and cannot
be fused into a single perception. This situation
cannot be tolerated, so a reflex pattern is devel-
oped whereby the brain ignores one of the pictures
it is receiving. The eye whose picture is ignored
gradually becomes lazy. It is not continually
stimulated and so does not develop. If one of the
eyes has a refractive error (hyperopic, myopic or
astigmatic), its retina receives and transmits a pic-
ture which is blurred or distorted and likewise
cannot be fused with the clear picture which the
brain receives from the fellow eye. Here again the
offending image is ignored, and central vision
does not develop.
This deficiency of central vision, or amblyopia,
is gradual in onset, and may be easily corrected if
discovered early. However, the reflex pattern
which has been set up soon becomes fixed. Once a
child has reached the age of seven or eight years,
it is seldom possible to restore or reclaim the lost
central vision.
Often times it is the fortunate child who has an
optical defect involving both eyes. He is frequently
discovered early in life and corrective glasses re-
store normal vision and permit further develop-
ment of that individual’s ability to see clearly and
binocularly. In such a case the presence of one
good eye did not mask the less fortunate fellow.
Whether due to an optically defective eye or a
crossed eye, amblyopia can usually be corrected —
and nearly always so, if discovered early. Glasses
can be prescribed and well tolerated by a child of
one year. The defective eye can be made to exer-
cise its capabilities by occlusion of the better eye.
Occlusion started within the first two or three
years of life is usually rapidly successful if cor-
rectly and continuously carried out. The am-
blyopia is not yet deep seated enough to be irrevei'-
sible. Corrective glasses, patching (occlusion) of
the good eye, and surgery when then necessary
to further straighten crossed eyes, may well result
in a normal child before school age. When, con-
versely, treatment is delayed until the age of five,
six or seven, the “isle of blindness” is so secure
that only prolonged continuous patching can result
in any improvement at all — and often this falls
far short of normal acuity.
Nowadays, the infant or preschool child with a
marked convergent or divergent strabismus is re-
ferred immediately to the office of an ophthalmo-
logist where he is treated and often completely
corrected before reaching school age. Less fortu-
nate is the child who has a slight strabismus with
a barely noticeable deviation. Often he is missed
entirely or, when discovered, not referred for treat-
ment because it is too widely felt, even among
physicians, that these small deviations will correct
themselves.
Although the diagnosis and treatment of such
cases has never been cut and dried, hours of
thought by many interested people is rapidly re-
sulting in a still changing but gradually crystalliz-
ing approach to the problem. The busy practi-
tioner who has been confused by opinions and
writings of our own members may now acquire
definite answers to most of his questions and be
given a simplified program which will satisfy most
ophthalmologists and save many eyes.
All of us understand that an infant of less than
three months has very little co-ordination and
only fair control over his voluntary muscular com-
ponents. His eyes may not always appear straight!
But neither will they always appear crossed! They
are normally straight, but may be temporarily in
poor alignment while moving to or from the
central position. Constant or nearly constant de-
viation of the visual axes is not normal in a child
of any age.
Very often, in conjunction with a “button-nose,”
an infant will have a wide epicanthal fold of skin
which covers a portion of the sclera medial to
the cornea and gives the appearance of crossed
eyes when the visual axes are indeed parallel.
This child may “needlessly” be referred to an
ophthalmologist. However, this is a mistake we
all make, and I have yet to see a mother angered
by the referral. The mistake is usually hers as well
as the doctor’s. She is relieved and, moreover,
thankful that her physician is interested and
attentive. It is an “error” in the right direction.
Even this small error may be avoided if the
doctor will draw together the skin over the bridge
March, 1957
337
PRESCHOOL EYE CARE— BLACKHURST
of the infant’s nose, thus uncovering the hidden
sclera, and look once more at the eyes. Further
security may be gained by a simple and effective
“light test.” Attract the infant with a small fixa-
tion light held three to five feet from its eyes. If
the corneal light reflex strikes the middle of both
pupils, the visual axes are normally aligned.
The thinking of most practicing ophthalmo-
logists has jelled on the matter of time for re-
ferral of these infants. We must “get them early.”
Crossed eyes do not correct themselves with time.
Time extends the physical and emotional defect.
The deviating eye becomes lazy; the brain estab-
lishes an abnormal pattern of seeing — one difficult
to break up: paretic muscles upset the ocular
muscle balance so that later diagnosis is more
difficult; and most importantly the child is getting
older — those few important months during which
a child’s brain develops the ability to use both
eyes together are rapidly slipping away. By the
time the child is of school age the battle has either
been won or lost. Parents appreciate their doctor’s
advice and will always continue to thank him for
that " early referral
The ophthalmologist has many things to deter-
mine and evaluate when he first sees this infant
with crossed eyes. Is the defect nonparalytic (the
common type) , or paralytic? If paralytic, what
muscle is involved? At what age was the defect
first seen? Was it at first constant or intermittent?
Is it always die same eye which deviates? Do
other members of the family have a similar de-
fect? Did the infant enjoy a normal, spontaneous,
full term birth?
Based on information gathered from you and
the parent, and on a careful and surprisingly
effective examination of the infant, he may sug-
gest temporary patching of the nondeviating eye,
or alternate patching of both. This helps him rule
out a possible paresis or anatomic defect of one or
more of the ocular muscles. In ocular tortecollis
it often helps him determine the affected eye and
thus the paretic muscle before the child is old
enough to co-operate in an objective study. More
commonly, it establishes the fact of equal or
unequal vision in the two eyes.
Before a child is one year old he may be care-
fully examined under cycloplegia, and if a large
or contributary refractive error is found in one or
both eyes, glasses will be prescribed and, surpris-
ingly enough, proudly and co-operatively worn.
Remember that this child is not enjoying normal
vision as we know it. When required, glasses are
quickly appreciated. If glasses alone do not correct
the deviation, supplementary surgery may effec-
tively be performed at this age.
It is apparent from the preceding paragraphs
that our only hope in reducing the number of
visual cripples in our school system is to begin
treatment long before the school bell rings. Ac-
cordingly, we appeal to already overburdened
general practitioners and pediatricians to add one
more item to the examination of the one, two, or
three-year-old infant. Make a sincere attempt to
evaluate the vision in each eye. Help us discover
amblyopia while there is still time for successful
treatment. Urge a child to fixate a pocket-light,
coin or a small toy. Cover one eye then the
other; ask yourself if he fixates and follows with
equal ease using either eye. Try him on a picture
chart while the eyes are alternately patched.
Throw a few cotton balls on the carpet before an
infant and see if he retrieves them with equal ease
using right and then left eye. If you question the
equality of vision; by all means repeat the tests
at a later date.
If further information is desired, dilate the
pupils with 5 per cent homatropine or 1 per cent
cyclogyl* and study each retina carefully. They
should be seen with equal ease and clarity. Refer
all doubtful cases to a capable eye physician. The
child and its parents will be grateful.
Practice these tests on your own child — you may
be surprised! Trouble is often found where least
expected!
*Cyclogyl 1 per cent, brand of cyclopentolate hydro-
chloride, Schieffelin & Company, New York 3, New York.
BRAIN TUMORS
In fifty brain tumors confined to the occipital lobe,
the symptoms in order of frequency were: headache,
nausea and vomiting, defect of visual field, failing visual
acuity, ataxia, hallucinations and diplopia.
The signs of brain tumor in this same series in order
of frequency were: defect of field, papilloedema, cere-
bellar signs, weakness of face or extremities., aphasia,
alexia, visual agnosia and agraphia, sixth nerve palsy,
inactive pupils and paresis of accommodation.
338
IMSMS
Rheumatic Fever Prophylaxis
By Robert E. Fisher, M.D.
Battle Creek, Michigan
A NOTE in Circulation, XIV, 1020 (Novem-
-*-ber, 1956) states that there were thirteen
recurrences of rheumatic fever in a group of 400
children who had been on prophylaxis two years.
Four were on sulfadiazine, nine on oral penicillin
and none on benzathine penicillin G intramuscu-
larly.
Effective Jauary 1, 1957, the prophylaxis pro-
gram of the Michigan Department of Health and
the Michigan Crippled Children Commission has
been expanded to include the use of sulfadiazine
when the doctor feels that benzathine penicillin
G is harmful to the child. He may secure sulfa-
diazine by so noting on the “Requistion for Benza-
thine Penicillin G,” Health Department Form
C-62A, in quantity of three bottles of 100 tablets
of 0.5 gm., a five-month’s supply for anyone
weighing over sixty pounds. This is obtainable
for anyone who has rheumatic heart disease or
who has had rheumatic fever upon reporting the
case on the requisition form, at no cost to the
doctor or his patient.
Fees for regular follow-up office visits and nec-
essary laboratory work may be paid from trust
funds administered by the Michigan Crippled
Children Commission when the child is not yet
twenty-one and has been the subject of a court
order under the Crippled or Afflicted Children’s
Acts. An amount equivalent to that which benza-
thine penicillin G administration would entail has
been made available for these services. The lab-
oratory work may be done by the doctor or by
the hospital to which he sends his cases; in the
latter case, the laboratory must be one at a hos-
pital approved for care of afflicted children. The
published Michigan Crippled Children Commis-
sion fee schedule applies.
An initial visit, with progress visits one, three,
five and then every two and one-half months
thereafter, with a urinalysis, hemoglobin, white
blood count, differential on the initial and next
two visits and at seven and one-half months and
Dr. Fisher is Medical Co-ordinator, Rheumatic Fever
Program, Michigan Crippled Children Commission.
March, 1957
every five months thereafter, can be alternated
with visits without laboratory work at five months
and every five months thereafter to check on the
use of medication, or the child can be seen less
frequently or more frequently, within the mone-
tary allowance, as the doctor desires.
A report is required on each visit. When four
visits have been made, the report is submitted
with an invoice-voucher for payment for the serv-
ice rendered.
Members of the Michigan State Medical Society
provide, through the Rheumatic Fever Diagnostic
Centers, consultation service for doctors seeking
clarification of the diagnosis and recomendations
for therapy. Where the cost of the consultation
prevents use of the service, in the case of a
minor, the doctor may execute Michigan Crippled
Children Commission Form 121 (Physician’s Cer-
tificate) requesting such a consultation. The cost
of transportation to the Center cannot be paid
by the Commission, but the Center’s fee for service
is paid under the order pursuant to the certificate.
Should the recommendation be that prophylaxis
is indicated, this patient who has had a court
order, albeit limited, is eligible for inclusion under
the prophylaxis program. It must be understood
that a court order is not a prerequisite to the ob-
taining of benzathine penicillin G or sulfadiazine
from the Michigan Department of Health, and
the doctor may charge a fee for its administration
and supervision with propriety.
As of January 1, 1957, the Michigan Crippled
Children Commission has received billings for
administration of 552 doses of benzathine peni-
cillin G to 140 children. In four cases injections
were discontinued. There were no rheumatic
fever recurrences reported, but one patient de-
veloped subacute bacterial endocarditis while on
benzathine penicillin G, was treated with penicil-
lin, and is back on benzathine penicillin G prophy-
laxis.
“A Diagnosis of Rheumatic Fever is a Man-
date for Prophylaxis”
339
Rubella in Pregnancy
TA UBELLA occurring in the pregnant woman
has recently been presenting an increasing
problem to obstetricians. What incidence of fetal
anomalies is to be expected? Is therapeutic abor-
tion justified when rubella occurs? What can we
tell our patients who develop rubella in early
pregnancy — in late pregnancy? There appears to
be considerable confusion as to the correct answers
to these questions, and we therefore undertook a
review of available information to clarify, insofar
as possible, our own thinking regarding these ques-
tions.
Rubella, or “German Measles,” is a self-limited
communicable viral disease, characterized by mild
constitutional symptoms, a transient maculopapu-
lar rash, and swollen, tender postauricular and
postoccipital lymph nodes. It often occurs in
epidemics with rubeola, especially in the spring,
and one attack confers a permanent immunity. It
can be distinguished without particular difficulty
from such conditions as scarlet fever, rubeola and
exanthem subitum. .However, because of the mild
nature of the disease a physician is not always
consulted.
Rubella had always been considered a benign
infectious disease of childhood until the epic work
of Gregg1 disclosed the high incidence of con-
genital cataracts in the eyes of infants delivered of
mothers who had contracted rubella during the
Australian epidemic of 1941. This was later am-
plified by Swan, et al,2 and gradually a series of
defects including deafness, congenital cataract,
congenital heart disease (largely patent ductus
arteriosus), central nervous system damage and
dental malformations were related to the disease.
Our concern here is with rubella only, and al-
though isolated case reports of a variety of defor-
mities in mumps, measles, chickenpox, herpes
zoster, infectious hepatitis, infectious mononu-
cleosis and poliomyelitis have been made, there
is at present insufficient evidence to incriminate
these in any way comparable to rubella.3 It is also
From the Department of Obstetrics & Gynecology,
University of Michigan, Ann Arbor.
By Warren H. Pearse, M.D.
Ann Arbor, Michigan
to be emphasized that the usual mild course of
rubella is seldom altered by pregnancy, and the
concern is not for the mother, but specifically re-
garding possible damage to the fetus.
What then are the possibilities of fetal damage
if the pregnant woman develops rubella? The data
from the Australian epidemic of 1941 have been
summarized by Collins.4 In 383 cases of maternal
rubella during various months of pregnancy the ;
incidence of fetal anomaly was as follows:
Month Per Cent
1 79%
2 90
3 80
4 78
5 24
6 21
7 27
8 25
9 0
However, the dangers of a retrospective study
(i.e., finding anomalies and then looking back to
see how many mothers have had rubella) have
been pointed out by most authors, and this study
was of that nature. In the same summary Collins
stated that a study in Queensland of every preg-
nant woman who had contracted rubella during
the first trimester of her pregnancy in the year
1941 revealed only a 30 per cent incidence of
affected infants.
An ideal study — one in which pregnant women
who develop rubella are observed to term and the
infants studied together with adequate controls — -
is difficult of realization. However, such an inves-
tigation has been approached by Lundstrom5 who
analyzed an epidemic of rubella in Sweden in
1951. All patients who delivered or aborted in a
maternity hospital (as do 94.1 per cent of Swedish
mothers) were questioned in detail about exposure
to or development of rubella. Lundstrom’s findings
are summarized below. Anomaly encompasses any
defect present at birth, including such things, be-
sides the “rubella syndrome,” as hypospadias, mul-
tiple nevi, hydrops fetalis and even asphyxia
neonatorum. The group of stillbirths and neonatal
deaths includes the occurrence of these from all
340
JMSMS
RUBELLA IN PREGNANCY— PEARSE
TABLE I. LUNDSTROM’S SUMMARY OF RUBELLA
EPIDEMIC IN SWEDEN IN 1951.
Group
Contracted
Rubella
Contact — No Infection
Controls
Non-Immune
Immune
1-16
16-40
weeks
weeks
1-16
16-40
1-16
16-40
Anomaly
4.5%
3.4%
1.8%
1.3%
5.4%
0.7%
1.4%
Stillbirth
& Neonatal
Death
5.9%
21%
3.5%
3.1%
4.4%
1.6%
3.2%
Cases
579
450
344
508
153
240
2226
causes except complications of late pregnancy and
delivery. This group also includes malformed
dead infants. Durations of pregnancy are calcu-
lated from the first day of the last menstrual period.
Some criticisms can be made. The diagnosis of
rubella in these cases was not always medically
confirmed. 275 cases who were “legally aborted”
were excluded, as were 107 who received convales-
cent serum. Some defects actually present, such as
deafness, might not have been recognized at birth.
Perhaps the latter would be compensated for by
the author’s inclusion of minor anomalies unre-
lated to the infection. In any event, this large
well-controlled study certainly indicates a much
lower fetal risk than previously believed.
Figures from the United States are not so readi-
ly available. Ingalls and Purshottam0 summarized
in 1953 the results of previous small studies to-
gether with their own.
—AD— table II
Greenberg7 (quoted by Krugman and Ward)
reported a series of eighty-two patients who con-
tracted rubella in the first trimester. There were
nine stillbirths (11 per cent) and five anomalies
(6 per cent). A recent report of Brawner8 con-
cerns twenty-six cases seen in a mild outbreak in
Georgia in 1952. These are listed as available
cases; whether others may have occurred is un-
known. Fifteen cases in the first trimester pro-
duced four anomalous infants and one stillbirth
(33 per cent). Seven cases in the remainder of
pregnancy gave rise to only two minor muscular
abnormalities, probably unrelated to rubella. Four
patients had therapeutic abortions performed.
As information accumulates, it would seem there
is little risk when the mother develops rubella
beyond the sixteenth week of gestation. Prior to
that time, we can estimate an incidence of about
5 to 7 per cent fetal anomalies and 6 to 10 per
cent stillbirths on the basis of the larger studies
presently available.
TABLE II. INGALLS AND PURSHOTTAM’S SUMMARY
OF RUBELLA AMONG PREGNANT WOMEN IN THE
UNITED STATES.
Cases
Anomalies
Stillbirths
1st Trimester
42
3
4
2nd Trimester
23
2
2
3rd Trimester
7
0
6
72
5 (7%)
6 (8%)
What should be the program when rubella
exposure occurs during the first sixteen weeks? At
present, pooled gamma globulin or convalescent
serum is being administered, but its effectiveness
is open to question. Krugman and Ward7 conclude
from four separate studies that neither convales-
cent serum nor ordinary gamma globulin has been
consistently effective in prevention of rubella.
With the use of these preparations there is an
additional problem. The course of rubella may
be modified so that it occurs in a subclinical form,
but anomalies apparently do develop from this
type of infection while the patient and her physi-
cian may be falsely reassured that the disease did
not occur.
If rubella develops in these first sixteen weeks,
should therapeutic abortion be performed? This
may, of course, be impossible because of moral or
religious beliefs. It is also interesting to note that
under the laws of the state of Michigan pregnancy
can be interrupted only to preserve the life of the
mother. Interruption for fetal indications would
be well outside this boundary. This latter dilemma
is not peculiar to Michigan, however, as a recent
summary of therapeutic abortions in New York9
states that even many abortions agreed to by a
hospital staff committee may be in a quasi-legal
group.
Outside the above considerations, certainly the
age, parity and ease of conception of the patient
must be taken into account. With these facts at
hand, each physician must decide whether a 5 to 7
per cent increased incidence of fetal anomaly or
the risk of stillbirth should prompt consideration
of interruption of pregnancy in a mother less than
sixteen weeks pregnant.
Summary
1. The rubella problem in pregnancy has been
reviewed.
2. Large series of recent years show an inci-
dence of fetal anomalies of 5 to 7 per cent and
(Continued on Page 363)
March, 1957
341
The Physician and the Adoption of Children
By Ernest H. Watson, M.D.
Ann Arbor, Michigan
HP HE ADOPTION of children is “big business.”
Each year there are approximately 150,000
illegitimate births and 25,000 to 30,000 young
children who lose their parents through death,
separation or desertion. Each year there are ap-
proximately 90,000 adoptive placements, about
half of which are not made by official agencies* *
Physicians, particularly general practitioners,
obstetricians and pediatricians, are frequently asked
by persons and agencies involved in adoption to
give opinions and lend aid in one way or another.
What may the physician ethically and properly
do to aid children find a home, and childless
couples to obtain a child? What should the physi-
cian refuse to do in this connection?
I should like to emphasize one point at the
beginning because it should have priority over all
others: The first consideration in all adoptive
placements should be the finding of a good home
for the child. Next, we can place the problem of
finding a child for a family, and of lesser import-
ance must be the solution of the social problems
of illegitimate pregnancy, payment of hospital
bills, relief of a county or community of the burden
of caring for a homeless child.
The first and most natural mistake for a physi-
cian to make is to agree to help some childless
couple find a child for adoption. The physician
is likely to place himself immediately in the parti-
san position of being an agent, in a sense, of the
childless couple. If they are friends or patients of
his it may be difficult for the physician to do what
he should do, and in some states the only thing he
can legally do, i.e., to refer the couple to an
official child placement agency. He is likely to feel
like he is “passing the buck” or letting his friends
down. Such is not the case. It may be a real
disservice in the long run to put the childless
couple in touch with some illegitimately pregnant
Dr. Watson is Chairman, Joint Committee on Adop-
tion, MSMS and Michigan Branch, Academy of Pe-
diatrics.
*An official agency in Michigan is one licensed by the
State Department of Social Welfare to place children
for adoption. The only public agency authorized to
place children for adoption in Michigan is the Michigan
Children’s Institute in Ann Arbor.
woman who is looking for financial aid and seek-
ing disposition of her unborn, unwanted baby.
As immediately helpful as this arrangement might
be to the child’s natural mother, it violates one
cardinal principle of successful adoptive practice,
namely, complete anonymity between natural and
adoptive parents. Blood relationship of parties
involved sometimes makes it necessary to ignore
this principle of anonymity, but even then the
future relationships are in some jeopardy.
The physician may believe that his knowledge
of a childless couple is as good or better than any
possible social history obtained by an agency work-
er and it may be so, but another principle of
proper adoptive practice involves an investigation
of the family by a completely nonpartisan agent.
This investigation must be thorough enough to
establish the quality and integrity of the family
and their motive for wanting to adopt a child.
This latter seems obvious at first glance, but is not
so simple. Some couples want children to be in
style in their social set; some want to pull together
a marriage threatening to fall apart; some wish to
replace a lost child; others because they love chil-
dren and feel an aching void because of their
childlessness.
The Child Welfare League of America has sug-
gested the following set of minimum safeguards in
adoption :
I. The safeguards that the child should be given are :
1. That he be not unnecessarily deprived of his
kinship ties.
2. That the family asking for him have a good
home and good family life to offer, and that
the prospective parents be well-adjusted to
each other.
3. That he is wanted for the purpose of com-
pleting an otherwise incomplete family group
in which he will be given support, education,
loving care, and the feeling of security to
which any child is entitled.
II. The safeguards that the adopting family should
expect are :
1 . That the identity of the adopting parents
should be kept from the natural parents.
2. That the child have the intelligence and the
physical and mental background to meet the
342
TMSMS
ADOPTION OF CHILDREN— WATSON
reasonable expectations of the adoptive par-
ents.
3. That the adoption proceedings be completed
without unnecessary publicity.
III. The safeguards that the state should require for
its own and the child’s protection are:
1. That the adopting parents should realize that,
in taking the child for adoption, they assume
as serious and permanent an obligation as do
parents rearing their own children, including
the right to inherit.
2. That there be a trial period of residence of
reasonable length for the best interests of the
family and the child, whether there be a legal
requirement for it or not.
3. That the adoption procedure be flexible
enough to avoid encouragement of illegiti-
macy on the one hand, and trafficking in
babies on the other.
4. That the birth records of an adopted child be
so revised as to shield him from unnecessary
embarrassment in case of illegitimacy.
The physician should be aware of the require-
ments of Michigan Law on adoption. The law
(comp. Laws Michigan (1948) Section 710.1 —
710.14) states that the judge of probate is re-
quired to have a full investigation “by the county
agent, probation officer, or by a placement agency
licensed by the state, or by the Michigan Chil-
dren’s Institute or the State Department of Social
Welfare.” The purpose of the investigation is to
determine several things: The integrity, health,
and stability of the home into which it is proposed
to adopt the child, the physical and mental health
of the child, the child’s family background and
suitability of the child and adoptive parents on
racial, religious and cultural backgrounds.
Legal Provisions Which the Physician
Should Know
1. Adoptions are under jurisdiction of the pro-
bate court of the county in which the petitioners
reside.
2. Consent of both parents must be obtained,
except in cases of illegitimacy where the natural
mother’s consent alone is enough.
3. Release of the child by its parents (or by its
natural mother in case of illegitimacy) to the
probate court prior to any steps toward adoption
is highly desirable, since it makes much easier the
preservation of complete anonymity between na-
tural and adoptive parents.
4. The probate court must order an investiga-
tion of the principals and circumstances in every
case of adoption.
5. The only entirely legal way in which the phy-
sician can act as the go-between or “arranger” in
the matter of adoption is either to have himself
appointed guardian of the child while arrange-
ments are being made, or, second, to obtain a
license from the Department of Social Welfare to
serve as an authorized child-placing agency. Both
of these activities seem out of character and at the
least an unusual role for the busy physician. He
could find himself with guardianship or other
responsibilities far more demanding than he had
bargained for.
6. A physician (or hospital) may not give “free”
services to an illegitimately pregnant woman on
the condition that she release her baby for adop-
tion to a certain couple.
7. A physician cannot legally prevent a mother
from seeing her child (as in case of a new born
illegitimate infant in the hospital) simply because
she has previously indicated an intention or even
an agreement to place the child for adoption. Only
the probate court can sever parental rights.
8. Hospitals, clinics and maternity homes giving
maternity service are required by Michigan law to
file a special report on illegitimate births. The
physician is liable to fine and worse if he conspires
to hide the fact of illegitimacy by having the
mother register at the hospital under an assumed
name and status. One common violation of the
law is to have the mother register in the name of
the wife of the couple planning to adopt the baby.
This, if it works, does get the baby a birth certifi-
cate carrying the family name he will presumably
have, but it is an illegal stratogem full of chance
of trouble for all concerned. There is no need to
go to such lengths as far as the birth certificate is
concerned. In cases of proper adoption the judge
of probate can issue a new birth certificate carry-
ing the adopted family name and covering the fact
of illegitimacy.
From the foregoing it can be seen that the judge
of probate will order a complete investigation and
that the physician cannot and should not attempt
to “short-cut” these necessary legal procedures
which are based on sound considerations. If there
is still doubt in the physician’s mind as to the
qualifications and desirability of an official adop-
tion agency taking charge, consider the following
contributions of the professional agency staff as
set forth in the Child Welfare League of America’s
publication “A Study of Adoption Practice” :
March, 1957
343
ADOPTION OF CHILDREN — WATSON
]. Only an agency offers the child and adoptive par-
ents a wide choice as a safeguard to suitable place-
ment. The agency may have a hundred couples
from which to choose just the right home for a
child.
2. An agency offers experienced staff to assemble and
evaluate professional data of various kinds —
medical, legal, psychological, et cetera — in the light
of the specific child-parent situation. (The physi-
cian is not a social worker.)
3. Only an agency prepares, preserves, and makes
available the record of the whole transaction.
4. There is the major advantage that the agency
acts as the confidential intermediary between the
natural parents and adoptive parents.
5. The agency brings a large body of experience into
this field, which cannot be matched by those doing
private adoptions.
6. The agency can assure care for the child if he
becomes unadoptable — a protection for the natural
parents and adoptive parents, as well as the child.
7. Casework with the natural parents, which can be
given only by an agency, gives assurance that the
surrender is final.
8. Assurance that the adoption will be consummated
legally, or else that some other appropriate form
of care will be provided for the child.
The physician can give advice to agencies and
persons involved in adoption practices only when
he knows certain facts relating to the principals
involved. He is most often called on to “give an
O.K.” on the physical and mental status of a child
to be placed. Obviously, the younger the child
the more difficult it is to appraise mental develop-
ment, even when a psychologist’s help is available.
In most instances, the physician is not given a
good enough medical history of the infant’s an-
cestors to enable him to give a good opinion on
the possible inheritance of undesirable traits by the
infant. Thus, it is obviously important that all
persons in a position to know facts of medical im-
portance in this connection make them a part
of the child’s hospital and agency record. Every-
one gives lip service to the ideal of early adoption
(early infancy) ; this may definitely be brought
about if a good family and medical history of both
natural parents is available. If babies are adopted
as early as a few weeks of age, it seems highly
advisable from the medical standpoint to insist
that the usual one-year probationary period not
be waived (it can be waived by the judge of
probate) and that the infant be re-examined re-
peatedly during this year. It should be kept in
mind, of course, that most couples who adopt
babies run little if any more risk that the child
will not “turn out well” than if they had been the
natural parents themselves. Proponents of the
environmental school will agree with this. Those
who believe that the genes largely determine the
traits, abilities, et cetera, of the adult will not
agree so wholeheartedly. Even so, most ventures
of life, such as marriage and parenthood, are i
fraught with some chance taking. Each adoption,
just as each birth of a child into a family has the
element of chance in the eventual outcome.
Summary
The role of the physician in adoptions should
be a medical one only. He is not a social worker,
nor should he try to substitute for the legally con-
stituted authorities in this very important function.
The physician is essential for only he can give I
advice on matters of health, growth and develop-
ment, and genetic influences relating to the infant,
and the natural mother’s prenatal care. The de-
tails of the birth, and medical and developmental
records on the infant are all extremely important
factors in final decisions as to placement. Few, if
any, human beings are perfect specimens. This
applies to babies up for adoption. Only a physi-
cian can advise on the probable long term influ-
ence of such adnormal findings as the child may
have. Physicians should know the agencies in the
community to which he can refer childless couples
seeking infants or natural parents who think they
cannot take care of children (born or unborn).
The physician is usually in a position to help the
agency and to increase its effectiveness and prestige
by his support. Finding the right home for a child
is sufficiently important for all persons involved
therein to work together.
Bibliography
1. How to Adopt a Child in Michigan. Michigan
Welfare League, 482 Hollister Building, Lansing,
Michigan.
2. A Study of Adoption Practice. Child Welfare
League of America, 345 E. 46th Street, New York
17, New York. Vol. I. Adoption Agencies and the
Children They Serve. Vol. II. Selected Scientific
Papers Presented at the National Conference on
Adoption, January, 1955.
Virtue, M. B. : Basic Structure of Children’s Serv-
ices. American Judicature Society, 1953.
Provisions of the Michigan Laws Regarding Adop-
tions. J. Mich. M. Soc., 410-413 (April) 1953.
Burke, J. : The Doctor’s Role in Adoptions. Wis-
consin M. J. (Jan., Mar., Apr.) 1956. Reprints
issued by Wisconsin State Department of Public
Welfare, August, 1956.
Young, Leontine: Out of Wedlock. New York:
McGraw-Hill Book Co., Inc., 1954.
344
JMSMS
Hyperextension of the Fetal Head
in Breech Presentation
By Theresa R. Palaszek, M.D.
Detroit, Michigan
r|~' HERE are several factors concerning the diag-
nosis and management of breech presentation
which are well known from repeated experience.
The purpose of this paper is to review available
literature on one complication of breech presen-
tation, namely the hyperextension of the fetal
head, and to present an additional case.
Though the incidence of breech presentation is
approximately 4 per cent of all deliveries in num-
erous reported series of breech studies, there are
to date only twenty cases of hyperextension of the
fetal head reported in the literature. The first
work was done by Brakemann,1 who estimated
that in 1 1 per cent of breech presentation the head
was extended in some degree. He postulated that
this increased the duration of labor and con-
tributed to a difficult delivery. This work was
supported by Stein2 in his study of deflexion of
fetal parts in breech presentations. He warned
that the fetal attitude and presentation must not
be assumed to be static. This concept must be
realized for the intelligent management of the
individual case. It may also explain the spon-
taneous correction of these abnormal presenta-
tions. The advisability of attempting external
version is cjuestioned because of the basic etiologic
conditions making the breech presentation neces-
sary. Stein does not consider deflexion attitudes
to be an indication for Cesarean section. He feels
that fundal pressure during delivery may be used
to deflex the extended parts. Vaginal delivery was
accomplished in the two cases reported, one using
manual flexion of the head through the vagina
before engagement of the head. The second case
was one with an arcuate urterus. In 1948, Taylor3
reported one case of hyperextension of the head in
a breech presentation which was delivered by
Cesarean section. Roentgen rays of the infant on
the sixth neonatal day demonstrated an anterior
dislocation of Cl on C2 and of C3 on C4. These
were treated successfully with splints. In the same
Dr. Palaszek was a resident. Division of Obstetrics and
Gynecology, Grace Hospital, Detroit, until March 1,
1957. His present address is 833 Lake Drive S.E., Grand
Rapids. Michigan.
March, 1957
year, Melody4 reported a case with spontaneous
correction of a hyperextended head. The infant
had bilateral posterior dislocations of the tibia,
suggesting the association of dislocations with hy-
perextension and flexibility of the spine.
Wilcox5 reported eleven cases of hyperexten-
sion of the head in a series of 1918 breech de-
liveries. The majority were treated conservatively.
Cesarean section was done in four of these cases:
two for contracted pelvis, and one each for pla-
centa praevia and prolonged labor. The fetal
morbidity was high. Following vaginal delivery,
one infant was stillborn and one had a transection
of the spinal cord. One baby delivered by Cesar-
ean section, had a cyst on the neck which may
have contributed to the extension of the head.
Wilcox disagrees with Brakemann in the manage-
ment of these cases. He recommends individualiza-
tion of the case and does advocate delivery by
Cesarean section. Reis and DeCosta0 report two
cases of hyperextension of the fetal head in breech
presentation with spontaneous resolution. They
state that this complication is not an indication
for Cesarean section. Dougherty7 reports one case,
delivered by Cesarean section, in which the in-
fant’s head remained in extension for several days
after delivery. Eurard and Allrich8 report two
cases, one of which was delivered by Cesarean
section from an arcuate uterus. The second pa-
tient was delivered per vaginum. The infant died
in twelve hours, and autopsy demonstrated a
transection of the spinal cord in the cervical area.
Case Presentation
The case presentation is that of a twenty-five-year-old
white female, gravida 2, para 1, admitted to the Grace
Hospital on December 17, 1955, not in labor. The last
menstrual period was February, 1955. The expected
date of confinement was December 3, 1955. The past
medical history was noncontributory. The obstetric
history consisted of one living male child, weighing six
pounds and twelve ounces, born by normal spontaneous
vaginal delivery following a twelve hour labor, in 1954.
The present pregnancy was uncomplicated. The blood
pressure remained normotensive throughout. The weight
gain was thirty-one pounds. One week prior to admis-
345
BREECH PRESENTATION— PALASZEK
sion a plus one edema of the ankles was noted. There
was a slight trace of albumin in the urine. The hemo-
globin was 13 grams. The red blood count was 4.14
million. X-ray of the pelvis demonstrated, in the right
Fig. 1. A flat plate of the abdomen demonstrating a
breech presentation with extreme hyperextension of the
fetal head onto the fetal spine. Hospital No. 216488.
anterior portion of the uterus, a double footling breech
presentation with the head in hyperextension. The pelvic
measurements were adequate except for a true con-
jugate of 10 cm. The patient went into spontaneous
labor at 5:40 a.m. on December 18, 1955. Anticipating
difficulty in delivery of the hyperextended fetal head,
a low cervical Cesarean section was done under local
and intravenous penthotal anesthesia. The living seven
pound, two ounce, female infant was of normal develop-
ment. The head tended to remain in hyperextension for
six weeks following delivery. No maternal factors were
noted to explain the breech presentation.
Discussion
Hyperextension of the fetal head in breech pre-
sentation is not common. It is defined as hyper-
extension of the fetal head with flexion of the
fetal spine, and with no relation to the position
of fetal extremities. It must be differentiated from
opisthotonus fetalis, which was defined in 1915 as
a condition in which the fetal spine is hyperex-
tended throughout its length. It usually occurs
in transverse presentations. The etiology of hyper-
extension of the fetal head in breech presentation
is not known. Reis and DeCosta favor chance
occurrence. Wilcox postulates fetal abnormalities,
such as cysts of the neck, spasm of the fetal mus-
cles, and uterine anomalies as the arcuate uterus ;
of Stein and of Eurard, or space-occupying uterine
tumors. Certain hypermobility of the fetal joints
must be considered as evidenced by the frequent
association of dislocations of the spine and other
fetal joints with cases of hyperextension of the
fetal head. The definite diagnosis is made by
x-ray.
The presence of this condition does not influ-
ence the course of the pregnancy. It does not in-
crease maternal morbidity except for that nor-
mally associated with Cesarean sections. Fetal
morbidity is increased due to the basic cause of the
breech and to the hyperextension of the head.
Transection of the spinal cord with dislocations of
the cervical vertebrae are the real dangers.
There is disagreement as to the management of
these cases. Stein and Reis and DeCosta advocate
vaginal delivery. Wilcox and Dougherty state that
this is an indication for Cesarean section, but that
the treatment in each case should be indivi-
dualized.
Summary
A review of the literature and a case presenta-
tion of hyperextension of the fetal head in breech
presentation is given. The etiology of this condi-
tion is unknown. The maternal morbidity is not
increased, but the fetal mortality and morbidity is
increased. The management is to effect delivery
through the vagina or by Cesarean section when
indicated.
• Acknowledgment
Grateful acknowledgment is given to Dr. K. Miller,
for permission to present this case.
References
1. Brakeman, O. F. : Geburtsh. u. Gynak., 112:154,
1936.
2. Stein, I. F.: J.A.M.A., 117:1430, 1941.
3. Taylor, J. C.: Am. J. Obst. & Gynec., 56:381,
1948
4. Melody, G. I.: California Med., 68:738, 1948.
5. Wilcox, H. L. : Am. J. Obst. & Gynec., 58:478,
1949.
6. Reis, R. A., and DeCosta, E. J. : Am. J. Obst. &
Gynec., 60:637, 1950.
7. Dougherty, C. M.; Mickey, L. J.; and Moore, J.
T.: Am. J. Obst. & Gynec., 66:175, 1953.
8. Eurard, J. R., and Allrich, J. H. : Obst. & Gynec.,
5:789, 1955.
346
TMSMS
Management of Breech Presentation
and Delivery
By Charles S. Stevenson, M.D.
Detroit, Michigan
TJ REECH presentation is always a timely topic
for discussion because breech delivery still
carries even a corrected fetal mortality of about
4.2 per cent1’2 in all but a few of the larger hos-
pitals and teaching centers in this country. This
correction is obtained by excluding all cases of
prematurity, previability, and developmental ab-
normalities. Thus breech delivery still entails
a fetal risk four times that of cephalic delivery.
Also, the fetal mortality is much higher when in-
fants weighing less than 2,500 grams and more
than 4,500 grams are delivered as breeches rather
than cephalically.
Autopsies on fetuses (not exhibiting congenital
anomalies) that died during breech delivery or
within the first two neonatal weeks have shown,
in 40 per cent, that death resulted from cerebral
hemorrhage, in 18 per cent from asphyxia, in
16 per cent from “unknown cause,” in 8 per cent
from prolapse of the cord, and from bronchopneu-
monia, cerebral edema, and stillbirth of unknown
cause in 4 per cent each.2 In Calkins’3 recently
reported series of breech deliveries nearly half of
the infants (again excluding the congenital an-
omalies) died of “trauma,” prolapsed cord, or
“unknown cause.”
While there has been no demonstrable increase
in maternal mortality with breech (as against
cephalic) delivery, the maternal morbidity asso-
ciated with breech delivery is from 8.52 to 9.94
per cent, representing, therefore, about a four to
five-fold increase over that of cephalic presenta-
tion. The morbid factors most commonly present
are urethritis, cystitis, pyelitis, thrombophlebitis,
infected and disrupted episiotomies, and endo-
metritis.2 The maternal morbidity in breech ex-
traction was 18.4 per cent, while in spontaneous
and aided breech deliveries it was only 5.3 per
cent; 10.3 per cent of primiparae having breech
From the Department of Obstetrics and Gynecology,
Wayne University College of Medicine, and the Ob-
stetric Service, Herman Kiefer Hospital, Detroit.
Presented, by invitation, at the Michigan Clinical In-
stitute, Detroit, March 9, 1956.
March, 1957
delivery were morbid, while only 6.9 per cent of
multiparae were so troubled.2
Prolonged labor occurred in 8.7 per cent of
Schmitz’s series of 1,512 breech deliveries,2 which
is an incidence several times greather than the av-
erage, and one-fifth of all the fetal deaths in his
series occurred in the prolonged labor group. A
particular danger of prolonged labor in breech
presentation is the inability to judge accurately
when dystocia is due to fetopelvic disproportion.
Thus we see that breech delivery offers some very
real problems, and, despite widespread improve-
ments in general obstetric care, and some real low-
ering of the fetal mortality rate in breech de-
livery in recent years, we are still faced with the
fact that it is about four times more fatal for
the infant and four times more morbid for the
mother than is cephalic delivery throughout the
country as a whole.
In view of the serious prognosis for the baby,
breech presentation should be corrected to ce-
phalic presentation before term whenever possible.
This can be done by external version, a procedure
which is easily carried out in the office with no
discomfort to the patient. While the majority of
the teaching centers in this country neither teach
nor advocate external cephalic version for the
correction of breech presentation, quite a few
do so, and in the hands of the obstetricians there
it has been shown to have no discernible risk
to mother or infant and is accepted as good ob-
stetric practice. It is certainly true, on the other
hand, that if a totally inexperienced physician
attempts to turn an infant in an unknowing and
nervous manner, he may very well cause some
separation of the placenta.
Ryder5 reported having done external cephalic
version personally in 290 cases in a series of
1,700 private patients, and stated that not one
fetus could be shown to have suffered any harm.
Adair6 published collected statistics on 1,105 at-
tempted external versions done by nine obstetri-
cians and found that vaginal bleeding occurred
347
BREECH PRESENTATION— STEVENSON
in only two instances, presumably from slight pla-
cental separation, or rupture of a small marginal
sinus. In a report from the Boston Lying-in
Hospital, Newell7 presented data on 793 patients
in whom breech presentation was detected in the
third trimester of pregnancy. In all, 1,161 exter-
nal cephalic versions were attempted, or 1.46 ver-
sions per case. Successful turning of the fetus was
accomplished in 829 cases, or 72 per cent; spon-
taneous recurrence of breech presentation follow-
ing successful external version occurred in 27 per
cent of cases, and was again corrected each time.
Including the 108 instances of spontaneous ce-
phalic version which occurred in cases in which
attempted external version had been unsuccess-
ful, only 10 per cent of the original group of
women arrived at term still with breech presen-
tation. The fetal mortality for the series was only
2.9 per cent, as against the usual figure of 4.2 per
cent.
The author was taught to perform external
version at the Boston Lying-in Hospital, and has
always practiced it, having succeeded in turn-
ing about 75 per cent of all breech-presenting
infants in thirteen years of practice, and this with-
out encountering any known vaginal bleeding or
other real difficulty. A few of the infants that
were successfully turned, to be sure, had to be
turned back at once the way they had come to their
original breech presentation because of some
slowing of the fetal heart. This occurs, pre-
sumably, because of compression of the umbilical
cord in their new cephalic position, but the re-
verse version is easily done and the fetal heart
has always picked up immediately and regained
its normal rate without mishap.
The author has delivered only three infants by
the breech in his private practice in the past
seven years. In all three, attempted external
version was unsuccessful because the breech was
frank, low, and engaged from practically the
twenty-eighth week of pregnancy on until term.
In one case there was a large baby, and corporo-
pelvic disproportion was evidenced after a few
hours of labor, so section was done. The other
two, both primiparae, required extraction. All
three infants survived. The making of routine
attempts at external version of all infants pre-
senting by the breech, starting at twenty-eight to
thirty-two weeks of pregnancy, and the repetition
of the version whenever the fetus returned to its
348
original breech presentation, has decreased the
incidence of breech delivery almost to the van-
ishing point in the practices of many obstetricians.
The infants, in primigravidae, must be turned not
later than the thirtieth to thirty-second week, in
most instances, lest the breech become too deeply
engaged in the pelvis to be dislodged; women
having their second viable infant had best have
version not later than the thirty-second week,
and those having their third or fourth child can
usually have the fetus turned anytime up until
six to four weeks of term. I have, on one occa-
sion, successfully performed external version be-
tween one uterine contraction and the next, in
early labor, in a para-5 whose membranes were
still intact, and who had a large baby and only
an average-sized pelvis.
A knowledge of the position of the in situ pla-
centa in the uterus is very important before one
attempts external version. This is so because the
placenta must not be handled or compressed dur-
ing performance of the maneuver. In breech
presentation it has been shown by the author8
that the common position of the placenta, in
single pregnancies within eight to ten weeks of
term, is in one uterine cornual region or the other,
and that this placental implantation site is the
basic cause of breech presentation. If the fetal
head lies in the right cornual region, then the
placenta will be found filling the left cornu, and
thus external version can be performed without
manipulation of that cornu which contains the
placenta.9 When in doubt as to the existence
of breech presentation, we always take a single
anteroposterior, soft-tissue x-ray picture. Be-
fore performing external version we have the
patient empty her bladder and lie on her back on
the examining table with one or two pillows un-
der her head and shoulders and another placed
beneath her knees. We explain that her baby is
presenting by its buttocks and that we are going
to gently “turn it around so its head will come
first.” Talcum powder applied to the patient’s
abdomen permits freer movement of the operator’s
hands over the abdominal skin in applying the
necessary pressure to the poles of the fetus. The
pressure applied should be firm, steady, and gen-
tle, and should be made by the flat of the hand
and not by one or two fingers. We carefully
auscultate the fetal heart before turning the fetus,
and then auscultate it again as soon as the fetus
has been placed in cephalic presentation. If the
JMSMS
BREECH PRESENTATION— STEVENSON
heart is not entirely normal in the new position
after one minute, the infant should be turned
back, retracing the way it came around, to its
original breech position. In our experience, when
seen the next week, sponstaneous cephalic ver-
sion has occurred safely in the meantime in most
of such cases.
The first step in performing the version is to
dislodge the breech from the pelvic inlet, and to
move it upwards on that side which will cause
the infant to turn in the direction in which it
is facing. If, for example, it lies in LST posi-
tion, and its head is in the right cornu of the
uterus, we would move the breech up along the
left lateral wall of the uterus so as to rotate the
baby in a counterclockwise direction. The op-
erator, with his other hand, then grasps the in-
fant’s head and brings it down along the right
lateral uterine wall, placing it finally in the mid-
line over the pelvic inlet. This manipulation can
be done safely as long as one does not attempt
to handle any fetal part if any of the placenta lies
between his hand and that part.
It is our belief that the principal danger one
encounters in doing external version, namely, trau-
matic separation of the placenta, can be eliminated
by determining in advance the placental implan-
tation site in each case and by strictly avoiding
the handling of that portion of the uterus which
contains the placenta while manipulating the fetal
poles. Palpation alone will disclose the fetal
head in one side or other of the uterine fundus,
and the placenta will then be in the opposite
side. Soft-tissue x-ray placentographic films will
show the location of the placenta and the exact
position of the fetus.
Anatomic factors which in general may make the
performance of external version difficult or im-
possible are: bicornuate uterus, primigravidity,
frank breech with extended legs, early deep en-
gagement of the (usually frank) breech, oligo-
hydramnios, “extended attitude” of the fetus, and
undue elongation of the amniotic sac resulting
from relatively low and lateral implantation of
the placenta in the cornual region it principally
occupies. When external version cannot readily
be accomplished (due to inability to disengage the
breech from the pelvic canal, or when the infant
cannot easily be turned after the breech has been
moved up into one iliac fossa) it is best to desist
in one’s attempts to turn the mfa?it. Our experi-
ence has shown that about two-thirds of such
fetuses will have undergone spontaneous version
when seen in the office one or two weeks later.
Real force should never be resorted to in the per-
formance of external cephalic version, and it will
rarely be necessary if the version is attempted be-
fore the fetal size has increased to that point
at which the turning becomes difficult.
The contraindications to external cephalic ver-
sion are: multiple pregnancy, history of vaginal
bleeding, history of previous section, marked de-
formities of the fetus (such as hydrocephalus
and anencephalus) , ruptured membranes, and
marked pelvic contracture making section a ne-
cessity. The generally accepted conditions under
which external cephalic version is permissible and
possible are: when the membranes are intact and
at least an appreciable amount of amniotic fluid
is present, when there is no polyhydramnios, when
the breech is not too firmly engaged and too low
in the pelvis to be safely dislodged, when a bi-
cornuate uterus is not being dealt with, when
placenta previa is not present, and when the an-
terior abdominal wall is not too obese to permit
the necessary manipulations.
The probable reasons why more physicians do
not perform external version are : ( 1 ) They are
so skilled at breech delivery that their corrected
personal fetal mortality rate is less than 1.5 per
cent and they therefore do not feel any need to
convert their breech presenting infants to cephalic
presentation — this would account, however, for
probably not more than 10 per cent of physicians
practicing obstetrics; (2) they do not palpate the
abdomen with the necessary accuracy required
by the definite intention of disclosing breech pre-
sentation, nor do they do this at twenty-eight,
thirty, and thirty-two weeks of pregnancy so as
to discover breech presentation while it is still easy
to perform external version (I have had several
physicians tell me that by the time they learn
that their primigravid and primiparous patients
have breech presentation, the breeches are en-
gaged and the infants cannot be readily turned) ;
(3) there is a fear (ungrounded, in my opinion)
that should they attempt external version they will
dislodge the placenta or otherwise damage the
infant. It is true that the same nervous hands
which might exert undue suprapubic force on the
aftercoming fetal head (accounting for most of
the fetal cerebral hemorrhage found at autopsy),
might cause some placental or fetal trauma when
external version is attempted. The maneuver, to
March, 1957
349
BREECH PRESENTATION— STEVENSON
be safe, must be done knowingly and gently by a
physician who is relaxed and free of unreasonable
fear.
Since all physicians practicing obstetrics must
be able to perform a carefully and properly con-
ducted breech delivery, most university teaching
hospitals will not engage in any extended pro-
gram of prenatal external cephalic version. Such
is the case of Herman Kiefer Hospital, but exter-
nal version is demonstrated here periodically so the
residents will know the method, and its indications
and contraindications. External cephalic version
lends itself admirably to routine use by a private
practicing physician.
The patient who has uncorrectable breech pre-
sentation and who is near term should have a care-
ful study which will disclose the normalcy of the
fetus, the adequacy of the pelvis, and the variety
of breech presentation. These points can usually
be determined by careful abdominal palpation
and by sterile vaginal examination, but in case of
doubt, roentgenographic studies should be made,
both of the pelvimetry and placentographic types.
If there are no contraindications to delivery
through the birth canal, labor should be allowed
to progress normally. Mild sedation, preferably
wth Demerol'®, should be given when good prog-
ress in labor has been achieved. It is essential
that the fetal heart sounds be auscultated at reg-
ular periods and with increasing frequency as
the second stage of labor progresses, because there
is then an increasing liability of fetal circulation
embarrassment due to compression of the cord.
When dilatation of the cervix is complete and the
breech descends onto the perineum, the patient
should be encouraged to bear down with each con.
traction. As soon as there is the slightest bulg-
ing of the perineum, we prefer to perform bi-
lateral pudendal nerve block, after the method so
well described and pictured by Klink,10 by inject-
ing 4 to 6 ccs. of 1 per cent xylocaine solution at
the mouth of Alcock’s canal on each side. As
soon as further bulging of the perineum occurs,
we make a generous left mediolateral episiotomy,
as this greatly aids the continuing extrusion of the
breech through the vulva. In the spontaneous
delivery, the passage of the shoulders and the
aftercoming head should be aided so that a good
mechanism can be maintained. Light inhalation
anesthesia may be desired by some during the last
two or three minutes of the second stage of labor,
but we customarily do not use it as the patient
has been told in advance that we may push on
her lower abdomen “to help the head through.”
An effective pudendal nerve block has proven
completely adequate in such cases in our hands.
In most breech labors, following blocking of
the pudendal nerves and making the episiotomy,
natural delivery to the umbilicus will take place
under the watchful eye of the waiting physician.
At this point we begin manual support of the in-
fant’s breech and trunk, keeping the back upward
while rotating the trunk gently from side to side,
if need be, so as to insure easy delivery of first
one and then the other scapula. We always have
a scrubbed assistant, and we have him hold the
trunk upward at a 45-degree angle from the hori-
zontal plane while the operator eases out the
aftercoming head. In some multiparae, as is well
known to all who practice obstetrics, the entire
infant may be extruded so rapidly that the ob-
stetrician is busy supporting it and making sure
that it does not fall in his lap.
In frank breech cases, particularly in primi-
gravidae, the operator may have to assist to a con-
siderable degree, even applying mild traction to
the breech with his index fingers gently inserted
in the groin on each side. This aids in guiding
and helping the passage of the breech through the
vulva. He then should rotate the breech so that
the infant’s back is uppermost, and may support
and apply gentle traction on the pelvic girdle,
drawing the thorax through the vulva. As soon
as the lower border of the thoracic cage starts
to come through the vaginal outlet we commence
rotations of the trunk, drawing the thorax through
the vulva as we do so. Grasping half of the
pelvis in each hand, with our thumbs over the
sacro-iliac region on each side, we make the
rotations of the trunk and thorax — clockwise, and
then counterclockwise — through an arc of a lit-
tle more than 180 degrees, each time bringing
one or the other of the scapulae up to the an-
terior midline of the outlet, as denoted by the
symphysis pubis. We also apply gentle traction,
and keep the infant’s back upward, or nearly so.
In this way, first one, and then the other, of
the scapulae are brought under the subpubic arch,
and the occurrence of a nuchal arm is nearly
impossible as the infant’s arms, because of the
thorax rotations, are kept moving about freely
in utero beside its head up until the moment of
their delivery.
We usually deliver the head by the applica-
350
JMSMS
BREECH PRESENTATION— STEVENSON
tion of gentle suprafundic pressure made with the
palm and heel of the hand, and not with the
finger tips or knuckled fist. If the head does not
descend readily to the pelvic floor with this pres-
sure, and if it does not then come through the
vulva without undue traction on the trunk or
pectoral girdle, Piper forceps are applied at once.
They are always kept sterile and in readiness in
every breech delivery so that there is no question
as to their immediate availability. They must be
applied gently to each side of the infant’s head,
and we feel that this can best be done by putting
the tip of the left blade inside the vaginal orifice and
then moving its handle over against the under sur-
face of the patient’s flexed and draped left thigh.
By guiding the tip of the blade gently around the
side of the head with his left hand, and grad-
ually swinging the handle of the blade through
a 90° arc in the horizontal plane with his right
hand, the operator can usually apply the left blade
without trauma or difficulty. The same principle
is then used with the opposite hands in applying
the right blade. Pudendal nerve block anesthesia
has proven adequate for forceps delivery of the
after-coming head in most cases in our hands.
The head must be manipulated so that it enters
the pelvic canal and comes down through it and
delivers. If it cannot be readily brought down
through the canal with suprapubic pressure alone,
then the operator should gently insert his index
finger in the infant’s mouth and also exert light
traction. With an assistant holding the infant
the operator can use one hand to exert the pres-
sure above and the other for traction below. This
dual maneuver will generally bring the head down
low enough in the canal to permit the safe appli-
cation of Piper forceps. When the head is high
and not even engaged, it is no safer to apply
forceps (to the aftercoming head) than when they
are applied to an unengaged head in cephalic
presentation; the head should at least be brought
down to about the mid-pelvic level before forceps
are applied.
Single and double footling breeches deliver more
readily and spontaneously than do frank breeches,
but they carry higher incidences of prolapsed and
compressed umbilical cord. One hopes, in single
and double footling breech cases, that labor will
progress to or nearly to full dilatation of the cer-
vix before the membranes rupture, since following
this event a leg frequently prolapses. Such an oc-
currence earlier in labor is undesirable since it
decreases the size of the breech and thus permits
it to pass through an incompletely dilated cervix,
which may not dilate nor prepare the cervix ade-
quately for easy passage of the aftercoming head.
Rectal examinations during labor, in such cases,
must be very infrequently and gently performed
so as not to hasten membrane rupture.
In those patients having adequately large pelves
and full dilatation of the cervix, in which there
is inadequately strong labor in the second stage, or
in primigravidae having resistant soft tissues and
relatively large infants, or when there is evidence
of fetal distress before the breech has appreciably
bulged the perineum, breech extraction should be
performed. Because breech extraction carries
from four to six times the rate of fetal mortality
as does spontaneous or aided breech delivery, it
must be executed with consummate gentleness and
skill. In those instances when there is frank
breech presentation of an overly large infant, and
there is only an average sized pelvis, particularly
if labor has been prolonged and difficult and ade-
quate progress is not being made, the idea of pel-
vic delivery had best be abandoned, section being
performed instead. It is true that at section it
is difficult to get the low, wedged-in breech back
up out of the pelvis, but we have always been
able to do so through a longitudinal (Kroenig)
incision in the lower uterine segment without too
much difficulty.
In performing extraction of the frank type of
breech, we again use pudendal nerve block anes-
thesia, and then make a liberal left mediolateral
episiotomy and quickly clamp and ligate the ma-
jor bleeding points in it. We grasp the breech
and pull it through the vulva until about half
of the thighs are visible, if this is possible. Next
we perform a Pinard maneuver on each leg in
turn, exercising gentleness and slow caution so
as not to further extend our episiotomy or to
otherwise lacerate the vagina. We next place a
dry towel around the pelvic girdle and, grasping
one half of the pelvis in each hand and keeping
the back generally up, we apply traction and
commence the alternate 180° rotations of the
trunk and thorax as described above. Sometimes
the scapula will lodge just inside the base of the
symphysis and not pass beneath it. We then gen-
tly insert an index finger above the scapula and
deliver it and the shoulder from under the arch.
Then the thorax is rotated 180° and the other
scapula-and-shoulder is brought up under the
March, 1957
351
BREECH PRESENTATION— STEVENSON
subpubic arch and delivered. T he head in such
a case, unless it comes out easily with supra-
pubic pressure, is delivered by Piper’s forceps.
In a difficult breech extraction, we give the
pudendal block anesthesia and make a wide
mediolateral episiotomy, and if the breech fits
snugly and cannot readily be brought down we
prefer to supplement at once with ether and
oxygen anesthesia, providing it is not contraindi-
cated by reason of a full stomach or respiratory
infection. If a competent inhalation anesthetist
is not available, and there is a real need for
uterine as well as soft-tissue relaxation, we then
resort to spinal anesthesia and give the dose or-
dinarily used for section, such as 70 mg. of pro-
caine injected through the third interspace with
the patient lying on her side. Such ether or
spinal anesthesia is essential in difficult extractions
when there has been a long and difficult labor
and there is reason to suspect the presence of a
hypertonic uterus and possibly even a constric-
tion ring. In all other cases we prefer pudendal
nerve block anesthesia, which rarely may have to
be supplemented for a few minutes with light
nitrous oxide-oxygen anesthesia. We like to use
pudendal nerve block principally because it per-
mits the uterus to remain in full and unattenuated
labor, and thus the percentage of spontaneous and
“easy assist” breech deliveries remains at a max-
imally high (and, as the statistics indicate, maxi-
mally safe) figure on our service. We have the
definite belief that the still strongly laboring uterus
helps appreciably in expressing the aftercoming
head, and that it is the wide use of pudendal
nerve block anesthesia which has decreased our
incidences of extraction and forceps deliveries.
The primary objective of Cesarean section in
the management of breech presentation is to as-
sure the birth of a living infant. Goethals11
summarized 159 Cesarean sections done for breech
delivery on 154 patients, five of whom were sub-
jected to two sections, each with breech presen-
tation. Aside from those common complications
requiring section regardless of cephalic or breech
presentation (e.g. diabetes, marked polyhydram-
nios, placenta previa, prolapse of cord, severe pre-
eclampsia), he found the paramount indications
for section to be: estimated fetopelvic dispropor-
tion, 71.7 per cent; elderly primiparity, 6.7 per
cent; estimated oversize fetus, 5.4 per cent, ob-
struction of birth canal (ovarian cyst, uterine
myomata, bicornate uterus) 2.7 per cent; and
miscellaneous (e.g. previous myomectomy, pro-
longed labor, fetal distress, and failed pelvic de-
livery), 13.5 per cent. The incidence of breech
presenting infants delivered by section at the Bos-
ton Lying-in Hospital prior to 1940 was 6 per cent,
whereas since that date it has been 11.2 per cent;
since 1940 the corrected fetal and neonatal mor-
tality rate for breeches delivered through the va-
gina was 2.6 per cent, while for those delivered
by section it was 2.3 per cent, all of which is a
marked improvement in fetal survival over that
of the period prior to 1940. X-ray pelvimetry,
plus relatively accurate estimation of fetal size,
permits a more knowing and valid anticipation of
fetopelvic disproportion, and thus the decision
as to the necessity of section is more readily
reached; section thus resorted to produces an in-
creased fetal survival.
A reduction of the fetal mortality in breech de-
livery to a corrected incidence of 2.5 per cent or
less throughout our country is an important and
attainable goal towards which obstetricians should
strive.
Summary
1. Breech delivery carries a four-times-greater
fetal mortality rate than does cephalic delivery,
and also a four-times-greater rate of maternal
morbidity. This is true of the country as a whole.
2. Breech delivery can be obviated in all but
about one-fourth of the cases by routine external
cephalic version of all breech presenting fetuses
found, by a regular program for detection, at
twenty-eight to thirty-four weeks of pregnancy.
The corrected fetal mortality, in skilled hands and
under such a plan, can be reduced to 1.5 per
cent or lower.
3. External cephalic version, when gently per-
formed, by knowing and careful physicians, car-
ries no detectable incidence of fetal or maternal
trauma or loss. It is a relatively easy maneuver,
and can readily be learned from one experienced
in its performance.
4. Breech delivery is best accomplished spon-
taneously, or by a single “assist,” under pudendal
nerve block anesthesia through a wide medio-
lateral episiotomy, and cases so delivered carry
the lowest rates of fetal mortality, and fetal and
maternal morbidity.
5. When a difficult frank breech extraction is
to be done, ether anesthesia may be indicated, and
(Continued on Page 363)
352
JMSMS
Shoulder-Hand Syndrome
By E. S. Gurdjian, M.D.
J. E. Webster, M.D.
Detroit, Michigan
' | 1 HE SHOULDER-HAND syndrome is char-
acterized by a painful shoulder, stiffness, swell-
ing and pain in the hand and fingers, as a result
of a reflexed neurovascular dystrophy following
diseases of the thorax, head and neck. This
condition may be seen after myocardial infarction.
segmental sensory loss is noted. The tendon re-
flexes are intact, early.
Mechanism
The mechanism of production of the shoulder-
hand syndrome is on a reflex basis. The afferent
Fig. 1. A working outline of reflex pathways resulting in shoulder-hand syndrome.
At first, the pain in the extremity is accompanied
by stiffness and swelling, eventually there may be
atrophy with flexion deformities of the fingers
and contractures with osteoporosis in some cases.
The shoulder-hand syndrome may follow myo-
cardial infarction. It is usually not present in
the acute phase, appearing two to three weeks
after the infarction. Increasing stiffness of the
upper extremity with pain in the shoulder and
the hand and swellings of the hand are noted.
This is followed by increasing disability, if some-
thing is not done to help cure the disease. No
From Wayne State University Neurosurgical Services,
Grace and Memorial Hospitals, Detroit.
Presented at the Michigan Clinical Institute, Detroit,
March, 1956.
March, 1957
stimuli coming from the injured or diseased area
in the thorax, or neck or the upper limbs activate
the internuncial pool in the spinal cord. This
then spreads to the anterolateral column stimulat-
ing sympathetic cell bodies as well as the cells
in the anterior horn. The preganglionic fibers in
turn activate the postganglionic fibers supplying
the blood vessels of the extremity, resulting in
a series of abnormalities, namely, stiffness of
joints, swelling, and aching and burning pain in
the hands and fingers (Fig. 1). It is important to
remember that such reflex dystrophy may occur
not only as a result of myocardial disease, but also
as a result of other diseases in the chest and the
mediastinum, as well as painful conditions in the
353
SHOULDER-HAND SYNDROME — GURDJIAN AND WEBSTER
upper extremity itself. 1 he mechanisms for the
causation of the neurovascular dystrophy and the
reflex arc aiding in its causation are available
through afferent discharges from the painful area
Fig. 2. This diagram shows the mechanism of com-
pression of the neurovascular structures (subclavian
vessels and the brachial plexus) by the anterior scalene
and the pectoralis minor muscles, as well as costo-
clavicular compression.
into the internuncial pool in the spinal cord with
sympathetic discharges and painful swelling with
aching and burning.
Differential Diagnosis
The differential diagnosis of shoulder-hand
syndrome includes a consideration of many of
the conditions that result in a painful state in
the upper extremity, that is, in the shoulder, hand,
or both. These include cervical ruptured or pro-
truded disc, Sudeck’s atrophy or painful osteo-
porosis with bone atrophy, cervical rib and an-
terior scalene syndrome, costoclavicular syndrome,
hyperabduction or subcoracoid syndrome, or pec-
toralis minor syndrome, causalgia due to nerve
injury and local diseases in the upper extremity
and the spine, including bursitis and osteoarthritis
of the spine and the extremity.
The cervical rib syndrome is usually seen in
the female patient in more than 75 per cent of
the cases. Only a quarter of those with cervical
rib or long transverse processes of the seventh
cervical vertebra have symptoms. There may be
sensory, muscular and vascular abnormalities with
the pain usually from the elbow down. Aching
and burning and, at times, shooting pain may
be complained of, with paresthesias in the fingers.
Often the ulnar portion of the hand is more
involved. The pain is usually made worse by
pressure in the supraclavicular area in the region
of the emergence of the lower portions of the
brachial plexus. Hyperesthesias and anesthesias
associated with pain may be noted. Wasting of
muscles, particularly in the thenar eminence is
frequent in the untreated cases of long standing.
At times there may be unusual pulsations in the
supraclavicular area because of an upward dis-
placement of the subclavian artery due to the
cervical rib. Depending upon whether or not
the brachial plexus is of the pre-fixed or of the
postfixed variety, there may be more involvement
of the median distribution in the former group
as compared with the latter group in which the
ulnar distribution is more frequently involved. At
times there may be a feeling of coldness with
pallor or cyanosis in the hand. Occasionally there
may be intermittent claudication with the ex-
tremity red, swollen and livid. The diagnosis of
the condition is based on the presence of a cervical
rib shown by x-ray and the symptoms. When the
head is turned toward the affected side and poster-
iorly, there may be a loss of the radial pulse.
The anterior scalene syndrome is caused by
compression of the lower brachial roots forming
the brachial plexus and/or the subclavian artery
by this muscle. A hypertrophy of the anterior
scalene muscle may compress the brachial plexus
and the subclavian artery. An obliteration of the
pulse may occur on turning the head toward or
away from the affected side or there may be in-
crease in the symptoms and signs by these ma-
neuvers. There may be tenderness of the muscle
on compression and relief of the complaints by
elevating the shoulder girdle. Injection of pro-
caine into the belly of the muscle may help relieve
the condition. In some cases, the vascular symp-
toms of a tight anterior scalene may be quite
serious with marked color changes in the hand,
in some even a gangrene of the distal portion
of the extremity may be noted. A swollen hand
354
TMSMS
SHOULDER-HAND SYNDROME— GURDJIAN AND WEBSTER
with shiny skin of the fingers and hand, difficulty
in flexion and extension of the fingers, pain in
the extremity, may be in part due to the com-
pression of the vessel and nerves and in part due
to reflex vasomotor abnormalities from activation
of the internuncial neurons in the spinal cord
and the sympathetic pathways (Fig. 2).
The subcoracoid or pectoralis minor syndrome
or hyperabduction syndrome is due as the name
suggests it, to hyperabduction either in work or
sleep with neurovascular changes associated with
pain in the hand or shoulder, at times Raynaud’s
phenomenon, paresthesias involving the entire
hand. The kinking of the subclavian vessels and
the brachial plexus by the edge of the pectoralis
minor results in the neurovascular abnormalities
(Fig. 2).
The costoclavicular syndrome is caused by a
compression of the subclavian artery and the
brachial plexus between the first rib and the
clavicle. An abnormal sagging of the shoulders
with a high first thoracic rib may result in this
syndrome. Hyperextension of the neck or back-
ward pulling of the shoulders may compress the
brachial plexus and the subclavian vessels between
the clavicle and the rib. The diagnosis may be
made on the basis of these maneuvers and the
presence of abnormal x-ray findings suggesting
such a condition.
Causalgia due to partial injury to one of the
nerves in the upper extremity is associated with
burning, aching, crushing feeling, paroxysms of
shooting pains. In instances of amputation neu-
roma, there may be pains in a phantom limb,
which according to the patient, is in a fixed,
immovable and cramped position. Causalgia as-
sociated with partial injury to the nerves may
be associated with a constant burning, aching
pain, with severe exacerbations on physical and
emotional stress. The hand may be cyanotic and
wet; in other instances, it may be dry and scaley.
More frequently, it is cold and wet with perspira-
tion. Eventual atrophic changes of the nails, and
a thin, shiny, hairless epidermis may be seen. In
many instances a beginning causalgic state may
improve early after its inception, but in others
the condition continues, to become an unbearable
state. Sympathectomy has been of value in this
condition.
Sudeck’s atrophy may often follow fractures of
bones and in some cases insignificant injuries to
an extremity. Spotty decalcification of the bone
with vasomotor disturbances and great pain in
the extremity are the diagnostic features of the
condition. Early there may be a swelling and dis-
coloration and intense pain with local vasodilation.
Later, the hyperemia may be followed by vaso-
spasm and a glossy skin with edema and cyanosis
in the dependent position. Sympathectomy is
valuable in management.
A cervical disc may or may not be associated
with a history of trauma. Evidences of focal sen-
sory changes in the upper extremity and in some
cases with loss of biceps and/or triceps tendon
reflexes are noted. The diagnosis may be based
upon the history of pain in the neck and radia-
tion into the upper limb. The movements of the
neck may cause radiations of pain in the affected
limb. The use of a cervical myelogram and the
presence of narrowed cervical intervertebral spaces
are valuable in diagnosis.
Diagnosis
The diagnosis of the condition is based on a
careful neurologic examination following a metic-
ulous history. The use of x-rays of the cervical
spine and the extremities and myelography may
be of help. In some cases, the possibility of two
conditions occurring simultaneously should be
kept in mind. This is particularly true among
those with hypertrophic osteoarthritis of the cer-
vical spine who may also have a myocardial in-
farction followed by a shoulder-hand syndrome.
Treatment
The treatment of the patient with shoulder-
hand syndrome is by the use of sympathetic
blocks, physiotherapy, massage, active and passive
movements of the extremity as well as the develop-
ment of a healty viewpoint toward one’s disabil-
ity. Since many of these patients are in the older
age group, the last-mentioned factor, that of the
emotional instability toward one’s disability, is
extremely important. To help overcome this is
an important part of the treatment of such cases.
Where definite disease entities have been found
which may be treated by special measures such
as sympathectomy, laminectomy, scalenotomy, et
cetera, these should be carried out.
March, 1957
355
Editorial
CHILD WELFARE ISSUE
This issue of The Journal is sponsored by the
Child Welfare Committee of the Michigan State
Medical Society. The term “Child Welfare bears
an unfortunate connotation. “Welfare,” to most
people, suggests social need and charity rather
than the physical and emotional well-being of all.
There are those who may feel that this issue,
dealing with children, is so restrictive as not to
concern them. We all, though, are concerned
with standard of living, and recently our standard
has risen greatly because of the improvement in
child health.
The health of no group is more before the
public’s eye than that of children. The medical
profession gets credit when there are advances —
as in perinatal morbidity, with the reduction of
retrolental blindless by limiting use of oxygen, or
with survival of infants with erythroblastosis by
replacement transfusions. Contrariwise, we are
criticized, usually vehemently, when there is some
breach in child care. Our critics do not think of
us as individual doctors but as a professional
group. We are praised or dammed as a group.
By force, then, all of us, must be deeply con-
cerned with “child welfare.”
Selection of an appropriate cover for a journal
is always a problem. I felt the little princess we
chose rather breath-taking; you can’t help but
look at her twice. Regardless of our critics and
standards of living and medicine, her attraction
to us demonstrates the instinctive love of children
we all have.
The child is the daughter of John Cook, and
the picture was taken by George Jennings, both
staff members of the State Department of Health.
Choosing this picture was appropriate and mani-
fests again the constant co-operation of assistance
given us by the State Department of Health.
Another cover was suggested, depicting “Opera-
tion Armor,” symbolizing the State Medical So-
ciety’s campaign to get all susceptible persons
vaccinated against polio, regardless of age. Here
the borderline between child and adult welfare
breaks down. The articles on polio, important to
us all, emphasize that we each, by every possible
means of education, must not only “get the vac-
cine to the patient, but get the patients to the
vaccine.”
How many of our own children needed glasses
before we doctors, the children’s fathers, were
aware of it? The vision screening tests performed
in schools throughout Michigan have revealed
many preventable or correctable eye conditions.
Might our own vision today have been better :
had our eyes been tested when we were younger?
What should we be doing in our offices to check i
vision ?
And how many inquiries do we have each year
about adoptions? Did you know that in this state
there has been no formal training of medical or
law students in the medical, legal, and ethical fac-
tors of adoptions? Yet our patients expect us to
be thoroughly conversant with at least the medical
phases of adoption. Are you?
Other articles summarize some of the interests
explored and conclusions reached by various mem-
bers of the Child Welfare Committee and of others
who have concentrated on child care.
The Committee is grateful to the State Medical
Society for the opportunity of bringing these to
your attention, and we appreciate the time and
effort of those who have contributed to this
issue.
Robert M. Heavenrich, M.D
PROPOSED NATIONAL LEGISLATION
The President’s Health Legislation program has
not yet been outlined to Congress but sufficient
has been indicated to give us a good idea of what
to look for. The Civil Service Commission has a
program left over from the 84th Congress provid-
ing hospital and medical services for more than
two million workers and their dependents. Last
year, the Congress almost agreed on a plan which
would give very liberal terms, the government
paying the first $25.00 of the premium. It pro-
posed that payroll deductions be authorized. This
last item was one reason the bill did not pass.
A commission was authorized to study its feasi-
bility. Government feared the workability in its
(Turn to Page 358)
356
JMSMS
Kids Are Important
In matters of Health, nothing has comparable public ap-
peal to the physical vicissitudes of children.
You and I know that the child is probably as indestructible
a human as any in existence, and that, barring accidents, he’s
going to live longer than any of the folks who worry about
him.
On the other hand, the old adage “as the twig is bent, the
tree is inclined” is perhaps truer in respect to physical and
mental health than it is to any other part of the child’s life,
insofar as his future well-being and success are concerned.
Consequently, it behooves us, as doctors and as medical
societies, both from the standpoint of good preventive medi-
cine and good public relations, to put increasingly strong
emphasis on the health welfare of children.
And that is what we are doing. Our all-inclusive im-
munization campaign called “Operation Armor,” our Rheu-
matic Fever Control program, the statewide studies of sight
and hearing in the schools, the programs for crippled and
afflicted children, the child guidance clinics — all are mani-
festations of the medical profession’s interest in children.
It strikes me that there is another reason why “kids are
important” and why we have a duty, not only as doctors but
as citizens, to do our part in seeing that America’s children
grow straight and tall and sound. It is that our national de-
fense, the future progress of our country, the maintenance of
a straight-thinking electorate, indeed, the future of our pro-
fession all depend on the “twig” that is so easily bent.
It’s quite a responsibility.
President, Michigan State Medical Society
March, 1957
357
EDITORIAL
own affairs; however, in formulating income tax
regulations, they had no hesitation to impose
withholding duties on industry.
The plans being considered for medical and
hospital “insurance” for government employes
seems to be favorable to the Blue Cross and Blue
Shield methods. A uniformity of contract is fa-
vored by some, but the Blue Shield can overcome
the differences in its seventy-four plans by using
its own reinsurance plans to cover items not in-
included in some plans. The Blue Shield plans
have the advantage of really representing the re-
quirements and facilities to which the people and
doctors of the section are accustomed. General
Motors has worked out this problem very satis-
factorily.
The President has been concerned with more
services for uninsured and uninsurable persons.
There are now about 14,000,000 persons over sixty-
five who are retired or are being retired — some
with social security but most with inadequate
resources. Of these, the government has grouped
four service programs in a special category: Aid
to Blind, Old Age Assistance, Dependent Children,
and Disabled.
From time immemorial, the state has had the
responsibility of feedings, housing and clothing
the indigent. Niggardly medical care also lias
been provided to the “medically indigent.” The
Federal Government has borne part of this cost.
It now provides matching funds to the states.
For several years, the four groups mentioned have
been included, but the last Congress in an effort
to improve care, authorized a special grant of
$3.00 for each adult and half that amount for
each child under nineteen with matching funds
from the states, to give additional medical aid
to the four classifications. The Michigan Depart-
ment of Social Welfare is considering using the
children’s share for dental care, and the adult
share for increasing hospital services.
Indigent Care
There are many people unemployed, unable to
work, or just unemployable who must have health
care. These are part of the President’s candidates
for “reinsurance.” Our Michigan Welfare depart-
ment is paying those on its rolls $3.00 a month
for miscellaneous medical care and a limited al-
lowance for doctor’s bills, provided they get a
doctor’s signature on their form each month. The
patient is supposed to pay the doctor, and more
are now doing so; however, this whole program
is cumbersome.
One county in Michigan, some years ago, of-
fered to contract for the necessary care of all the
indigents for the exact amount they were costing
the welfare agencies, the county society agreeing
to pay the doctors. It was believed that complete
care could be given for the current costs. That
plan was blocked by rulings that the Welfare
Department must not pay direct for health care.
Another scheme suggested was a “cost-plus”
basis — the Department to authorize care and pay
for it through an intermediary (MMS). That
seemed most logical — government has the respons-
ibility of health care for these people — the plan
could work. It has worked in several of our states
in care of service-connected disabilities of our vet-
erans. The same program is now in operation
throughout the United States for the dependents
of military service personnel.
Blue Cross and Blue Shield over the nation have
indicated their ability and willingness to care for
the uninsurable and the worthy wards of the Gov-
ernment. The last groups mentioned herein are
historically admitted to be the responsibility of
government. Available sponsors have always been
the charity hospitals and the sympathizing doctors.
The voluntary health service plans have pointed
the way, and government should accept its re-
sponsibility. So far, the only cost to the govern-
ment has been administrative, because we have
used our own set-up at cost. Government has sug-
gested subsidies to cover the plans we have been
discussing. The Blue plans do not want any
subsidity but would be willing to work on a
“cost-plus” arrangement.
Jenkins-Keogh
Another piece of national legislation is the
renewed Jenkins-Keogh bills, again numbered 9
and 10. They have been modified but in general
provide for the assigning of part of income, up
to a limit, w'hich can be invested in approved
methods to build up a retirement program, to
be tax-free until the funds are drawn upon for
retirement purposes, at which time they will be
taxable in a reduced amount. The bills propose
to allow self-employed men the same tax-exempt
formula now being used by industry to establish
endowments for its employed persons. This bill
now has the support of the American Bar Associa-
tion and hopefully will be remembered by our
358
JMSMS
EDITORIAL
representatives when the time of action comes.
Last year, it might have been enacted. Let’s see
that it is enacted this term.
Murray-Dingell
Congressman Dingell, son of our former repre-
sentative from Michigan, has joined with Senator
Murray so that in each House a bill much like
our old friend of fourteen years ago has been in-
troduced. Many items of the original bill have
been enacted piecemeal during the years. We now
have education and health personnel; medical re-
search; Hill-Burton hospital construction (ex-
panded) ; aid to rural and shortage areas; state
grants (matching) for health work; grants for
national health; grants for child welfare.
The Dingell-Murray scheme is similar to social
security, establishing a system of health insurance
requiring workers to contribute 1.5 per cent of
earnings up to $90 a year, matched by employers.
Eligible workers and their families would receive
preventive and diagnostic examinations, x-ray and
laboratory', hospitalization up to ninety days, more
expensive drugs, appliances, glasses. This prac-
tically covers the field for all employed persons.
PREPAYMENT
Great proportions of our members are happy
in the service we have been able to render our
patients because of our Michigan Medical Service.
Too many have accepted returns for services to
patients, have been critical of the amounts of
payments, and in general have critized “that in-
surance company.” We have heard it for years,
Unfortunately, many do not remember the time
before “prepayment.” The man who collected
over 75 per cent considered himself a good busi-
nessman. The effort and time consumed in col-
lecting amounted to a staggering amount. That
is all gone with Michigan Medical Service. No
collecting expense, only one detailed report neces-
sary, and a rather prompt check. At its inception
Blue Shield had its most important purpose to
guarantee health services to a large proportion
of our patients who were primarily in the lower
income bracket, and to whom a trip to the hospital
was a calamity. The hospital, the doctor, the
grocer, all had to wait. Unfortunately, too many
of us do not respect Blue Shield as our own child,
our best friend, our guard in former years against
socialized medicine of the Wagner-Murray-Din-
gell type.
A new Murray-Dingell bill is now in the hopper,
but our watchful medical leaders are much more
concerned with a threat to the time-honored sys-
tem of private practice of medicine. Some at-
tempts have been made to put groups of the pro-
fession on a salary or capitation basis, but not
too successfully. The older doctors in Detroit re-
member the consternation when the Ford Hospi-
tal instituted its work through salaried doctors.
Some remember the Ross-Loos Clinic of Cali-
fornia. The Kaiser Permanente NTI plan caused
concern and much readjustment in California.
HIP in New York City uses capitation.
Because Michigan has very few groups or
clinics, and not much experience with that type
of practice, we were taken aback with the an-
nouncement of the Community Health Association,
and its announced intention of employing doctors
on salary, for the care of their insured people.
Should the plan grow and need large numbers
of doctors, that would place our profession, in
large measure, in the position of contract prac-
tice, the union leader being the dictator of care
and loyalty. The CHA Board has stated its intent
never to interfere in the professional services.
How long will that promise last when the em-
ployer is the creature of a most powerful pressure
group?
The Council of the Michigan State Medical
Society believes this threat to private practice
can be countered by two concerted efforts. First,
Michigan Medical Service is offering more com-
plete coverage as a rider. The service can be
rendered at a surprisingly small price, but it
must be paid for. Those services cannot be given
free. Second, it will probably be necessary for all
of our members to accept the offerings of Michi-
gan Medical Service and meticulously not over-
charge the under-income-level persons. Savings
on collection costs and loss from unpaid bills will
probably amply overbalance the contemplated
overcharges in the long run.
The most important advantage will be the pro-
tection of our right to practice medicine as we
have in the past — placing our own peers over us
instead of a government hierarchy, or a strong
labor group.
Too much is at stake to take chances — all of
us must co-operate.
March, 1957
359
EDITORIAL
WHAT MAKES BLUE SHIELD
DIFFERENT?
One frequently hears doctors ask, “Isn’t Blue
Shield just ‘another insurance company’?” This
question usually comes from a member of the
generation of new doctors who have come into
practice since the early ‘40’s, and who know little
of the desperate challenge that gave rise to the
Blue Shield idea and the hard work with which
its accoucheurs gave it birth.
Blue Shield represents a vast and triumphant
effort on the part of American medicine to prove
to the people of the United States that, with their
help, their doctors can solve urgent problems of
medical economics without governmental inter-
ference or dictation. Blue Shield was created at
a time when the insurance industry questioned the
actuarial feasibility of voluntary medical care
insurance on any large scale, and even many
doctors feared that a voluntary program would
inevitably lead to a compulsory health insurance
system under government auspices.
Blue Shield has little in common with commer-
cial accident and health insurance beyond the
fact that it utilizes actuarial principles. Where
the insurance company underwrites selected groups
to produce a profit. Blue Shield, reflecting the
service ideals of the medical profession, makes
its services available to the entire community, at
rates based on the needs and experience of the
community — including most particularly those
people in the low income groups who most need
medical prepayment protection.
Where commercial insurance companies offer
cash allowances which may or may not have
any relation to the doctor’s normal charge for
his services, Blue Shield’s schedules of payment
are negotiated and approved by the local medical
profession. In most areas Blue Shield benefits take
the form of fully paid professional services, through
the co-operation of the “participating physicians.”
Even where “service benefits” are not provided
by formal agreement of the doctors, Plan sched-
ules generally attempt to approximate the normal
charges of the local physicians for services ren-
dered people in the lower income brackets, and
the local physicians frequently accept these fees
as full payment.
Blue Shield Plans are distinguished by non-
profit operation, which means that their only
purpose is service to the people and their doctors.
Non-profit operation also means that all the funds
contributed by the subscribers are available for
payment of benefits, with a minimum retained
for actual operating costs and reserves for future
claims.
Over and above all requirements of state law,
Blue Shield Plans are required to maintain strict
“membership standards” in order to use the name
and symbol “Blue Shield.” These standards pro-
vide that the Plan must have the continuous
approval of the local medical society; must render
an annual report to the society; and must secure
the formal participation of at least 51 per cent
of all the physicians in the Plan area.
Blue Shield utilizes insurance principles, but.
because of the participation of the great majority
of American physicians, it is able to transcend the
limits of insurance — to become a true community
service on behalf of America’s physicians.
DEATHS BALANCE BIRTHS
Over the past thirty years, extensive maternal
mortality studies have been carried on in Michi-
gan. Due at least in part to the application of
information obtained from these studies, the ma-
ternal mortality rate in Michigan has dropped
92.3 per cent. However, during the same period,
deaths of newborn infants have declined only
55.8 per cent.
It is probable that one reason for this dispro-
portionate decline in mortality rates is a lack of
information and research regarding the exact
cause of many perinatal deaths. Although defini-
tions vary somewhat, the most commonly accepted
meaning of the term “perinatal mortality” relates
to the total fetal deaths from twenty weeks or
more gestation and newborn deaths within the
first seven days of life. If these deaths are to be
reduced significantly, it is necessary to obtain
complete and reliable information regarding the
pregnancy, delivery, condition of the infant at
birth, and treatment and care of both mother
and child.
A number of Michigan physicians, concerned
about fetal wastage as well as handicapping con-
ditions in surviving infants, have organized com-
mittees to study perinatal deaths and factors as-
sociated with them. Included among the leaders
in organizing such committees are physicians in
Wayne County, Grand Rapids, Saginaw and Lan-
sing. They realize that the perinatal period offers
360
TMSMS
EDITORIAL
one of the most fruitful areas for research and
education, not only in terms of preventing deaths
and disability but in saving taxpayers’ money. A
factor which causes the death of one child may
cause a seriously handicapping condition in an-
other who survives. Preventing such conditions
from developing must certainly be considered as a
primary purpose of these perinatal studies.
A perinatal mortality study committee usually
includes general practitioners, obstetricians, ped-
iatricians, pathologists, anesthesiologists and pub-
lic health workers. Accurate and complete infor-
mation on birth and death certificates and hospital
records is the basic requisite for a valid study. In
this, all physicians caring for mothers and new-
born infants can co-operate. A uniform pro-
cedure for reporting data throughout the state
is essential because it makes valid comparison pos-
sible and provides statistics of significance and
value.
Assistance with the planning of such studies and
standard forms for the tabulation of data and sta-
tistical analysis will be provided by the Michigan
Department of Health upon request.
The need for such studies is highlighted by the
fact that prematurity is the leading cause of death
among newborn infants. In 1954, physicians stat-
ed on death certificates of infants under twenty-
eight days of life that prematurity was the sole
cause of 36 per cent of the deaths and an asso-
ciated cause in an additional 26 per cent. It
would seem apparent, then, that emphasis should
be placed on the prevention of prematurity. Fac-
tors to be considered in such prevention are early
and adequate prenatal care and the avoidance
of surgical or medical induction of labor until ma-
turity has been assured by radiologic or clinical
means. When necessary, gestation can often be
prolonged by judicious sedation and rest.
Of course, prematurity is often inescapable;
some infants refuse to delay their arrival into
the world despite the best efforts of all concerned.
In such cases, death can often be prevented by
thorough preparation before delivery for imme-
diate care of the expected premature infant. This,
of course, requires adequate hospital equipment
and facilities, as well as highly competent medi-
cal and nursing care. In addition, instruction of
the mother regarding the care of the infant in
the home is extremely important. Many physi-
cians routinely request home visits by public health
nurses for premature infants and are convinced
of their value in saving lives.
Michigan ranks high among the states in terms
of quality of medical care, hospital beds, public
health services and economic status. It is also
fortunate in having so many physicians who de-
vote much of their time and energy to public
and community health. Yet, by a more effective
co-ordination of these forces, a higher level of
health for Michigan children can be attained.
This would include: greater participation by
physicians in lay education regarding child health;
research and studies of fetal wastage and handi-
capping conditions in children, both congenial
and acquired; further improvement in hospital
care, both in nursery facilities and pediatric de-
partments; and better utilization by practicing
physicians of the services and materials provided
by the state and local health departments.
Certainly, there is still a great deal of room
for improvement in further reducing perinatal
deaths in Michigan. By establishing committees
to investigate all known factors pertaining to peri-
natal deaths and by analyzing probably prevent-
able factors which lead directly to these deaths
or conditions contributing to death, it is not un-
reasonable to suppose that a significant reduction
can be achieved.
Goldie B. Corneliuson, M.D., Director
Division of Maternal and Child Health
Michigan Department of Health
Careful perimetric studies are by far the best method
of localizing occipital lobe tumors.
* * *
Significant alterations in the orbital veins, whether
congenital or the results of pathological degeneration
of the vascular walls, neoplasms or trauma, give rise
to venous aneurysms.
* * *
The radioactive isotopes are among the more promis-
ing of the newer techniques for determining the loca-
tion and demarcation of intracranial neoplasms.
* * *
There has been neither morbidity nor mortality traced
to action of the radioactive dyes in tests for brain
tumor localization.
* * *
Early brain tumors are often mistaken for chronic
indigestion, migraine, mental illness, hypochrondria, or
just plain laziness.
* * *
Any attitude of hopelessness in regard to brain
surgery and its results is a distinct anachronism. Opera-
tive mortality rates have been greatly reduced and many
patients permanently benefit from modern operative
procedures.
March, 1957
361
L. Fernald Foster, M.D.
Servant and Director of Medicine
L. Fernald Foster, M.D., Bay City, will devote
his full time to the carrying out of duties of his
two offices — President of Michigan Medical Serv-
ice and Secretary' of the Michigan State Medical
Society as Medical Executive Administrator.
Dr. Foster has been a member of the Board of
Directors of Michigan Medical Service since its
inception in 1939. For the past twenty years, he
has been Secretary of the
MSMS.
The list of Dr. Foster’s
activities in behalf of the
medical profession seems
endless. Here are a few
highlights :
In December 1956, he
resigned as Secretary of the
Bay County Medical So-
ciety after a tenure in that
office of thirty-six years.
This tenure was broken only
by a year of service to that
organization in the office of
President, during which
time the Secretary’s books
never left his office. Recog-
nized as an outstanding
pediatrician in Bay City, he
held at some time, during his years of practice
there, every office of importance in the hospitals
concerned with the medical staff or his specialty.
At the same time, he served as a consultant in
pediatrics in surrounding community hospitals.
His impact has been felt most, in spite of his
outstanding record in his hometown, on the state
and national levels. Known for many years as the
man who was always aware of what was going to
happen before it happened in medical society af-
fairs, a plan to make him “President-for-a-Day”
was successfully kept secret from him until the
resolution was passed by the House of Delegates
in 1954. He had deliberately refused any attempt
to put his name up for the presidency on many
previous occasions and had likewise refused to
accept a chance to become a trustee of the
American Medical Association.
He was told at that time: “With your ability
there isn’t any doubt in our minds that you’ll be
362
President of AMA.” Said Foster: “But I don’t
want to be President.”
His work with the Michigan State Medical
Society includes activity in connection with nearly
every committee and project of that organization
and so are too numerous to mention. However,
with his understanding of the medical profession
as a springboard, he has inaugurated many a
program and project which
are now accepted as stand-
ard parts of the warp and
woof of health services.
A founder of Michigan
Medical Service, he is also :
a founder of the Michigan
Heart Association, serving
as its first Secretary and its
present Vice President. He
started the Michigan Rheu-
matic Fever Control Pro-
gram when he was serving
as a member of the Board
of Directors of the Michi-
gan Society for Crippled
Children and Adults. He
aided in the organization of
the National Conference of
Medical Service and served
as its President. As Chairman of the Board of
Directors of the Cooperative Medical Advertising
Bureau of the AMA, he was influential in the
establishment of the present, independent State
Medical Journal Advertising Bureau, upon which
he still serves as a member of the Board of Direc-
tors and Chairman of the Advertising Committee.
With MSMS Past-President Andrew S. Brunk,
M.D., he formed the Conference of Presidents
and other Officers of State Medical Societies; and
the list goes on and on.
Nor has his activity been limited to general
phases of organized medicine. Although a front-
line favorite of the general practitioner, he is a
specialist. Following graduation from Lafayette
College in Easton, Pennsylvania, with a Ph.B. de-
gree, he received his medical degree from the
University of Pennsylvania School of Medicine in
1919 and interned at the Presbyterian Hospital
and Childrens Hospital in Philadelphia. He took
TMSMS
L. FERNALD FOSTER, M.D.
I his residency in pediatrics at the Presbyterian Hos-
pital and was Chief Resident of Childrens Hos-
pital there. He took postgraduate work at Wash-
ington and Johns Hopkins Universities and be-
came successively diplomate of the National Board
of Medical Examiners, diplomate of the American
Board of Pediatrics and member of the American
Academy of Pediatrics.
Besides his wide activity in medical circles, he
is a member of Rotary and several other fraternal
organizations including the American Legion, the
latter following his military record as a member
of the Medical Reserve Corps in World War I.
Although his chief love is medical organization,
his inquiring mind became intrigued with fire
fighting. Today, he is an authority on fire-fighting
equipment and installations, and his persuasive
personality as a speaker has resulted in improve-
ments in fire department equipment, not only in
Bay City, but in several other Michigan com-
munities.
He sees no disparity between his interest in
medical organization and fire fighting, probably
because he’s put out many a fire that threatened
his chosen profession and certainly has built a fire
under many a slow-moving colleague when action
was urgently needed.
As he goes into full-time service in MMS and
MSMS, you can expect to see the same inten-
sified, extensive programs take form that have
characterized his past performance.
RUBELLA IN PREGNANCY
(Continued from Page 341)
stillbirths of 6 to 10 per cent, where maternal
rubella occurs in the first sixteen weeks of sfesta-
tion.
3. The effectiveness of gamma globulin in pro-
phylaxis is questionable.
4. Many considerations deter the physician who
considers therapeutic abortion.
References
1. Gregg, N. M.: Congenital cataract following Ger-
man measles in the mother. Tr. Ophth. Soc. Aus-
tralia, 3:35, 1941.
2. Swan, C.; Tostevin, A. L.; Mayo, H. ; and Black,
G. B. : Congenital defect in infants following infec-
tious disease during pregnancy. M. J. Australia,
2:201, 1943.
3. Wesselhoeft, C.: Acute infectious disease in preg-
nancy. Ann. Int. Med.. 42:555, 1955.
March, 1957
4. Collins, I. S.: Incidence of congenital malforma-
tions following maternal rubella at various stages of
pregnancy. M. J. Australia, 2:456, 1953.
5. Lundstrom, Rolf: Rubella during pregnancy. Acta
paediat., 41:583, 1952.
6. Ingalls, T. H., and Purshottam, N. : Fetal risks from
rubella during pregnancy. New England J. Med.,
249:454, 1953.
7. Krugman, S., and Ward, R. : The rubella problem:
Clinical aspects, risks of fetal abnormality and
methods of prevention. J. Pediat., 44:489, 1954.
8. Brawner, D. L. : Maternal rubella; results follow-
ing an epidemic. J. M. A. Georgia, 44:451, 1955.
9. Guttmacher, A. F.: Therapeutic abortion, the doc-
tor’s dilemma. J. Mt. Sinai Hosp., 21:111, 1954.
MANAGEMENT OF BREECH
PRESENTATION AND DELIVERY
(Continued from Page 352)
great care and gentleness must be exercised so as
not to damage the fetus or traumatize the mother.
6. In breech delivery, the episiotomy, in our
hands, is best made under pudendal nerve block,
or local, anesthesia in all cases. Following this,
spontaneous or assisted delivery, also most
breech extractions, can readily be performed. Ad-
ditional or supplementary inhalation anesthesia is
reserved for the most difficult breech extractions,
and most forceps deliveries of the aftercoming
head can readily be performed under pudendal
nerve block anesthesia.
7. The use of x-ray pelvimentry, plus a rela-
tively accurate assessment of fetal size, permits a
more ready determination of anticipated feto-
pelvic disproportion, and thus the decision as
to the necessity of section is more validly reached.
References
1. Dieckmann, W. J.: Am. J. Obst. & Gynec., 52:399,
1946.
2. Schmitz, H. E.; Smith, C. J. ; and Clumpner, E.
R.: Am. J. Obst. & Gynec., 69:987, 1955.
3. Calkins, L. A.: Am. J. Obst. & Gynec., 69:980,
1955.
4. Meyer, H.: Am. J. Obst. & Gynec., 56:375, 1948.
5. Ryder, O. H. : Am. J. Obst. & Gynec., 45:1004,
1943.
6. Adair, F. L.: Textbook of Obstetrics and Gyne-
cology, Vol. 2, p. 871. Philadelphia: Lea and
Febiger, 1940.
7. Newell, J. L.: Am. J. Obst. & Gynec., 42:256,
1941.
8. Stevenson, C. S.: Am. J. Obst. & Gynec., 60:41,
1950.
9. Stevenson, C. S.: Am. J. Obst. & Gynec., 62:488,
1951.
10. Klink, E. W.: Obst. & Gynec., 1:137, 1953.
11. Goethals, T. R.: Am. J. Obst. & Gynec., 71:536,
1956.
363
Michigan State Medical Society
Annual Session of the Council
January 24-25, 1957
HIGHLIGHTS
• The Auditors’ Report for the year 1956 and the budgets for 1957 were ap-
proved (see page 375).
• Annual Reports of the Secretary, Treasurer, Editor and Rheumatic Fever Co-
ordinator were presented and approved. Reports of the three Standing Com-
mittees of The Council (County Societies, Finance, Publication) meetings of
January 23, 1957, were accepted.
• Secretary L. Fernald Foster, M.D., Bay City; Treasurer William A. Hyland,
M.D., Grand Rapids; Editor Wilfrid Haughey, M.D., Battle Creek, were re-
elected for 1957.
• Progress report on Michigan Medical Service was presented by L. Fernald
Foster, M.D., President, and Jay C. Ketchum, Executive Vice President of Blue
Shield; progress report on Michigan Hospital Service was given by Wm. S.
McNary, Executive Vice President of Michigan Blue Cross.
• Annual reports of individual Councilors on the condition of the profession in
their Districts were presented.
• Monthly reports of Council Chairman D. Bruce Wiley, M.D., Utica; President
Arch Walls, M.D., Detroit; President-Elect G. W. Slagle, M.D., Battle Creek;
Secretary L. Fernald Foster, M.D., Bay City; and Speaker K. H. Johnson, M.D.,
Lansing, were presented and accepted.
• Michigan Health Commissioner A. E. Heustis, M.D., Lansing, informed The
Council on current problems in preventive medicine. The Council approved
five items in the Michigan Health Department’s budgetary recommendations to
the 1957 Legislature including appropriation for polio vaccine; tuberculosis
post-sanatorium care; follow-up for prevention of relapse of mental illness; ap-
propriation for inspection of nursing homes; and migrant workers’ health pro-
gram. The Council specifically disapproved two other items: re establishment
of consultant team in long-term illness; and home-care nursing programs. The
Council took no action on the proposal re air-pollution control.
• Committee on Site for New MSMS Headquarters Building reported on various
opportunities available in Lansing and environs, and was instructed to continue
its studies.
• Home Town Medical Care Program. — Jay C. Ketchum, representing Michigan
Medical Service which has served as intermediary for this program in Michigan
over the last ten years, reported on a crisis resulting from recent VA regulation
that practically cuts Blue Shield services to merely issuing payment checks. A
committee of three (William Bromme, M.D., Detroit, Chairman; W. S. Jones,
M.D., Menominee, and G. W. Slagle, M.D., Battle Creek) was appointed to
study this matter, to attend an AMA-sponsored meeting in Chicago on the
subject, and report to the MSMS Executive Committee of The Council on
March 12.
• Beaumont Memorial. — Recent contributions to the Beaumont Memorial from
members of the Michigan State Medical Society total $7,652.50. A vote of
thanks to these generous donors was placed on the minutes of The Council.
364
JMSMS
ANNUAL SESSION OF THE COUNCIL
• Dr. Harlan H. Hatcher, President of the University of Michigan, acknowledged
receipt of MSMS letter containing the resolution recommending the establish-
ment of a department of general practice in medical schools, it was reported.
• Final plans for organization of the Mid-Summer Session of The Council were
presented and approved. To expedite the increased load of work, the session is
being moved up twenty-four hours, resulting in a three-day instead of a two-
day meeting, as in the past.
• Employment of a Scientific Director for the Michigan State Medical Society, as
recommended in the Secretary’s Annual Report, was approved.
• The President appointed the Tuberculosis Control Committee (an MSMS
standing committee) as the committee to study excess tuberculosis beds in
sanatoriums, in accordance with the 1956 MSMS House of Delegates resolution.
• C. E. Umphrey, M.D., Detroit, Past President of MSMS, was chosen as Chair-
man for Michigan of the American Medical Education Foundation, on appoint-
ment of President Walls.
• Michigan Crippled Children Commission Director Carleton Dean, M.D.,
Lansing, outlined mutual problems to The Councilors for their information and
advice.
• Committee reports were presented by: (1) Iodized Salt Committee, meeting of
December 14; (2) Arbitration Committee, December 28 and January 11; (3)
Preventive Medicine, January 10; (4) Legislative Committee, January 10; (5)
Tuberculosis Control Committee, January 11; (6) Medical Advisory Committee
to State Department of Social Welfare, December 12 and January 20; (7) Joint
Committee to Meet with Michigan Society of Neurology and Psychiatry and
Michigan Psychological Association, January 2; (8) Committee on Michigan
Medical Service, January 23; (9) Comprehensive Prepaid Medical Care Plans,
January 11; (10) Medical Advisory Committee to Michigan Hospital Service,
January 16; (11) Permanent Conference Committee, January 16; (12) Post-
graduate Medical Education Committee, January 17.
• Immunization Procedures. — The Council reaffirmed its policy of furthering —
through adequate publicity to the public — the value of polio immunization and
all other immunization procedures through proper media.
• Report of S. E. Gould, M.D., of Eloise, re Code of Procedure and Ethics Re-
lating to Autopsies, was presented and approved with thanks.
• Community Health Association. — Creation of this proposed “association” under
sponsorship of the UAW-CIO, was thoroughly discussed. The MSMS Com-
mittee on Michigan Medical Service was authorized to develop whatever pro-
gram it recommends and to communicate with the Speaker of the House of
Delegates to call a special session of the House, when ready.
• Program for the MSMS County Secretaries- Public Relations Seminar of Jan-
uary 25-26-27, in Detroit, was presented and approved.
• The Council congratulated the Michigan Cancer Coordinating Committee on
its new brochure “Strength Through Unity Against Cancer,” for lay distribution.
• The Home-Visit Program of the Pediatrics Department, University of Michigan,
was approved — subject to approval by the county medical societies in the areas
where this program is to be used.
• Public Relations Counsel’s monthly report included factual data on legislation;
polio immunization publicity campaign; health exhibits at state and county
fairs; Parade article by President Walls; and January 17 meeting with practicing
pharmacists and representatives of Michigan Board of Pharmacy on a legal
matter.
vIarch, 1957
365
ANNUAL SESSION OF THE COUNCIL
SECRETARY'S ANNUAL REPORT— 1956
TO: The Council of the Michigan State Medical So-
ciety:
I herewith submit the annual report of the Secretary
for the year 1956.
MEMBERSHIP
The Michigan State Medical Society membership for
1956 showed a total of 6,360 members, including 58
retired, 264 Life and Emeritus. 454 Associate-Military
and 6 Honorary members. The total paid membership
was 5,687 with net dues of $300,745.25. The 1956
membership was once again at the highest peak in the
history of the Society. The number of members with
unpaid dues for 1956 was 108.*
DEATHS DURING 1956
I must regretfully report a total of one hundred ten
deaths among members during the past year.
Alpena County — P. W. Butterfield, Alpena, Michigan.
Bay County — Edward S. Huckins, M.D., Bay City;
F. Pitkin Husted, M.D., Bay City; Robert S. Taylor,
M.D., Bay City; Edward C. Warren, M.D., Vanderbilt.
Berrien County — Wm. L. Helkie, M.D., Three Oaks;
Charles E. Tompkins, M.D., Benton Harbor.
Chippewa County — Donald A. Cowan, M.D., Sault
Ste. Marie; Dwight F. Scott, M.D., Sault Ste. Marie.
Delta County — John J. Walch, M.D., Escanaba.
Genesee County — Tohn C. Benson, Sr., M.D.. Flint;
John H. Charters, M.D., Fenton; Raymond S. Halligan,
M.D., Flint; Arthur J. Hamilton, M.D.. Flint; Kenneth
B. Moore, M.D., Flint; Wells C. Reid, M.D., Goodrich;
Arthur J. Reynolds, M.D., Flint; David L. Treat, M.D.,
Flint.
Grand Traverse County — Charles Scott Miller, M.D.,
Traverse City; R. Philip Sheets, M.D., Traverse City;
Lewis R. Way, M.D., Traverse City.
Houghton County — W. T. S. Gregg, M.D., Eagle
Harbor.
Huron County — Duncan J. Monroe, M.D., Elkton.
Ingham County — Earl H. Foust, M.D., Lansing; Le-
Roy A. Potter (Honorary) Lansing; Harold W. Wiley,
M.D., Lansing.
Jackson County — Thomas E. Hackett, M.D., Jackson ;
Lester J. Harris, M.D., Jackson.
Kalamazoo County — Howard C. Jackson, M.D.. Kala-
mazoo.
Kent County — Jacob D. Brook, M.D., Grandville;
Louis H. Chamberlain, M.D., Grand Rapids; Thies De-
Young, M.D.. Sparta; James Henry, M.D., Grand
Rapids; Clarice L. McDougall, M.D., Grand Rapids;
Joseph L. McKenna, M.D., Grand Rapids; Albert
Noordewier, M.D.. Grand Rapids; Torrance Reed, M.D.,
Grand Rapids; Edwin M. Smith, M.D.. Grand Rapids.
Lapeer County — Henry G. Merz, M.D., Lapeer.
Lenawee County — Ara B. Hewes, M.D., Adrian.
Macomb County — B. Morgan Parker, M.D.. Utica.
Marquette- Alger County— Frank O. Pauli, M.D.,
Marquette.
Menominee County — Allen R. Peterson, M.D., Dag-
gett.
Midland County — Joseph H. Sherk, M.D., Midland.
Monroe County — Wm. J. Gelhaus, M.D., Monroe.
Muskegon County — Charles J. Bloom. M.D., Muske-
gon; John L. Loomis, M.D., Vista, California; Walter
C. Swartout, M.D., Muskegon; Charles A. Teifer, M.D.,
Muskegon.
Oakland County — Robert H. Baker, M.D., Pontiac;
Robert B. Hasner, M.D., Royal Oak; H. A. Sibley,
M.D., Pontiac; Milton J. Uloth, M.D., Ortonville; Har-
old L. Van Haltern, M.D., Pontiac.
Oceana County — Arthur R. Hayton, M.D., Shelby.
*The detailed Membership Record by counties will
be published in the April number.
Ottawa County — Abraham Leenhouts, M.D., Holland.
Saginaw County — Fred J. Hohn, M.D., Saginaw.
St. Clair County — Robert J. Biggar, M.D., Persian
Gulf; Edmond W. Fitzgerald, M.D., Port Huron.
St. Joseph County — Frank J. Tesar, M.D., Centerville.
Shiawassee County — Scott B. Hambly, M.D., Mor-
rice; Julius S. Janci, M.D., Owosso.
Tuscola County — Gottlieb H. Kaven, M.D., Union-
ville.
Van Buren County — John R. Giffen, M.D., Bangor.
Washtenaw County — William M. Brace, M.D., Ann
Arbor; George F. Muehlig, M.D., Ann Arbor.
Wayne County — Frederick B. Ashton, M.D., Detroit;
Samuel Balofsky, M.D., Detroit; Robert Beattie, M.D.,
Detroit; Clark D. Brooks, M.D., Detriot; Cornelius
Carey, M.D., Detroit; Claire H. Carpenter, M.D., De-
troit; William Edward Chase, M.D., Detroit; Lewis E.
Daniels, M.D., Detroit; William A. Defnet, M.D., De-
troit; Louis L. Denison, M.D., Detroit; Karl Dubper-
nell, M.D., Detroit; Osborn H. B. Ensing, M.D., De-
troit; William A. Evans, Jr., M.D., Detroit; Sylvester
Ford, M.D., Detroit; Daniel P. Foster, M.D., Detroit;
Leonard Fox, M.D., Wyandotte; George E. Frothing-
ham, M.D., Detroit; Robert W. Gillman, M.D., De-
troit; John E. Gleason, M.D., Detroit; William Hamil-
ton, M.D., Detroit; Joseph O. Hayes, M.D., Detroit;
John E. Hopkins, M.D., Detroit; Thomas F. Horrigan,
M.D., Harper Woods; Louis O. Horvath, M.D., De-
troit; Ralph G. Hubbard. M.D., Detroit; Ernest H.
Jensen, M.D., Eloise; Ned Block Kalder, M.D., Detroit;
L. W. Lang, M.D., Detroit; Arthur W. McGarvah, M.D.,
Detroit; John B. Morin, M.D., Detroit; Joseph A.
Nowicki, M.D., Detroit; James A. Owen, M.D., De-
troit; John P. Parsons, M.D., Grosse Pointe Park;
George W. Renton, M.D., Detroit; Tohn F. Rieg, M.D.,
Detroit; Stanley B. Robertson, M.D., Detroit; Frederic
L. Robinson. M.D., East Dearborn: John C. Russell,
M. D., Detroit; Foster D. Scruton, M.D., Detroit; Emil
R. Simon, M.D., Detroit; Clarence E. Simpson, M.D.,
Detroit; William S. Sims, M.D., Detroit; Karl L. Swift,
M.D., Detroit; Harry E. Vergosen, M.D., Detroit.
1956 ANNUAL SESSION
Once again records of attendance were broken and
the 1956 Annual Session chalked up a total registration
of 4,290. The figure includes Doctors of Medicine 2,454;
Guests 649; Exhibitors 554; Woman’s Auxiliary mem-
bers 232 and Medical Assistants Society members 401.
The General Assembly type of program with discussion
conference was continued as in previous years and the
102 technical exhibits received the usual generous at-
tention of the registrants.
ORGANIZATIONAL ACTIVITIES
MICHIGAN CLINICAL INSTITUTE
The Tenth Michigan Clinical Institute was held in
Detroit, March 7-8-9, 1956. Total registration was
2,475 and the Operating Room Nurses Conference was
held in conjunction with this year’s M.C.I. as well as a
special conference for Residents, Interns and Senior
Medical Students. Nine members of the Michigan
State Medical Society who were Presidents of na-
tional medical organizations received special awards at
a luncheon held in their honor.
ANNUAL SECRETARIE S -P U BLIC RELATIONS
CONFERENCE
In 1956 the three-day County Secretaries-Public
Relations Seminar was inaugurated and was held Janu-
ary 27-28-29. The program was so successful that the
participants voted overwhelmingly to continue the three-
day format next year.
366
JMSMS
ANNUAL SESSION OF THE COUNCIL
secretary’s letters
As part of the Society’s general educational and infor-
mational program for individual members and for com-
ponent County Societies there were issued during the
year 1956 eight Secretary’s Letters (three to all members
and five to County Secretaries and keymen). These infor-
mational bulletins were in addition to the monthly
issues of The Journal with its scientific articles and
informative news items. In addition, eight Legislative
Bulletins were issued to keymen during the 1956 Legis-
lative Session to keep the membership informed of
activities in the State Legislature pertaining to the
practice of medicine.
COMMITTEES
Time and space do not permit the listing in detail of
the many activities of all the committees contributing
to the many splendid programs of the State Society.
The accomplishments of the committees of the Society
were achieved at the expense of many hours of personal
sacrifice on the part of the personnel of the various
committees. During 1956, eighty-one meetings were held
by the forty-eight committees of the Michigan State
Medical Society. Practically every meeting was attended
by your Executive Director or Secretary. A total of 527
members of your State Medical Society gave freely of
their time to attend these meetings and assist in the
operational activities of the State Society. Too much
commendation cannot be accorded the committee mem-
bers who contributed their time and effort to develop
and execute constructive programs — both scientific and
economic — for the public welfare and to maintain the
position of leadership enjoyed by the Michigan State
Medical Society in the field of progressive medical plan-
ning.
FINANCES
An audit of the books of the Society was completed
by Knostman & Smith as of December 24, 1956. This
has been submitted to the Finance Committee for study
and is available to any member of the Society for perusal
at the Executive office, 606 Townsend St., Lansing,
Michigan. A brief summary of the audit produces the
following information:
Assets :
Cash $ 29,813.31
Accounts Receivable 23,977.95
Investments 229,795.25
Property & Equipment 53,279.20
Other Assets 231.66
Total Assets $337,097.37
Liabilities :
Accounts Payable $ 16,292.44
Deferred Income 15,810.00
Total Liabilities $ 32,102.44
Society Equities
Reserved for Special Purposes
Public Education Reserve $ 57,245.00
Public Education Program 73,891.87
Public Service Account 3,675.16
Professional Relations Account 4,897.50
Rheumatic Fever Control Program 7,675.56
Contingent Fund 53,614.34
Building Maintenance 14,124.94
General Society Equity 89,870.56
Total Liabilities & Equities $337,097.37
It is noted from the Income and Expense summary of
the period December 24, 1955, to December 24, 1956,
that the total income for the period was $440,607.90 less
expenses of $400,547.59 producing a net gain for the
year of $40,060.31 with a balance on hand December
24, 1956, of $304,994.93.
THE JOURNAL
The following financial information relative to The
Journal is found in the annual audit report of Knost-
man & Smith.
Income was $94,400.27 which is $10,500.27 over the
tentative budget for 1956. Expenses were $93,303.57
which was $9,403.57 over the 1956 estimated budget.
However, this figure indicates a net gain for the year
1956 of $1,096.70.
Included in the total income of $94,400.27 was only
$8,173.49 received from the allocation of membership
dues.
During 1956, the cover illustrations continued to be
done by Mr. Dirk Gringhuis and graphically depicted
various activities of the MSMS.
1956 HOUSE OF DELEGATES
The 91st Annual Session of the Michigan State Medi-
cal Society’s House of Delegates was held in Detroit,
September 24-25, 1956.
The House of Delegates:
1. Adopted with thanks the President’s Address, the
President-Elect’s Address, the report of Delegates to the
American Medical Association, the Annual Report of
the President of Woman’s Auxiliary to Michigan State
Medical Society, and the Annual Report of the Presi-
dent of Michigan State Medical Assistants Society.
2. The Annual Reports of The Council (including the
Annual Reports of Committees of The Council) were
adopted as amended.
3. Adopted Annual Reports of all Standing Commit-
tees and of all Special Committees of the Society; also
the report of the House of Delegates’ Committee to
Study MSMS Financial Structure.
4. Elected Ralph G. Cook, M.D., Kalamazoo, and
J. H. Sherk, M.D., Midland (posthumously), as Michi-
gan’s Foremost Family Physicians for 1956.
5. Took action on proposed amendments to Consti-
tution and By-Laws, as follows: (a) By-Laws, Chapter
8, Section 10-g — procedure in case of vacancy on Coun-
cil— approved as amended; (b) By-Laws, Chapter 2,
Section 2 — re membership in county of practice — disap-
proved; (c) Constitution, Article X, Sections 1-2-3 —
to make Vice Speaker a voting member of The Council
and of its Executive Committee — to 1957 House of
Delegates; (d) By-Laws, Chapter 8, Section 10-j (13)
— changing name of a House of Delegates Reference
Committee (National Defense and Disaster Planning)
— approved.
6. Adopted resolutions concerning : (a) Deferring
Action re Discipline of Members; (b) Continuation of
Councilor Conferences; (c) Establishment of Depart-
ments of General Practice in Medical Schools; (d)
Committee to Study Use of Word “Clinic”; (e) Equal
Health Opportunities for All: (f) Permanent Advisory
Committee on Fees (as amended) ; (g) Practice of
Psychiatry is Practice of Medicine; (h) Honorary Mem-
bership to J. Joseph Herbert and Dean Gordon H.
Scott; (i) Expansion of Medical School Facilities at
Wayne State University; (j) Regulation of Ambulance
Operation approved and referred to Committee on
Traffic Safety; (k) Adequate Funds to carry out Civil
Defense (as amended); (1) Medical Classes at Medical
Schools to send Representatives to House of Delegates
Sessions (as amended) ; (m) MSMS representatives on
Committee Drafting Uniform Autopsy Code (as amend-
ed) ; (n) Esteem of House of Delegates for J. Joseph
Herbert; (o) Appreciation of Henry A. Luce, M.D.;
(p) New MSMS Headquarters; (q) Appreciation to
H. V. Higley, Veterans Administration Administrator;
(r) Committee to Study excess beds in Tuberculosis
Sanatoriums.
7. Adopted substitute resolutions concerning: (a)
Michigan Medical Service Annual Report to MSMS
House of Delegates; (b) Comprehensive Prepaid Medi-
March, 1957
367
ANNUAL SESSION OF THE COUNCIL
cal Care Insurance Plans and Blue Shield Plans for
Diagnostic Out-Patient Services; (c) (Urging Total
Participation of M.D.’s in Michigan Medical Service
(two resolutions); (d) Plan for Expediting Work of
House of Delegates.
8. Tabled Motion re Information from AM A Dele-
gates.
9. Deferred Resolutions re: (a) Postgraduate Edu-
cation of Other Healing Arts; (b) MSMS Attitude re
Other Healing Arts; (c) Approval of Mediation-Ethics-
Grievance Committee’s Recommendations.
10. Disapproved Resolutions concerning: (a) Council
Minutes to all MSMS Delegates; (b) Annual Registra-
tion of M.D.’s (c) Submission of House of Delegates
Resolutions in Advance; (d) Report Within Seven Days
of House of Delegates Proceedings; (e) State and
County Prerogatives in Discipline of Members; (f)
MSMS Approval of County Society Constitution and
By-Laws Revisions.
11. Elected to Special Memberships:
(a) Thirty-one members to Life Membership: (Ber-
rien County) Clarence Gillette, M.D.; (Genesee Coun-
ty) Henry Cook, M.D. ; (Ionia County) J. W. C.
Fleming, M.D. ; (Kalamazoo County) U. Sherman
Gregg, M.D.; (Marquette County) Celestin LeGolvan,
M.D., and George M. Waldie, M.D.; (Muskegon Coun-
ty) Harry L. Clark, M.D., Marie Keilin, M.D., and
Eugene S. Thornton, M.D.; (Oakland County) George
L. Hagman, M.D., and John K. Ormond, M.D.;
(Wayne County) Stilson R. Ashe, M.D., William N.
Braley, M.D., Fritz W. Bramigk, M.D., Bruno B.
Brunke, M.D., Peter H. Darpin, M.D., Henri L. Grat-
ton, M.D., Sarkis K. Keshishian, M.D., John C. Koch,
M. D., Alfred D. LaFerte, M.D., Wm. W. MacGregor,
M.D., Emil V. Mayer, M.D., Wm. R. McClure, M.D.,
Cary P. McCord, M.D., Wm. E. Miller, M.D., Grover
C. Penberthy, M.D., Lyman J. Pinney, M.D., Ralph
W. Ridge, M.D., Paul C. Rhode, M.D., Jacob M.
Sutherland, M.D., and Elmer L. Whitney, M.D.
(b) Nine members to Retired Membership: (Calhoun)
A. D. Sharp, M.D.; (Saginaw County) Lloyd A. Camp-
bell, M.D.; (Wayne County) Ladislaus Bogusz, M.D.;
Clyde H. Chase, M.D., James C. Danforth, Sr., M.D.;
Frank MacKenzie, M.D., William D. Ryan, M.D.,
Clarence E. Weaver, M.D., and Wirt A. Dawson, M.D.
(c) Fifty-nine M.D.’s to Associate Membership: (Mar-
quette-Alger County) Sara Schweinsberg, M.D.; (Mus-
kegon County) Mary Ellen Hennessey, M.D. ; (Washte-
naw County) Malcolm A. Bagshaw, M.D., Joseph B.
Boulos, M.D., Gerald L. Brody, M.D., Joseph H. Chand-
ler, M.D., Norman E. Clarke, Jr., M.D., Mark A. Ev-
erett, M.D., Norman A. Fox, Jr., M.D., Robert L.
Gillett, M.D., Glen G. Golloway, M.D., Jack E. Good-
win, M.D., John T. Hayes, M.D., Erwin P. Hoffman,
M.D., Clifford L. House, M.D., Edwin M. Hubbard,
M.D., A. Hartwell Jewell, Jr., M.D., J. A. Arthur
Lavigne, M.D., George E. Lewis, Jr., M.D., John D.
Lynch, M.D., James W. Mackenzie, M.D., Henry E.
Malcolm, M.D., Rolf F. Miller, M.D., Robert F. Muller,
M.D., Paul Natvig, M.D., Rudolf E. Nobel, M.D., Leon
D. Ostrander, Jr., M.D., Warren H. Pearse, M.D.,
Chrisostomo C. Santos, M.D., Harry J. Schmidt, M.D.,
Russell Scott, Jr., M.D., Irving Shapiro, M.D., Edwin
M. Smith, M.D., Philip R. Steinmetz, M.D., John P.
Stewart, M.D., George R. Thompson, M.D., Frederik
S. Van Reesema, M.D., Peter D. Vreede, M.D., Donald
J. Holmes, M.D., Prasana K. Pati, M.D., John B.
Tisserand, M.D., William S. Wilson, M.D. , and James
A. Wood, M.D. ; (Wayne County) Oscar L. Barland,
M.D., Robert Borchak, M.D., Richard A. Bruehl, M.D.’
John P. Connolly, M.D., Douglas R. Coyne, M.D.]
Leonard Fox, M.D., Maurice J. Hauser, M.d!, Loyal
W. Jodar, M.D., Benjamin Mihay. M.D., John H.
368
Schlemer, M.D., Fredrick L. Sperry, M.D., Bela J.
Szappanyos, M.D., Jerome S. Weingarten, M.D., Frank
A. Weiser, M.D., Joseph Weiss, M.D., and Charles R.
Williams, M.D.
12. Elected the following officers:
(a) A. E. Schiller, M.D., Detroit, as Councilor of the
1st District (1961).
(b) H. J. Meier, M.D., Coldwater, as Councilor of the
3rd District (1961).
(c) Ralph W. Shook, M.D., Kalamazoo, as Councilor of
the 4th District (1961).
(d) C. Allen Payne, M.D., Grand Rapids, as Councilor
of the 5th District (1961).
(e) H. H. Hiscock, M.D., Flint, as Councilor of the
6th District (1961).
(f) W. D. Barrett, M.D., Detroit (1958); W. H.
Huron, M.D., Iron Mountain (1958); and R. L.
Novy, M.D., Detroit (1958), as Delegates to the
American Medical Association.
(g) Wm. Bromme, M.D., Detroit (1958) ; J. R. Rodger,
M.D., Bellaire (1958); and G. W. Slagle, M.D.,
Battle Creek (1958), as Alternate Delegates to the
American Medical Association.
(h) G. W. Slagle, M.D., Battle Creek, as President-
Elect.
(i) K. H. Johnson, M.D., Lansing, as Speaker, House
of Delegates.
(j ) J. J. Lightbody, M.D., Detroit, as Vice Speaker,
House of Delegates.
OTHER ORGANIZATIONAL ACTIVITIES
1. The Residents-Internes-Senior Medical Students
Conference was held in Detroit, March 7, 1956. The
MSMS again financially sponsored sending Delegates
from Michigan's two Medical Schools to the Student
AMA Convention in Chicago May 1956.
2. Semi-anuual meetings of the seven MSMS dele-
gates to the AMA and the alternate delegates were
held as usual.
3. Modern membership recording was instituted dur-
ing the year to facilitate the MSMS records and billing.
This was done by utilizing IBM equipment. The re-
sults of this have already justified the judgment of
The Council in installing this method. For instance,
in January 1956, a total of 231 members paid dues,
totaling $12,690.00; to January 21, 1957, a total of
1,737 paid dues, totaling $98,185.00.
4. Councilor District meetings were held throughout
the state as an innovation in better informing the mem-
bers of the MSMS House of Delegates in matters to be
considered at the annual meeting in September.
MICHIGAN MEDICAL SERVICE
This organization continues to be a major activity
of the MSMS. During the year several additional MSMS
members were added to the Board of Directors. Of
the officer personel your secretary became President,
MSMS President Arch Walls was chosen Vice-President,
Editor Wilfrid Haughey became Chairman of the Board
and Councilor Harris succeeded the late Robert H.
Baker, M.D., as secretary.
Appreciation of the need for changes in the MMS
contracts and benefits is evidenced by the fact that three
committees of Doctors of Medicine, one from the House
of Delegates, one from the MSMS and one from MMS
are now studying changes to meet the various de-
mands, better service to the public and services con-
sistent with constant economic changes. These studies
will be made with the greatest possible realism and
with constant attention to actuarial soundness.
Women’s Auxuliary. — The Auxiliary continued its
many projects and had a very successful and active year.
Medical Assistants Society. — This group continued its
activities and expanded its organization in The Upper
.TMSMS
ANNUAL SESSION OF THE COUNCIL
Peninsula. Michigan Delegates and members of the
Advisory Committee played an important part in the
development of a National Organization at a meeting
held in Milwaukee.
Contacts with Governmental and Voluntary agencies
have been maintained effectively during the year.
BEAUMONT MEMORIAL RESTORATION
The Beaumont Committee, under the chairmanship
of Otto O. Beck, M.D., has actively pursued its activi-
ties. A drive for additional funds to liquidate the
$9,000.00 deficit was successful in raising over $7,600.00.
PUBLIC RELATIONS
Serious attempts to influence public opinion against
voluntary health insurance were made during the past
twelve months. This naturally affected doctors of medi-
cine both directly and indirectly.
Certainly, this is no news to you and perhaps does
not belong in the Secretary’s report on MSMS public
relations activities. But I think it will serve as a
contrasting background for the following outline of
positive public relations endeavor.
It would seem that the medical profession could
now say that it is “Winning Friends for Medicine.” And
the MSMS PR guidebook is still the “bible” for county
medical societies in developing their increasingly ef-
ficient public relations programs.
Sparking this job of carrying the PR message were
MSMS officers and Councilors as well as C. Allen
Payne, M.D., Immediate Past Chairman of the PR
Committee, PR Counsel H. W. Brenneman and the
public relations field secretaries. Special recognition
should go to William S. Jones, M.D., for his contribu-
tion to good relations by attending a meeting of nearly
every component county society. As you realize, this
entailed literally thousands of miles of travel and in-
numerable days away from his busy practice.
In September, following Doctor Payne’s election as
Councilor, R. Wallace Teed, M.D., was appointed
Chairman of the MSMS PR Committee, succeeding
Doctor Payne.
Press relations, despite the attack previously men-
tioned, improved a good deal in 1956, due principally
to the forthrightness which MSMS exhibited in its
contact with writers and editors.
Figures or statistics on the amount of newspaper
coverage devoted to medicine and M.D.’s are sometimes
meaningless unless they can be related in more under-
standable terms. For example, the most recent press
release prepared by our staff was reprinted in 101
Michigan newspapers. The item was the MSMS im-
munization campaign, “Operation Armor.” Similar cov-
erage was accorded releases on other MSMS programs
and activities, such as Traffic Safety, Annual Session,
Awards, and so on.
Television programming supplied by MSMS during
1956 amounted to just under forty-five hours on both
Detroit and outstate stations. Total running time of
motion pictures furnished by MSMS to civic groups,
TV stations amounted to over 150 hours. Radio re-
ceived special attention in 1956 and in addition to the
448 hours of radio programming supplied by MSMS,
special news releases and tape recordings were sent
periodically to all Michigan stations. The final bright
spot in the communications picture is the outstanding
coverage accorded our 1956 Annual Session by all
media.
A new project and service is currently under develop-
ment in our Public Relations Office. This is the PR
Library, being set up by a qualified librarian so that
the information it contains can be put to maximum use
by MSMS members and other interested groups. Ours
is the first state medical society to organize a library
that is specifically adapted to existing and future medi-
March, 1957
cal PR needs. The secretary who will serve as part-
time librarian, will be responsible for filling loan re-
quests for reference material in scientific and socio-
economic areas as well as for motion pictures, radio
tapes, scripts and other material too numerous to
mention.
Hardly a year goes by that Michigan’s PR effort is not
cited for excellence. The year 1956 was no exception
for our state-wide campaign during Medical Education
Week received national attention and our program out-
line and scrapbook was reproduced for distribution to
PR departments of the nation’s eighty-one medical
schools.
I should like, at this point, to forego the detailing
of our comprehensive PR program, other than to men-
tion the broader spheres of activity. These include:
pamphlet production and distribution, exhibits, general
society liaison and committee service, attendance at
state and national meetings by Society Officers and PR
staff, annual awards, legislative activity, motion picture
production.
The past PR effort is important only in relation to
the future and, gentlemen, our future for 1957 is al-
ready overcast with storm clouds. The forecast is not
all gloom and doom, but a storm is most certainly
coming and our ability to weather it will depend in
large measure on the success of our individual and
collective relations with the public. We believe that
1957 will be a year of decision for the voluntary health
insurance plans and thus, inescapably, it will be a year
of decision for the medical profession. We shall need
every ounce of good will that we can garner. We shall
need public understanding. We shall need press under-
standing and support. We shall need to make progress
in becoming the recognized leaders in the field of health
care and perhaps this could best be done by willingly
accepting the challenges of tomorrow that are already
apparent.
These things must be done this year, soon, now —
before it is too late — or we shall fail.
LEGISLATION
The 1956 sessions of the Michigan Legislature and the
national Congress have been duly recorded in the mid-
summer report of The Council. No elaboration is need-
ed here. However, since both of these legislative bodies
are now preparing to embark on a new year’s delibera-
tion, this is a propitious time to look ahead to the
tasks confronting Michigan Doctors of Medicine in the
legislative and political fields.
The Legislative Committee of MSMS, in meeting
January 10, apprised us that we may expect the intro-
duction of approximately eighty legislative proposals in
Lansing affecting the field of health; many will be
revivals of proposals previously defeated in the House
and Senate, while some will be the products of the chang-
ing times, such as those in the realms of atomic energy,
automation and specialization. More concise informa-
tion will be forthcoming from the MSMS executive
office as the legislation appears in fact.
Noteworthy, though, is the progress being made by
a liaison committee between the MSMS and the
Michigan Osteopathic Association toward better agree-
ment between the two professional groups, in contrast
to past legislative differences.
There is one fact that becomes more evident each
year. The impact of legislative activity and political
action upon the medical profession is powerful, and
vice versa. At no time in history has it been more
patent that the individual M.D. has a stake, a place
and a responsibility in the political sphere. The doctor
is a man of his community, and the obligations of his
oath to provide the best health care to his patient
go beyond his office door into the legislative halls in
Lansing and Washington. This is the age of socio-
369
ANNUAL SESSION OF THE COUNCIL
economic change in the practice of medicine as well as
scientific progress in the art of healing.
THE EXECUTIVE OFFICE AND PERSONNEL
Various improvements have been made in the Execu-
tive Offices. Increased parking facilities have been
provided. A library has been established in the base-
ment to house various reference records, recordings,
legal opinions and publications.
During 1956, the MSMS suffered a loss in the death
of its Legal Counsel, J. Joseph Herbert. This position
was filled by securing the services of Mr. Lester Dodd
of Detroit. Mr. Dodd is a past president of the Michi-
gan State Bar.
During the year, Assistant Public Relations Counsel,
DeWitt Brewer, resigned and was replaced by Warren
Tryloff, Field Secretary in the Detroit office. He, in
turn, was replaced by Jack Pardee as Field Secretary
for the Detroit area. Several additions and replacements
were made in the stenographic pool, and Miss Vada
Studt was transferred from the pool to the third floor
where she becomes an Assistant Secretary in the Public
Relations Department and assumes the new duties of
Librarian.
The stenographic pool is still operating shorthanded
and there is an urgent increasing need for an assistant
bookkeeper to relieve Mr. Roney of some of his activi-
ties which now include all the bookkeeping, membership
records and Journal advertising activities.
During the year, a committee was appointed to take
a “Big Look” at the general organizational set-up and
physical plant of the Society. This committee has
already recommended some changes in titles of our
MSMS office personnel.
Elsewhere on the agenda of this meeting, pursuant
to your instructions, your Secretary is making sugges-
tions regarding changes in the MSMS job classification
and salary schedule.
The need for increasing office personnel is indicated in
the ever-increasing office detail as illustrated in the
following figures:
In 1956, the Addressograph ran 386,000 pieces
In 1956, the Meter Machine ran 215,022 pieces
Total 601,022 pieces
Averages 7,700 pieces a week
1,540 pieces a day
THE COUNCIL
Two new Councilors were elected by the 1956
House of Delegates.
C. Allen Payne, M.D., Grand Rapids, succeeded J. D
Miller, M.D., in the 5th District.
Harold J. Meier, M.D., Coldwater. succeeded George
W. Slagle, M.D., in the 3rd District.
HIGHLIGHTS IN PROGRESS DURING 1956
1. New Councilor Conferences were held in every
District between July 23 and September 23 to outline
socio-economic progress to MSMS Delegates, Alternate
Delegates and County Society Officers.
2. “Medicare” was inaugurated during the past year
(U. S. Public Law 539) to provide medical and surgical
care for servicemen’s dependents. The contract for
Michigan was negotiated October 24, in Washington,
D. C. Michigan Medical Service was appointed agent
of MSMS in this new program.
3. The Governor’s Public Health Study Commission
was supplied with a statement outlining the position of
the Michigan State Medical Society on various public
health measures. The outline was presented by MSMS
President Arch Walls, M.D.
4. The Governor’s Study Commission on Prepaid
Hospital Care Plans requested MSMS to name a con-
sultant to work with the Commission in undertaking this
study. Secretary Foster was appointed. (The study was
370
held in abeyance pending selection of a director and ob-
taining of adequate funds.)
5. A Liaison Committee with the Michigan State
Board of Registration in Medicine was appointed. The
Council, and subsequently the House of Delegates,
adopted resolutions recommending that the Legislature
make the office of Executive Secretary of the State
Board a full-time position, with adequate remuneration.
6. Adoption of National Board Examinations in
Michigan was discussed at a joint meeting with repre-
sentatives of the two medical schools in this State and
the State Board of Registration.
7. The Veterans Administration “home-town medical
care program” was continued in Michigan, after MSMS
protest against its discontinuance scheduled for July
1, 1957. This insures a continuation of good medical
care to the veteran, rendered in his home community.
8. The Council, and subsequently the House of
Delegates, adopted resolutions urging increase in the
teaching personnel of Wayne State University College
of Medicine, to permit addition of fifty more first-year
students annually. Necessary funds to cover this needed
increase have been requested of the 1957 Legislature
by WSU.
9. Establishment of full-time chairs of preventive
medicine and public health at each of the two medical
schools in Michigan was endorsed by MSMS — provided
such chairs are filled by Doctors of Medicine.
10. The MSMS Medical Advisory Committee to
Michigan Hospital Service was reactivated in August
at the specific invitation of MMS President John W.
Paynter.
11. Michigan Week was endorsed and all MSMS
members were urged to actively cooperate in reminding
patients that Michigan is a good state to live in. MSMS
Executive Director Wm. J. Burns was a member of the
Board of Michigan Week.
12. President Arch Walls, M.D., was authorized to
appoint an MSMS Committee to meet with officers
of the UAW-CIO to discuss medical matters. Com-
mittee was appointed and several meetings have been
held.
13. The Council and the House of Delegates author-
ized the selection of a new site and the erection of
a new MSMS headquarters building, to adequately
house the growing facilities of the Society. Several
meetings of the planning committee have been held.
14. The generosity of the membership is best indi-
cated by recent contributions to the Beaumont Me
morial Restoration : in less than two months, up tc
January 23, a total of $7,652.50 was received againr
the $9,000 indebtedness.
15. Two important committees were appointed durii
the past year, one to study care of the mentally d
turbed in order to obviate long-time hospitalization;
the other a Committee on Healing Arts Study.
16. A Gold Medal Award for scientific achievement
in this state was created by MSMS during the ’•ast
year.
17. To service physicians covered by the Mr
health and accident insurance program. Richard M.
McDermott was appointed as full-time Michigan c
resentative by the Provident Life and Accident Insur-
ance Company.
18. IBM Equipment was installed by MSMS in 1956
to expedite the handling of MSMS records, beginning
January 1, 1957 and to aid the busy doctor with this
annual bit of detail.
19. “So You’ve Been Elected,” an organizational
handbook for county society officers was developed by
MSMS and distributed at the County Secretaries-Public
Relations Seminary of January 29, 1956.
The County Secretaries one-day Conference was
broadened into a three-day Seminar in 1956, with
further up-to-date information to county society officers
on socio-economic problems.
.TMSMS
ANNUAL SESSION OF THE COUNCIL
20. “Progress” — Because Doctors Work Together”
was another informative brochure printed by MSMS
during the past year which outlined MSMS services,
scientific work, socio-economic activities and its grow-
ing scope of interest in the Michigan scene.
REGOM MENDATIONS
After a careful consideration of the continued suc-
cessful operation of the MSMS and its many projects,
I respectfully submit the following recommendations:
1. That MSMS inaugurate necessary surveys on
strictly economic and sociologic phases of medical prac-
tice, to ascertain where the medical profession is and
where it is going in the next ten years in incomes and
economic status. According to the Medical Economic
survey, Michigan physicians enjoy the greatest incomes
(both for general practitioners and for specialist) among
all the states in the Union. MSMS should continue
to insure such a happy condition for its members.
However, very few M.D.’s get much information on
economic matters — other than those who attend the
Annual County Secretaries Seminar. Hence the above
recommendation.
2. That studies be inaugurated concerning the re-
lationships and responsibilities between county medical
societies and hospitals in the separate communities.
This would show the position of greater and greater
importance to the medical practitioner now assumed by
the hospital staff — to the detriment of the county medi-
cal society. It will also indicate the proper spheres of
influence which rightfully belongs to the M.D. in
hospital administration.
3. That a medical coordinator be employed for all
scientific activities of the MSMS, both in Postgraduate
and Preventive medicine fields.
This man would be a successor to Dr. DeVel, with
his duties enlarged. One advantage of this action would
be that MSMS might receive more grants from fund
raising organizations — such as it now receives for the
rheumatic fever activity from the Michigan Heart As-
sociation.
4. That the audit date of MSMS books be changed to
November 30, to achieve reports to all members of The
Council weeks in advance of the annual meeting of
The Council.
5. That the MSMS employ a bookeeper with the
title of Assistant Secretary and that such an employe
be assigned exclusively to Mr. Roney’s department —
dealing with bookkeeping, membership and Journal
advertising.
6. That, subject to approval by component societies,
that MSMS assume responsibility for the mailing of
follow-up letters (no less than three) to those members
in arrears after April 1 of each official year, in order
to bring to a minimum the number of members who
are subject to suspension according to MSMS By-Laws,
Chapter XV, Section 2.
7. That consideration be given to the ground break-
ing of the new MSMS headquarters in the year 1957
so that the building may be available for use in late
1958.
Some $150,000.00 could be available by 1958 and
balance could be financed through a bank and paid off
in some two to four years, depending upon the cost
of the building. Meanwhile, the Executive Offices
could be efficiently run in a larger and modern build-
ing and the prestige of the Society would go up with
the public as well as with the medical profession.
Your Secretary is grateful for the helpful cooperation
given him by this Council during the past year.
Too much commendation cannot be accorded the
Executive Office staff for their untiring efforts and
loyalty to the MSMS.
Your Secretary is especially appreciative of the con-
structive advice and services accorded him by Win, J.
Burns, Executive Director, Mr. Dodd, Legal Counsel,
Hugh Brenneman, Public Relations Counsel and his
staff, Wilfrid Haughey, M.D., Editor, and Robert
Roney, Assistant Executive Director. Our field secre-
taries did an unusual job in their legislative activities.
To everyone who has aided so generously and willing-
ly in the discharge of his duties, your Secretary is most
grateful.
Respectfully Submitted
L. Fernald Foster, M.D.
Secretary
TREASURER S ANNUAL REPORT— 1956
(January 1 to December 24, 1956)
11 rr. Chairman and members of the Council
the Michigan State Medical Society:
T herewith submit a report of the securities and cash
Lc onging to the Michigan State Medical Society in
my possession as duly elected Treasurer for the year
January 1956 to January 1957.
The appended list of bonds and time certificates
totaling $92,000 face value are in lock box C131 Michi-
gan National Bank Trust Department in Grand Rapids.
B' lance on hand as of January 1, 1956. $6,368.01
erest received from bonds and certificates of
^eposit — January 1, 1956, to January 1, 1957 $2,345.00
Balance on hand as of December 31, 1956 $8,713.01
Respectfully submitted,
William A. Hyland, M.D.
T reasurer
MICHIGAN STATE MEDICAL SOCIETY SECURITIES
3 Michigan National Bank Savings Certificates @ $5,000 ea...$15,000
1 Michigan National Bank Savings Certificate 25,000
7 United States Savings Bonds, Series G @ $5,000 ea 35.000
5 United States Savings Bonds, Series G @ $1,000 ea 5,000
4 United States Savings Bonds, Series K (S> $1,000 ea 4.000
8 United States Government Notes 75-80 @ $1,000 ea 8,000
.$92,000
Also in Lock Box Cl 31 are the following safe-keeping
receipts covering government bonds in the name of the
Society:
Michigan National Bank, Grand Rapids — Receipt #4378
dated April 27, 1956 $25,000
(These securities are held for us in the vaults of the First
National Bank of Chicago under their receipt #108665)
Michigan National Bank, Lansing — Receipt #A718 dated
January 11, 1956 45,000
Michigan National Bank, Lansing — Receipt #A726 dated
February 16, 1955 10,000
Michigan National Bank, Lansing — Receipt #A864 dated
March 1, 1956 25,000
Michigan National Bank, Grand Rapids — Receipt #4536
dated August 29, 1956 35,000
Total $140,000
TOTAL DEPOSITS MADE INTO THE TREASURER'S
COMMERCIAL ACCOUNT DURING 1956
February 1, 1956 $ 375.00
March 5, 1956 62.50
April 30, 1956 297.50
May 1, 1956 62.50
August 14, 1956 375.00
September 21, 1956 250.00
October 26, 1956 110.00
November 1. 1956 62.50
November 16, 1956 437.50
November 21, 1956 312.50
Total
March, 1957
Total
$2,345.00
371
ANNUAL SESSION OF THE COUNCIL
EDITOR S ANNUAL REPORT— 1956
The Journal of the Michigan State Medical
Society has now completed fifty-five years of publi-
cation. You may remember it was established by An-
drew P. Biddle, M.D., Secretary of the Society, to
replace the annually published “Transactions.” The
Society had just been thoroughly reorganized into a
democratic body with members, branches (County
Medical Societies) and a state organization including,
besides the usual officers, a Council (Board of Directors)
and a legislative body (House of Delegates) on a basis
of one representative for every fifty members or major
fraction thereof.
The activities of the Society were being stepped up
and an attempt was being made to stimulate the interest
of all the doctors in the work of the Society. Previously,
there had been only one meeting a year, and very little
fraternizing. The Council and the newly appointed
Editor established The Journal as a means of com-
munication among all members at least once a month.
The Editor published news, activities and reports, as
well as scientific papers, abstracts, and reviews. Pages
of The Journal were set aside and assistant editors
appointed to review the latest information on such
departments as medicine, surgery, et cetera. The
Journal was immediately successful. The membership
in the Society grew. Dr. Biddle was an educator as
well as being interested in organizational medical affairs.
Down through the years our editors have carried on
in somewhat the same vein. The House of Delegates is
the policy-making body, The Council is charged with
the financial end but interprets policy in the interim
between House of Delegates meetings. The Editor is
charged with the interpretation of both bodies, express-
ing their ideals and theory of organization; publishing
for the membership the latest of scientific information,
as well as reporting primarily on the economic, socio-
and medico-political affairs upon which the very ex-
istence of the private practice of medicine depends.
The last fifteen years have been ones of great eco-
nomic and social importance. Pressure groups, as well
as government, have attempted to hamper our tradi-
tional and established liberties and privileges. Legisla-
tion has been proposed to which the profession has
objected, until it became an established idea that the
medical profession was opposed to everything. During
these years, we have increased the size of The Journal
almost 50 per cent. We have adopted a strong editorial
policy of keeping our members aware of policies being
offered by our detractors, and socio-economic conditions
affecting our very existence.
The editorial and news features of The Journal
have stressed to the readers an awareness to such prob-
lems as seemed of most interest, to the extent at times
of a possible over-emphasis. The scientific section of
The Journal has always presented as fine and ad-
vanced material as the best thinkers in our Society and
our invited guests could give. During the year, we
had 161 different names signed to our original papers.
Eleven of these names appeared twice, making an
average of over fourteen authors for each number.
We have prepared and published sixty editorials,
forty-seven book reviews, and forty-nine memorial trib-
utes, one to Past-President Robert Baker, and one to
our Legal Counsel, J. Joseph Herbert. Nine of our
members were honored for having been president of
some national medical or hospital organization.
About thriteen years ago, we abandoned the stereo-
typed cover and began using that page of The Journal
to honor some of our still living Past Presidents and
Speakers of the House of Delegates. We then began
casting about for specialty interesting items of value
to the membership or the Society. During that thirteen
years there have not been two covers of The Journal
alike. Early we assigned certain specified numbers to
some special interest of the profession. We published
the first medical journal devoted to Atomic Medicine.
We have stressed many special fields. During the year
1956, we continued to recognize distinct and compelling
interests. In most instances, a proportion of the sci-
entific papers appearing in any special number have
had a bearing on the cover selected. In fact, the
covers in almost every instance have been built about
the subject matter.
Our January numbers for several years have been
devoted in some special manner to Heart. This year
it was “Rheumatic Fever — The Chain Can Be Broken.”
In February, we honored the University of Michigan
Medical School (1850-1956) with sketches of some new
buildings. March saluted Wayne State University School
of Medicine with some of its most modern new buildings
and its history. April, traditionally Cancer month, fea-
tured “Education-Research-Service” — “Three Swords
Against Cancer.” May was dedicated to the Michigan
Foundation for Medical and Health Education — stress-
ing rural M.D.’s. June, assigned to Michigan Medical
Service for many years, featured the Blue Shield. July
announced and published the program for the 91st
Annual Session “All Roads Lead to Detroit.” August — -
“Trauma,” and as a supplement a directory of our
membership, the Auxiliary, and Medical Assistants.
September — Ingham County Medical Society and its
28th Annual Clinic Day. October — “Diabetes,” featur-
ing and picturing the five great leaders: Aretaeus, Lang-
erhans, Muncowski, Kussmaul and Banting. Novem-
ber— “The Physician Serves His Patient — The Society
Serves the Public,” a public relations number with
reports of the presidents or chairmen of twenty-eight
committees, agencies or groups serving the public. De-
cember presented the Michigan Clinical Institute pro-
gram for next March in Detroit.
We are proud of this year’s Michigan State Medical
Society accomplishments in every field of endeavor, and
especially honored to have been active in spreading the
record in a permanent form.
This year’s Directory was again published in a sep-
arate section, but delayed the publication of that num-
ber of The Journal for three weeks. We are hoping
that in the year of 1957, we may prepare the Directory
and have it all printed except the cover, then make it
part II of the number next due. July has been selected
as the date of the Directory, but I trust our members
will be complacent if we do not delay The Journal
to accommodate some late proof or item.
The Editor wishes to express his unbounded gratitude
to his Publication Committee, to all the numerous ones
who have had duties in assemblying special number
material, and to the Council’s each and every member
who has made his work so enjoyable.
Again the Editor has found stimulation and enormous
satisfaction in our friendly associations.
Respectfully submitted,
Wilfrid Haughey, M.D.
Editor
JMSMS
ANNUAL SESSION OF THE COUNCIL
REPORT ON AND EVALUATION OF THE MSMS RHEUMATIC FEVER
CONTROL PROGRAM— 1956
CHRONOLOGY AND SALIENT FEATURES
April 26, 1945: Preventive Medicine Committee
MSMS. — Extract of minutes: “The Preventive Medicine
Committee respectfully recommends to the Executive
Committee of the Council MSMS that the Chairman
of the Child Welfare Committee, the Chairman of the
Heart and Degenerative Disease Committee, the Di-
rector of the Michigan Crippled Children Commission,
together with Secretary Foster confer for the purpose
of expanding the program of education, control and care
of the rheumatic fever patient and that the Committee’s
findings be submitted to the Council MSMS.”
May 13, 1945: Special Rheumatic Fever Committee.
■ — Extract of the minutes: “A rheumatic fever program
should concern itself with ( 1 ) Education — lay and
professional; (2) Research; (3) Case finding, diagnos-
tic services, treatment and follow-up services and school-
ing facilities. This program is the combined effort of
the Michigan State Medical Society and the Michigan
Crippled Children Commission to provide adequate
facilities for the finding, treatment and prevention of
rheumatic fever. It is designed to keep the activity in
the hands of the practicing profession with no disturb-
ance of the established physician — patient relationship.”
July 13-14, 1945: The Council MSMS. — The report
of the meeting of May 13, 1945 of the Special Rheu-
matic Fever Committee was presented to the Council.
After full discussion motion was made that the report
of the Committee be received with thanks and that the
Committee be commended for its efforts; carried unani-
mously.
September 6, 1945: Rheumatic Fever Control Com-
mittee.— First meeting of the Committee. Proposed
Diagnostic and Consultation Centers: Marquette, Tra-
verse City, Bay City, Grand Rapids, Lansing, Flint, Ann
Arbor, Jackson and Kalamazoo.
Fundamental rules for Diagnostic and Consultation
Centers:
1. The work shall be limited to diagnostic and con-
sultation service only.
2. All reports and recommendations must go to a
private doctor of medicine.
3. Indigents are the responsibility of the Michigan
Crippled Children Commission. Private patients must
be charged a fee.
4. Reporting shall be made of all cases to the Michi-
gan Department of Health.
5. Uniform blanks shall be used by all Centers. Ac-
curate records shall be kept, together with follow-up
reports.
6. Definite follow-ups should be established and be
included among the recommendations to the referring
doctor of medicine.
January 17, 1946: Michigan Society for Crippled
Children and Adults, Inc. — agrees to financial support
on a year-to-year basis, beginning with the sum of $15,-
000.00 for the year 1946.
January 18, 1947: Wayne County Medical Society
Rheumatic Fever Control Committee appointed by the
Society’s President.
April 16, 1947: The Executive Committee of the
Council establishes the principle of voluntary partici-
pation by County Medical Societies.
July 22, 1948: Medical Coordinator for the MSMS
Rheumatic Fever Control Program recommended by
the Rheumatic Fever Control Committee and approved
by the Council, effective January 1, 1949.
January 5, 1949: Michigan Heart Association incor-
porated.
June 22, 1949: Michigan Heart Association offers
March. 1957
financial support on a year to year basis, beginning
with $32,515.72 for the year 1949.
May 10, 1950: Michigan Chapter of the Arthritis and
Rheumatism Foundation makes Financial contribution
of $2,250.00.
May 2, 1951: Annual Postgraduate Fellowships for
the Study of Rheumatic Fever established.
October 31, 1951: Series of “Physician’s Desk Refer-
ence Cards for Rheumatic Fever begun.
1949-1954 : New Rheumatic Fever Diagnostic and
Consultation Centers organized: Alpena, Benton Harbor
— St. Joseph, Muskegon, Saginaw, Sault Ste Marie,
Royal Oak, Petoskey.
January 20, 1954: Health Department Participation
in Heart Disease Control. — The Rheumatic Fever Con-
trol Committee and the Executive Committee of the
Council (May 19, 1954) : Approval of the general
principles of Health Department participation in heart
disease control. . . . Implementation to be framed
within the needs and capabilities of each community
as determined jointly between the local County Medical
Society and the local Health Department, with partici-
pation of interested organizations.
September 8, 1954: Liaison with the Special Educa-
tion Committee of the Michigan Department of Public
Instruction established, for a study of the needs of the
cardiac and the rheumatic child in school.
February 2, 1955: Penicillin Distribution. — Rheumatic
Fever Control Committee and Executive Committee of
the Council (February 23, 1955): (1) Statement of
policy that the Rheumatic Fever Control Committee
is a diagnostic and consultation service and it is not
within its province to prescribe or distribute drugs;
(2) that prophylaxis of rheumatic fever (recurrences)
(by the use of penicillin) for the medical indigent should
be handled similar to the present regulation govern-
ing distribution of gamma globulin, i.e., the drug used
by the physician to be replaced by the local Health
Department.
December 7 , 1955: Michigan Crippled Children Com-
mission Program of Rheumatic Fever Prophylaxis. —
Under this plan the Michigan Crippled Children Com-
mission will undertake to pay the physician — out of
Trust Funds administered by the Commission — a stand-
ard fee of $3.00 for the monthly administration of
penicillin to rheumatic children under age 21 who
qualify under the Crippled and/or Afflicted Children’s
Acts.
January 16, 1956: Distribution of Injectable Peni-
cillin by the Health Department for the prevention of
streptococcal infections in persons who have had rheu-
matic fever or who have rheumatic heart disease, on
application by the family physician, and the Rheumatic
Fever Prophylaxis Program of the Michigan Crippled
Children Commission become effective.
FINANCIAL SUMMARY
Expenditures
Total expenditures 1945-1956 incl. (12 years) $205,785.87
Smallest annual expenditure (1945) 520.30
Largest annual expenditure (1952) 26,318.23
Average annual expenditure 12 years 17,788.45
Average annual expenditure last 10 years 20,534.90
Financial Contributions by
Michigan Society for Crippled Children & Adults 58,140.14
Arthritis & Rheumatism Foundation 4,500.00
Michigan Heart Association 150,821.29
ACHIEVEMENTS IN EDUCATION
Lay Education:
1. Pamphlet entitled: “Rheumatic Fever. Nine Ques-
tions and Answers for Parents” prepared by the Rheu-
matic Fever Control Committee, printed and distributed
373
ANNUAL SESSION OF THE COUNCIL
by the Michigan Department of Health. Approximately
50,000 copies.
2. Pamphlet entitled: “The Cardiac and the Rheu-
matic Child in School. Five Questions and Answers for
Teachers,” prepared jointly by the Rheumatic Fever
Control Committee and the Committee on Education
of Exceptional Children of the Michigan Department
of Public Instruction, printed and published by the
Rheumatic Fever Control Committee, distributed by
the joint sponsors. 20,000 copies.
3. Numerous (untabulated talks on the subject of
rheumatic fever for lay groups, such as Service Clubs,
PTA Health Groups, Community Health Councils, and
the like.
4. Radio and TV spot announcements in cooperation
with the Michigan Heart Association. TV programs and
interviews.
5. Liaison with the Committee on Education of Ex-
ceptional Children of the Department of Public Instruc-
tion.
6. Cooperation with the Michigan Heart Association’s
Heart Units.
Professional Education:
1. Series of “Physician’s Desk Reference Cards for
Rheumatic Fever,” twenty topics related to the problems
of rheumatic fever and rheumatic heart disease, with
frequent revisions, prepared by the Rheumatic Fever
Control Committee and distributed at intervals to all
members of the Michigan State Medical Society.
2. Presentation of one or more scientific programs on
rheumatic fever for twenty-seven County Medical So-
cieties.
3. Presentations by outstanding national authorities on
rheumatic fever, annually on Heart Day of the Michi-
gan Clinical Institute.
4. Publication of scientific papers on Rheumatic
Fever in The Journal of the Michigan State
Medical Society.
5. Annual Postgraduate Fellowships for the Study
of Rheumatic Fever, carrying a stipend of not to exceed
$500.00, awarded to date to twenty-three doctors of
medicine who meet the Committee’s requirements for
applicants.
ACHIEVEMENTS IN RESEARCH
By decision of the Rheumatic Fever Control Commit-
tee (May 13, 1945), problems of research are to be
left to other auspices.
ACHIEVEMENTS IN CASE FINDING
In the matter of case finding, one of the primary
objectives of the Rheumatic Fever Control Program
(May 13, 1945), the feature undertaking is the organ-
ization of the several Rheumatic Fever Diagnostic and
Consultation Centers. The basic principles governing this
project can be summarized as follows:
1. Rheumatic Fever Diagnostic and Consultation
Centers shall be organized, controlled and operated by
the local County Medical Society in cooperation with
the MSMS Rheumatic Fever Control Committee.
2. The services rendered shall be consultative and
diagnostic exclusively and the Centers shall not under-
take treatment.
3. Patients shall be admitted to the Centers on direct
referral by a physician exclusively.
4. The Centers shall not be “free” clinics. A stand-
ard fee for examination shall be charged. In the case
of the medically indigent this charge may be paid by
another party.
5. Reports and recommendations shall be forwarded
to the referring physician for use at his discretion.
374
Acceptance. — The principle of Rheumatic Fever Di-
agnostic and Consultation Centers has been accepted by
the County Medical Societies located in the cities listed
in paragraph I, of this report. Only 3 important
County Medical Societies (Calhoun, Genesee, St. Clair)
have elected not to participate in the MSMS program.
Cumulative statistics, as of December 31, 1956, reflect
the combined activity of all the MSMS Centers:
New Admissions 3,825
Diagnosed rheumatic fever/rheumatic heart disease. .. 1,394
Re-examinations and follow-up 2,602
Total examinations made 6,427
Analysis of the complete statistical report shows that
there is extreme variability among the several Centers,
from total inactivity to considerable progress. Three
Centers (Grand Rapids, Kalamazoo, Traverse City)
account for nearly 50 per cent of new admissions to the
program. Among the reasons for this variability are:
a genuine belief that there is no need for a diagnostic
program; indifference to the problems of rheumatic
fever; misunderstanding of the objectives of the project.
The more successful County Medical Societies are to
be commended for their important contribution to the
MSMS program.
CONCLUSION
While it cannot be said that on a statewide basis
the Rheumatic Fever Control Program of the MSMS
has been 100 per cent successful, it is readily apparent
that a great deal of progress has been made in the
twelve years of its existence. There is now much
more awareness of and interest in the problems of
rheumatic fever and of rheumatic heart disease, both
on the part of the medical profession and on the part
of the public, than there was in 1945. This, of course,
is the implied final objective of the project. The
progress made in the past few years should not be
allowed to regress, but a continued sustained effort
should be maintained for its enlargement.
The success of a program such as this reflects favor-
ably upon the Michigan medical profession in the eyes
of the public.
RECOMMENDATIONS
Your medical coordinator respectfully submits the
following recommendations for consideration by the
Council:
1. Continuation and expansion of the MSMS Rheu-
matic Fever Control Program as presently constituted
and as guided by the Rheumatic Fever Control Commit-
tee; i.e., (a) education, both lay and professional;
(b) diagnostic and consultation service to the practicing
physician at his request.
2. Moral support and continued financial assistance
to those Rheumatic Fever Centers which are now ac-
tively engaged in rheumatic fever control and desire
to continue and expand their programs.
3. Maintaining an open door to those Medical Soci-
eties who may wish to participate in the MSMS pro-
gram at a later date.
4. Financial support of the Postgraduate Education
Program (Postgraduate Fellowships) and extension of
this program to attendance at recognized rheumatic
fever centers elsewhere in the U.S.A., without formal
course, in selected cases.
5. Maintaining the position of Medical Coordinator
on either a full-time or a part-time basis, with the
provision that the medical coordinator shall reside in
the Southeastern part of the State, for the reason that
most doctors and a large segment of the population are
concentrated in that area.
JMSMS
ANNUAL SESSION OF THE COUNCIL
6. Maintaining good relations and cooperation with
the Rheumatic Fever Programs of the Michigan Crip-
pled Children Commission and of the Michigan De-
partment of Health.
7. Maintaining good relations and cooperation with
the Michigan Heart Association, which not only sup-
ports the MSMS program financially, but is itself a
voluntary organization engaged in the fight against
heart disease, and has delegated the major share of its
interest in the problems of rheumatic fever to the
Michigan State Medical Society.
Respectfully submitted,
Leon DeVel, M.D.
Medical Coordinator
MSMS RHEUMATIC FEVER CONTROL COMMITTEE
Statistical Report from January 1, 1956, to December 31, 1956
*Tota1 Register Jan. 1, 1956 Jan. 1, 1956, to Dec. 31, 1956 *Total Register Dec. 31, 1956
No. Adm.
Rh.F.
Reex.
Total
No. Adm. Rh.F.
Reex.
Total
No. Adm.
Rh.F.
Reex.
Total
Center**
125
53
25
150
14
11
5
19
139
64
30
169
Alpena (19)
225
197
265
490
18
34
62
80
243
231
327
570
Ann Arbor (6)
219
80
89
308
10
5
3
13
229
85
92
321
Bay City (9)
25
8
4
29
0
0
0
0
25
8
4
29
Benton Harbor (14)
277
45
6
283
35
9
2
37
312
54
8
320
Detroit- Wayne ( 1 )
677
261
496
1173
45
14
33
78
722
275
529
1251
Grand Rapids (3)
136
45
28
164
3
3
0
3
139
48
28
167
Jackson (15)
528
168
567
1095
60
15
67
127
588
183
634
1222
Kalamazoo ( 10)
107
13
20
127
8
0
0
8
115
13
20
135
Lansing (5)
—
—
—
—
INACTIVE
—
—
—
—
Marquette (8)
245
79
195
440
6
4
10
16
251
83
205
456
Muskegon (11)
23
21
16
39
INACTIVE
—
23
21
16
39
Petoskey (18)
239
55
88
327
16
5
6
22
255
60
94
349
Pontiac-Royal Oak (2)
91
27
8
99
INACTIVE
—
91
27
8
99
Saginaw (7)
—
—
—
—
INACTIVE
H HS
—
—
Sault Ste. Marie (17)
647
199
552
1199
46
43
55
101
693
242
607
1300
Traverse City (13)
—
TOTALS
3564
1251
2359
5923
261
143
243
504
3825
1394
2602
6427
*Cases and examinations on record from the beginning of the Center’s activities.
**Number indicates rank of importance according to population.
UNORGANIZED CENTERS: Battle Creek (12)
Flint (4)
Port Huron (16)
MSMS 1957 BUDGET ESTIMATES
GENERAL FUND
ACCOUNT TITLE 1957 Estimate
INCOME
5250 members @ $55.00 $288,750.00
Less: $1.50 to The Journal 7,875.00
$6.25 to Public Education 32,812.50
$3.50 to Public Service 18,375.00
$5.25 to Professional Relations 27,562.50
$5.00 to MSMS New Headquarters Fund 26,250.00
$2.00 to Building Maintenance Fund 10,500,00
$3.00 to Public Education Reserve 15,750.00
Balance to General Fund (5/ $28.50 $149,625.00
Interest and Miscellaneous Income — 0 —
TOTAL FUNDS AVAILABLE $149,625.00
EXPENSES (Administrative and General)
Printing, Mailing and Postage $ 10,000.00
Office Supplies 3,000.00
Insurance and Bonds 5,000.00
Auditing 750.00
Salaries: Administrative and Office 37,000.00
General Counsel Retainer and Expense 7,000.00
Equipment and Repairs 3,500.00
Telephone and Telegraph 4,000.00
Taxes (Other than Property) 2,500.00
Miscellaneous Expenses and Contributions 3,000.00
Employe’s Retirement Trust 10,000.00
Resident’s and Interns Conference — 0 —
Total Administrative and General Expense $ 85,750.00
EXPENSES (Society Activities)
Council Expense $ 15,000.00
AMA Delegates and Alternates 7,000.00
General Society Travel and Entertainment 7,200.00
Officers Travel 6,200.00
Secretary’s Letters and Office Expense 900.00
Woman’s Auxiliary 600.00
Dues Collection Expense 3,000.00
Total Society Activities $ 39,900.00
EXPENSES (Committees) .
Cancer Coordinating Committee $ 1,000.00
Child Welfare Committee 400.00
National Defense 400.00
Geriatrics 500.00
Industrial Health 100.00
Legislative 1,500.00
Maternal Health 400.00
Mental Health 400.00
Michigan Health Council 10,000.00
Postgraduate Medical Education 4,000.00
Preventive Medicine 100.00
Permanent Conference 100.00
Rural Medical Service 200.00
Scientific Radio 1,400.00
Tuberculosis Control 200.00
Venereal Disease 100.00
Beaumont Memorial Restoration 500.00
Highway Accident Committee 400.00
Sundry Committee Expense 2,000.00
Total Committee Expense $ 23,700.00
TOTAL GENERAL FUND EXPENSES $149,350.00
GAIN FOR THE YEAR 275.00
BALANCE FROM PRIOR YEARS 89,870.56
$ 90,145.56
NET GAIN OR LOSS FROM ANNUAL SESSION,
MCI AND JOURNAL — 0—
BALANCE TO 1958 $ 90,145.56
BUILDING MAINTENANCE FUND
income:
Allocation from membership dues $ 10,500.00
EXPENSES
Maintenance: Utilities, Decorating, supplies, yard
work, etc. $ 3,000.00
Salaries: Janitor 2,000.00
Property Taxes 850.00
Insurance: Fire and Liability 500.00
Depreciation 1,750.00
Furnishings 200.00
Remodeling 200.00
Parking Area — 0 —
Miscellaneous — 0 —
Total Building Maintenance Expense $ 8,500.00
GAIN FOR THE YEAR 2,000.00
BALANCE FROM PRIOR YEARS 14,124.94
BALANCE TO 1958 $ 16,124.94
March, 1957
375
ANNUAL SESSION OF THE COUNCIL
ANNUAL SESSION
INCOME
Booth Sales: 132 Spaces •>
EXPENSES
Scientific Meeting Expense -t>
Exhibit Expense
Registration and Hotel Expense
State Society and Officers Night ■ ■■
Promotion: Printing, Mailing, Postage and Scientific
Work Committee
Press Expense
Salaries ••• ••• ;•••••"•
House of Delegates Expense (including Special Guests)..
Miscellaneous Expense
29,000.00
4.500.00
5.000. 00
800.00
4.200.00
3.300.00
1.400.00
8.000. 00
2.200.00
1,600.00
Total Annual Session
Expense..
31,000.00
MSMS NEW HEADQUARTERS FUND
INCOME
Allocation from membership dues -•-$ 26,250.00
CONTINGENT FUND
INCOME
Allocation from membership dues.
Balance from prior years
■$
53,614.34
Total
.$ 53,614.34
MICHIGAN CLINICAL INSTITUTE
INCOME
Booth Sales: 74 Spaces ?
EXPENSES
Scientific Meeting $
Exhibit Expense
Registration and Hotel
Promotion: Printing, Mailing, Postage and Committee
meetings
Press Expense -
Salaries
Residents and Interns Conference
Miscellaneous Expenses
13,650.00
2.500.00
3.500.00
900.00
3.300.00
1.300.00
1.950.00
200.00
Total MCI Expense
.$ 13,650.00
PUBLIC EDUCATION ACCOUNT
INCOME
Allocation from membership dues $ 32.812.50
Other Income — 0 —
Total Income $ 32 812.50
EXPENSES
Committee meetings $ 500.00
Equipment and Repairs 500.00
Printing, Mailing and Postage 2,500.00
Office Supplies 1,000.00
Salaries 18,350.00
Telephone and Telegraph 1,500.00
Travel and Entertainment 5,000.00
Exhibit Expenses 1,000.00
Publications, Pamphlets, clippings 1,000.00
Radio, TV and Cinema 10,000.00
Miscellaneous Expense 600.00
Total Expenses $ 41,950.00
LOSS FOR THE YEAR $ 9,137.50
BALANCE FROM PRIOR YEARS $ 73,891.87
BALANCE TO 1958 $ 64,754.37
PROFESSIONAL RELATIONS
INCOME
Allocation from membership dues $ 27,562.50
EXPENSES
Rent to Wayne County Medical Society $ 720.00
Salaries 18,150.00
Telephone and Telegraph 1,000.00
Travel and Entertainment 5,000.00
National Meeting Expense 2,000.00
County Secretary’s — PR Conference 6,000.00
County Society and Field Secretary meetings 1,000.00
Woman’s Auxiliary _ 1,000.00
Miscellaneous Expenses 100.00
Committee Meetings — 0 —
Printing, Mailing and Postage 750.00
Total Expenses $ 35,720.00
LOSS FOR THE YEAR 8,157.50
BALANCE FROM PRIOR YEARS 4,897.50
BALANCE TO 1958 (Loss) $ 3.260.00
THE JOURNAL
INCOME
Allocation from membership dues $ 7,875.00
Subscriptions — non-members 800.00
Advertising Sales 80,000.00
Reprint and Cut Sales 4,000.00
Miscellaneous Income 100.00
Total Income $ 92,775.00
EXPENSES
Editor’s Expense $ 3,000.00
Printing, Mailing and Postage 54,000.00
Reprint and Cut Expense 3,500.00
Salaries 14,550.00
Discounts and Commissions 19,400.00
Miscellaneous Expenses 125.00
Total Expenses $ 94,575.00
PUBLIC EDUCATION RESERVE
income:
Allocation from membership dues $ 15,750.00
Balance from prior years 57,245.00
Total $ 72,995.00
PUBLIC SERVICE ACCOUNT
INCOME
Allocation from membership dues
EXPENSES
Salaries
Telephone and Telegraph
Travel and Entertainment
Rural Health Conference
Miscellaneous Expense
Committee meetings
Total Expenses
LOSS FOR THE YEAR
BALANCE FROM PRIOR YEARS
BALANCE TO 1958 (Loss)
.$ 18,375.00
.$ 18,150.00
. 1,000.00
. 5,000.00
250.00
. — 0-
100.00
.$ 24,500.00
6,125.00
3,675.16
.$ 2.449.84
RHEUMATIC FEVER CONTROL PROGRAM
INCOME
From Michigan Heart Association $ 39,574.44
EXPENSES (Central Office)
Committee meetings $ 500.00
Equipment and Repairs 2,500.00
Payroll Taxes 300.00
Printing, Mailing and Postage 1,750.00
Office Supplies 200.00
Publications and Pamphlets 100.00
Salaries: Administrative and Office 11,600.00
Travel 1,500.00
Fellowships 3,000.00
Telephone and Telegraph 100.00
Laboratory Aid Plan 1,000.00
Travel Fellowships 3,000.00
Annual Rheumatic Fever Day 4,000.00
Circulating Exhibits 3,000.00
Total Central Office Expense $ 32,550.00
EXPENSES (Control Centers)
Alpena $ 500.00
Ann Arbor 1,500.00
Bay City 1,000.00
Benton Harbor 200.00
Detroit 4,000.00
Grand Rapids and Muskegon 4,000.00
Jackson 100.00
Kalamazoo 1,500.00
Lansing 100.00
Petoskey 100.00
Pontiac and Royal Oak 200.00
Saginaw 200.00
Sault Ste. Marie 100.00
Traverse City 1,200.00
Total Control Center Expenses $ 14,700.00
Total Rheumatic Fever Expenses 47,250.00
LOSS FOR THE YEAR 7,675.56
BALANCE FROM PRIOR YEARS $ 7,675.56
376
TMSMS
TRUE ANTICHOLINERGIC ACTION
Pro-Banthine® Inhibits Excess
Parasympathetic Stimuli in Peptic Ulcer
Medical literature now contains more than
500 references to the beneficial role of Pro-
Banthlne Bromide (brand of propantheline
bromide) and Banthlne® Bromide (brand of
methantheline bromide) as evidenced by a
marked healing response of peptic ulcers.
Rapid symptomatic improvement, particu-
larly with reference to pain relief, is followed
by roentgenographic demonstration of
crater filling.
The therapeutic action of Pro-Banthine in
decreasing hypermotility and hyperacidity,
together with the remarkable early subjective
benefit, is a desired approach in the manage-
ment of ulcers.
The initial suggested dosage is one tablet,
15 mg., with meals and two tablets at bed-
time. An increased dosage may be necessary
for severe manifestations and then two or
more tablets four times a day may be indi-
cated. G. D. Searle & Co., Chicago 80, Illi-
nois, Research in the Service of Medicine.
SEARLE
March, 1957
Say you saw it in the Journal of the Michigan State Medical Society
377
Michigan’s Department of Health
Albert E. Heustis, M.D., Commissioner
IN-SERVICE TRAINING
IMPROVES HEALTH PROGRAM
Continuing and intensive in-service training for per-
sonnel of local and state health departments in Michi-
gan is carried on by the Michigan Department of
Health.
All of the specialties involved in the program of the
Michigan Department of Health, administration, public
health dentistry, public health nursing, sanitation, oc-
cupational health, laboratory, statistics, nutrition, health
education and clerical work, are represented on the
Co-ordinating Committee that conducts the training
program. Dr. J. K. Atland, Director of the Division
of Local Health Administration, is chairman of this
committee. Working under the Co-ordinating Commit-
tee are technical committees in each specialty, headed
by division directors or section chiefs of the state
department and made up of representatives of state
and local health departments and interested individuals.
The technical committees are responsible for recruit-
ment as well as training.
Much of the in-service training is informal and non-
accredited, covering a broad scope of interests. A
total of 1,250 state and local health department work-
ers took part in some way in activities sponsored in
1955-56. Examples of non-accredited training offered
this year were: institutes of varying length on sub-
jects such as long-term illness; workshops for local
health department nurses, sanitarians and clerks; courses
in public administration for supervisory personnel and
courses for water and sewage treatment plant operators.
In the accredited training program, a limited num-
ber of fellowships for advanced study are available each
year to state and local health department personnel.
In general, the fellowships are considered a bonus given
to persons already in the field of public health who
have demonstrated a capacity for growth and a dedica-
tion to their work. The grants are not used as a means
of recruiting new persons for the profession. The
training enables a person to fill a need identified as
important in the position which he holds.
About fifteen persons receive the one-year fellowships
awarded annually. Winners of the grants this year
included public health physicians, nurses, sanitarians
and laboratorians. Most of the fifteen are studying
toward master’s degrees in public health at the School
of Public Health of the University of Michigan.
Persons applying for fellowships are first screened by
the technical committees. On the basis of its findings,
each committee makes recommendations to the Co-
ordinating Committee on the applicants in its specialty.
In its final choice of candidates to be recommended
to the State Health Commissioner for fellowships, the
Co-ordinating Committee works through a Fellowship
378
Selection Committee. On this committee are repre-
sentatives of the specialties found in the Michigan
Department of Health and also local health depart-
ment staff members.
The Fellowship Selection Committee interviews all
applicants and on the basis of its findings and the
recommendations of the technical committees submits
names to the State Health Commissioner in the order
of choice. The Commissioner makes final selections.
The state-administered program of advanced training
is independent of the fellowship program being con-
ducted by the U. S. Public Health Service. Goal of the
federal program is to attract newcomers to the field
of public health. The two programs are supplementary
and have the single objective of meeting the demands
for more and better qualified public health personnel.
VENEREAL DISEASE POSTGRADUATE
CONFERENCE
The 26th Venereal Disease Postgraduate Conference
for physicians sponsored by the University of Tennessee
College of Medicine, the Public Health Service and
the Tennessee State Department of Health will be held at
the College of Medicine in Memphis, April 18-20. No
tuition will be charged. Applications for admission
are to be sent to Dr. Henry Packer, Department of
Preventive Medicine. College of Medicine, University
of Tennessee, Memphis 3, Tennessee.
PROPHYLACTICS FOR EYES OF
NEWBORN
Frequent inquiries are received from physicians as
to prophylactics to be used in the eyes of newborn
infants.
Michigan law requires the State Health Commissioner
“to officially name and approve a prophylaxis to be
used in treating the eyes of newly born infants.”
In compliance with this law, the State Council of
Health approved silver nitrate, 1.0 per cent in solution,
as the prophylactic to be used in every child’s eyes
immediately after birth.
A change in regulations concerning eye prophylaxis
was made in 195.3. The use of prophylactics other than
silver nitrate may be permitted under controlled re-
search conditions when such research studies have been
previously approved by the State Health Commissioner.
In an analysis of 1,000 cases of pelvic cancer,
physician delay was established in 158, and delay on
the part of both physician and patient in 437.
* ■*■ *
It seems incredible that any medical graduate would
not know that postmenopausal or intermenstrual bleed-
ing might and often does mean cancer, and that only
a proper examination can throw light on the cause of
the bleeding.
1MSMS
ST. JOSEPH’S RETREAT
Member: American Hospital Association
Catholic Hospital Association
National Association of Private
Mental Hospitals
The Central Neuro-Psychiatric
Hospital Association
Under the direction of the
Daughters of Charity of St. Vincent de Paul
Serving Metropolitan Detroit
and Michigan almost a century
Martin H. Hoffmann, M.D.
Medical Director
23200 West Michigan Avenue
Dearborn
Logan 1-1400
A PREFERRED BEVERAGE FOR HOME AND HOSPITAL
March, 1957
Say you saw it in the Journal of the Michigan State Medical Society
379
In Memoriam
Jacob D. Brook, M.D., eighty, of Grandville, died
December 20, 1956, at Grand Rapids.
Doctor Brook was a Past President of the Michigan
State Medical Society, having served as chief execu-
tive in 1929.
Born in 1877 at Cleveland, Ohio, Doctor Brook came
to Grandville in 1892. After receiving his M.D. degree
from Detroit College of Medicine (now Wayne State
University) in 1902, he began general practice in Grand-
ville and continued for twenty-nine years until he be-
came Kent County’s first fulltime health officer.
Doctor Brook also served as President of the Kent
County Medical Society, the Michigan State Board of
Registration in Medicine and the Michigan Public Health
Association. He was a member of the American Medical
Association and served as Michigan delegate to the
AMA House of Delegates for twenty-four years.
* * *
Samuel Balofsky, M.D., forty-seven, Detroit, Associate
Professor of Radiology at Wayne State University Col-
lege of Medicine, was a member of Wayne County Medi-
cal Society and a staff member at Receiving and Detroit
Memorial Hospitals, Detroit. Dr. Balofsky died August
11, 1956.
* * *
Robert Beattie, M.D., eighty-five, retired Detroit phy-
sician, was a 1903 graduate of the Detroit College of
Medicine (Wayne University). He had practiced in
Detroit fifty-two years before he retired in 1955. He
was a member of the Wayne County Medical Society
and a Life Member of the Michigan State Medical
Society. He died August 18, 1956.
* * *
Robert J. Biggar, M.D., forty-seven, formerly of Port
Huron, was chief medical officer for the California
Texas Oil Company, Ltd. He received his M.D. degree
from the Detroit College of Medicine (Wayne Univer-
sity) in 1936. He was a member of the St. Clair County
Medical Society. He died September 21, 1956.
* * *
P. W. Butterfield, M.D., forty-seven, pathologist at
Alpena General Hospital, Alpena, was born in 1909 in
East Wilton, Maine. He received his M.D. degree from
Boston University Medical School, and had practiced in
Alpena for three years. He died October 19, 1956.
* * *
Wm. A. Evans, M.D., forty-nine, Detroit physician for
more than twenty years, was a native of Bellaire, and
had lived in Detroit for forty-five years. He was gradu-
ated from the Johns Hopkins Medical School, and was
a member of the Wayne County Medical Society. He
died October 17, 1956.
* * *
Daniel P. Foster, M.D., sixty-four, Detroit, head of
Henry Ford Hospital’s metabolism department, received
his M.D. degree from Harvard Medical School in 1922.
Dr. Foster was a member of the Wayne County Medical
Society. He died August 21, 1956.
* * *
Leonard Fox, M.D., thirty-three, of Wyandotte, was
born in Canada. Dr. Fox graduated from the Univer-
sity of Michigan Medical School in 1945. He had prac-
ticed in Wyandotte for four years. He died October
7, 1956.
John R. Giffen, M.D., eighty-five, practitioner in
Bangor for over sixty years, was born in Mayfield,
Ontario, Canada, in 1870. He received his M.D. degree
at Willamette University, Willamette, Oregon. Dr.
Giffen was a member of the Van Buren County Medical
Society, and an Emeritus Member of the Michigan
State Medical Society. He died July 24, 1956.
W. T. S. Gregg, M.D., eighty-five, of Eagle Harbor,
practicing physician for over half a century, was born
in 1871, in Southfield, Michigan. Dr. Gregg retired from
practice in 1946. He was a member of the Houghton-
Baraga-Keweenaw County Medical Society and an Em-
eritus Member of the Michigan State Medical Society.
He died July 15, 1956.
* * *
Arthur J. Hamilton, M.D., fifty-eight, of Flint, was
born in 1898, in Tecumseh. He was graduated from
the University of Tennessee Medical School. He was a
member of the Genesee County Medical Society, and
had practiced in Detroit prior to coming to Flint ten
years ago. He died August 11, 1956.
* * *
William Hamilton, M.D., sixty-six, of Highland Park,
was born near Huntsville, Ontario. Dr. Hamilton re-
ceived his M.D. degree from the University of Toronto
in 1916. He had practiced in Detroit for forty years
following his graduation. He died August 2, 1956.
* * *
Robert B. Hasner, M.D., seventy-two, of Royal Oak,
was born in Independence, Iowa. Dr. Hasner received
his M.D. degree from Rush Medical College. He had
practiced medicine in Royal Oak for thirty-five years.
He was a Past President of the Oakland County Medical
Society, and a Life Member of the Michigan State Medi-
cal Society. He died September 16, 1956.
380
JMSMS
IN MEMORIAM
Arthur R. Hayton, M.D., seventy-eight, practicing
physician in Shelby since 1905, was born in New York
City in 1878. He received his M.D. degree from the
University of Illinois in 1905. He was a member of the
Oceana County Medical Society and a Life Member
of the Michigan State Medical Society. He died De-
cember 27, 1956.
* * *
Ara B. Hewes, M.D., eighty-two, well-known Adrian
physician and surgeon, was born in 1873, at Medina,
Ohio. He received his M.D. degree from the Cleveland
Homeopathic Medical College in 1903. Dr. Hewes had
practiced in Adrian for more than fifty years, beginning
his first practice here in 1903. He was a Past Presi-
dent of the Lenawee County Medical Society. He died
July 30, 1956.
* * *
J. E. Hopkins, M.D., fifty-nine, Detroit, staff physi-
cian at Lincoln Hospital, was born in Canada. Dr. Hop-
kins received his M.D. degree from the University of
Toronto Medical School. He was a member of the
Wayne County Medical Society. He died suddenly
November 25, 1956.
* * *
Ralph G. Hubbard, M.D., fifty-eight, of Detroit, was
born in New Baltimore. Dr. Hubbard had lived in De-
troit since 1915. He was graduated from the University
of Michigan Medical School in 1926. He was a mem-
ber of the Wayne County Medical Society and an
Associate Member of the Michigan State Medical So-
ciety. He died August 31, 1956.
* * *
E. S. Huckins, M.D., sixty-four, Bay City practitioner
since 1916, was born in Bay City in 1892. He was
graduated from the University of Cincinnati Medical
School in 1915. He was a Past President of the Bay
County Medical Society and a Retired Member of the
Michigan State Medical Society. He died December
29, 1956.
* * *
Ned B. Kalder, M.D., forty-three. Chief of Staff at
Mt. Carmel Mercy Hospital, Detroit, was a member of
Wayne County Medical Society. He died in a traffic
accident July 15, 1956.
* * *
John L. Loomis, M.D., retired member of the Mus-
kegon County Medical Society, was graduated from
the University of Pennsylvania Medical School, and
practiced in Muskegon, Michigan, until illness forced
his retirement. He died May 1, 1956, in Santa Ana,
California.
* * *
J. L. McKenna, M.D., fifty-four, Grand Rapids physi-
cian and surgeon, was a native of Ionia. Dr. McKenna
had been a resident of Grand Rapids most of his life,
receiving his M.D. degree from the University of Michi-
gan in 1926. He was a member of the Kent County
Medical Society. He died August 25, 1956.
EVERY WOMAN
WHO SUFFERS
IN THE
MENOPAUSE
DESERVES
"PREM ARIN:
widely used
natural s oral
estrogen
AYERST LABORATORIES
New York, N. Y. • Montreal, Canada
5645
March, 1957
Say you saw it in the Journal of the Michigan State Medical Society
381
IN MEMORIAM
CARBASED
acetylcarbromal tablets
• Proved safe and effective by 6 years’
clinical use.
• Soothes the central nervous system,
produces calmness without hypnosis.
• Non-toxic, non-cumulative, non-addict-
ing, no known contraindications.
• Does not impair mental or physical
function.
• Orally effective within 30 minutes for
sustained action up to 6 hours.
Henry G. Merz, M.D., eighty-six, of Lapeer, was born
in 1869 at Castroville, Texas. He graduated from
Homeopathic College, Chicago, in 1892. He had prac-
ticed medicine for sixty-four years; in Lapeer, for the
past thirty-one years. He was a member of the Lapeer
County Medical Society and an Emeritus Member of
the Michigan State Medical Society. He died Sep-
tember 22, 1956.
* * *
John P. Parsons, M.D., sixty-seven, of Grosse Pointe
Park, was a native of Eau Claire, Wisconsin. Dr. Par-
sons was graduated from the University of Michigan
Medical School in 1919. He had practiced in Detroit
since 1934, and was a member of the Wayne County
Medical Society. He died September 17, 1956.
* * *
Edwin M. Smith, M.D., sixty, Grand Rapids physi-
cian since 1926, was born near Brown City. He re-
ceived his M.D. degree from the University of Michi-
gan, and was a member of the Kent County Medical
Society. He died August 3, 1956.
* * *
W. C. Swartout, M.D., seventy-six, of Muskegon, a
medical practitioner for more than fifty years, was born
in 1880 at Chicago. Dr. Swartout was graduated from
the University of Illinois School of Medicine and prac-
ticed in Chicago prior to coming to Muskegon in 1919.
He was a Life Member of the Michigan State Medical
Society, and a member of the Muskegon County Medi-
cal Society. He died October 22, 1956.
* * *
John J. Walch, M.D., sixty-nine, of Escanaba, retired
physician and surgeon, was born in 1887 in Escanaba.
He received his M.D. degree from the University of
Michigan in 1912. He had practiced in Escanaba from
1915 until his retirement. Dr. Walch was a Past Presi-
dent of the Delta-Schoolcraft County Medical Society
and a long-time member of the MSMS House of Dele-
gates. He died September 5, 1956.
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Harold W. Wiley, M.D., sixty-seven, of Lansing, di-
rector of procurement and distribution of blood for
Michigan Department of Health since 1952, was born
in 1889, in Lansing. Dr. Wiley obtained his M.D.
degree from the University of Michigan. He was in
private practice in Lansing for twenty-seven years until
1950. Doctor Wiley was a Past President of the Ingham
County Medical Society and former Delegate from
Ingham County to the MSMS House of Delegates. He
died suddenly July 15, 1956.
Just as other disease processes has been coped with
when not every mechanism of their induction was
understood, so advantage must be taken of the existing
knowledge of environmental cancers.
382
Say you saw it in the Journal of the Michigan State Medical Society
JMSMS
Correspondence
Dear Mr. Burns:
I have just returned from the National Trauma Com-
mittee Meeting of the American College of Surgeons
which was held in Cleveland on the 1st and 2nd of
February.
I am very pleased to report that for the sixth time
in the past seven years the Michigan report on educa-
tional activities concerned with trauma was given first
place. Credit for this achievement must be given to all
of the Michigan physicians who co-operated so well in
all of the educational activities of this committee, and
especially to the many local committee chairmen who
sponsored such fine programs throughout the year.
I want to thank you very kindly for your help in pub-
lishing some of our trauma papers in the August issue
on Trauma and for the fine publicity which you gave
us throughout the year in the State Journal. It is the
hope of the Trauma Committee that you will continue
to aid our efforts and that we may remain in first place
when the National Committee meets next year in
Florida.
Sincerely yours,
Homer M. Smathers, M.D.,
Chairman, Michigan Regional
Committee on Trauma,
American College of Surgeons
Detroit, Michigan
February 7 , 1957
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practice. Accordingly, special pains have been taken
to mark the specific paths of procedure, define the line
of objective interrogation and sharply focus the powers
of visual observation which, when applied in unison,
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Say you saw it in the Journal of the Michigan State Medical Society
383
NEWS MEDICAL
MICHIGAN AUTHORS
Henry J. Montoye, Ph.D., Wayne D. Van Huss,
Ph.D., Herbert Olson, M.S., Andrew Hudee, M.S. and
Earl Mahoney, M.S., East Lansing, are the authors of
an article entitled “Study of the Longevity and Mor-
bidity of College Athletes” published in The Journal
of the American Medical Association , November 17,
1956.
R. W. Waggoner, M.D., Ann Arbor, is the author of
an article entitled “History of the Department of Psy-
chiatry at the University of Michigan,” presented be-
fore the Sixth Triennial Medical Alumni Conference in
Ann Arbor, September, 1956, and published in Univer-
sity of Michigan Medical Bulletin, October, 1956.
Thomas Francis, Jr., M.D., Ann Arbor, is the author
of an article entitled “Approaches to the Prevention of
Poliomyelitis,” published in the University of Michigan
Medical Bulletin, October, 1956.
Ross V. Taylor, M.D., Jackson, is the author of an
article entitled “Amebiasis Treated with Biallylamicol
Hydrochloride,” published in the American Journal of
Gastroenterology , December, 1956.
R. Patterson, M.D., and W. A. Grade, M.D., Ann
Arbor, are the authors of an article entitled “The Rapid
Approximation of Plasma Glucose by Means of Indicator
Tape,” published in the University of Michigan Medical
Bulletin, October, 1956.
John S. De Tar, M.D., Milan, is the author of an
article published in GP for November, 1956, which is
the text of the Dedication Address given on Septem-
ber 1, 1956, at the formal dedication of the new nation-
al headquarters building of the Academy for General
Practice, of which Dr. De Tar is President.
Robert S. Knighton, M.D., and J. DeWitt Fox, M.D.,
Detroit, are the authors of an article entitled “Diagnosis
and Treatment of Eosinophilic Granuloma of Skull,”
published in The Journal of the American Medical
Association, December 1, 1956.
John T. Ferguson, M.D., Frank V. Z. Linn, M.D.,
John A. Sheets, Jr., M.D., and Mervyn M. Nickels,
M.D., Traverse City, are the authors of an article en-
titled “Methylphenidate (Ritalin) Hydrochloride Par-
enteral Solution, published in The Journal of the
American Medical Association, December 1, 1956.
H. G. Kobrak, M.D., Detroit, is the author of an
article entitled “Objective Audiometry,” which was
published in the AM A Archives of Otolaryngology,
January, 1957.
Irving Shapire, M.D., Ann Arbor, is the author of
article entitled, Radioactive Phosphorus in Differen-
tial Diagnosis of Ocular Tumors,” presented at the
scientific session following the Third National Cancer
Conference, Thursday, June 7, 1956, Ann Arbor, and
published in AMA Archives of O phthalmology, January,
1957.
M. K. Newman, M.D., Detroit, is the author of an
article entitled, “Electromyography in Neurological
Diagnosis,” appearing in the Annals of Rehabilitation,
Vol. Ill, Mexico City, Mexico.
Edward W. Kelly, Jr., M.D., and Hermann Pinkus,
M.D., Detroit, are the authors of an article entitled
“Local Application of 8-Methoxvpsoralen in Vitiligo,”
published in the Journal of Investigative Dermatology,
December, 1955.
Rosie Hunter, Herman Pinkus, M.D., and Catherine
Heise Steele, M.D., Detroit, are the authors of an
article entitled, “Examination of the Epidermis by the
Strip Method,” published in the Journal of Investiga-
tive Dermatology, July, 1956.
Hermann Pinkus, M.D., Monroe, and James R. Rogin,
M.D., and Perry Goldman, M.D., Detroit, are the
authors of an article entitled “Eccrine Poroma” and
published in AMA Archives of Dermatology, November,
1956.
Hermann Pinkus, M.D., and Catherine Heise Steele,
M.D., Detroit, are the authors of an article and exhibit
entitled “Structure and Dynamics of the Human
Epidermis,” published in AMA Scientific Exhibits, 1955,
Grune and Stratton, Publishers. The exhibit was shown
at the American Academy of Dermatology and Syphil-
ology, Chicago in 1954 and at the AMA meeting, At-
lantic City in 1955, where it received Honorable Men-
tion in the Section of Dermatology.
Carey P. McCord, M.D., Ann Arbor, is the author
of an article entitled, “The Blind Hog in the British
Isles,” published in Industrial Medicine and Surgery,
January, 1957.
W. E. Rush, M.D., J. P. Truant, M.D., J. C. Sieracki,
M.D., and G. Manson, M.D., Detroit, are the authors
of an article entitled “Actinomycosis-Cerebral Infec-
tion Presenting as a Brain Tumor,” published in Henry
Ford Hospital Medical Bulletin, December, 1956.
Shirley A. Johnson, Ph.D., M. June Caldwell, B.A.,
and Edward McCall Priest, M.D., Detroit, are the
authors of an article entitled, “The Effect of the Ad-
ministration of the Anticoagulant Marcumar on the
Blood Coagulation Mechanisms,” published in Henry
Ford Hospital Medical Bulletin, December, 1956.
Robert F. Ziegler, M.D., Detroit, is the author of
an article entitled “The Electrocardiogram in Inter-
atrial Septal Defect,” presented before the VUIth
International Congress of Pediatrics, Copenhagen, Den-
mark, July, 1956, and published in Henry Ford Hospi-
tal Medical Bulletin, December, 1956.
384
JMSMS
NEWS MEDICAL
Fred W. Whitehouse, M.D., Detroit, is the author
of an article entitled, “The Clinical Value of the Plasma
Acetone Test,” published in the Henry Ford Hospital
Medical Bulletin , December, 1956.
Joseph Beninson, M.D., Detroit, is the author of an
article entitled “Preliminary Report on the use of a
Pressure Gradient, Elastic Support in Conditions As-
sociated with Impaired Vascular Reserve,” presented
before the Central States Dermatological Association,
Henry Ford Hospital, April, 1956, a resume of which
is published in the Henry Ford Hospital Medical Bul-
letin, December, 1956.
Hugh W. Brenneman, Lansing, is the author of an
article entitled “Are Professions on Their Way Out?”
published in The New Physician, January, 1957.
J. Chandler Smith, M.D., Saginaw, is the author of
an article entitled “The Treatment of Cancer of the
Breast, published in Surgery, Gynecology and Obstetrics,
January, 1957.
E. R. Jennings, M.D., and J. W. Landers, M.D., De-
troit, are the authors of an article entitled “The Use of
Frozen Section in Cancer Diagnosis,” published in
Surgery, Gynecology and Obstetrics, January, 1957.
A. Waite Bohne, M.D., and Dale R. Drew, M.D.,
Detroit, are the authors of an article entitled “A Com-
parative Evaluation of Intravenous Pyelographic Media,”
published in AM A Archives of Surgery, December,
1956.
Robert C. Hendrix, M.D., Ann Arbor, is the author
of an article entitled “Neoplasm in Children: A Re-
view of Necropsy Records in 244 Cases,” published in
University of Michigan Medical Bulletin, November,
1956.
John G. Batsakis, M.D., Ann Arbor, is the author
of an article entitled “Calcospherites and Thyroid Car-
cinoma,” published in the University of Michigan
Medical Bulletin, November, 1956.
Robert M. Nalbandian, M.D., Seymour Gordon, M.D.,
Ruth Campbell, M.D., and J. M. Kaufman, M.D., are
the authors of an article entilted “A New Quantitative
Digitalis Tolerance Test,” published in Harper Hospital
Bulletin, November-December, 1956.
Maria Huebbe, M.D., and Irving F. Burton, M.D.,
Detroit, are the authors of an article entitled “Tuber-
culosis of the Cervical Lymph Glands,” published in
Harper Hospital Bulletin, November-December, 1956.
William S. Carpenter, M.D., and Paul J. Connolly,
M.D., Detroit, are the authors of an article entitled
“Surgical Treatment of Ulcerative Colitis,” published
in Harper Hospital Bulletin, November-December, 1956.
B. Berglund, M.D., and A. Kohlmeier, M.D., Detroit,
tre the authors of an article entitled “An Analysis of
Fatality,” published in Harper Hospital Bulletin, No-
vember-December, 1956.
E. S. Gurdjian, M.D., F.A.C.S., and J. E. Webster,
M.D., F.A.C.S., Detroit, are the authors of an article
entitled “Experiences in the Surgical Management of
Intrcranial Suppuration,” published in Surgery, Gyne-
cology and Obstetrics, February, 1957.
Donald C. Durman, M.D., Saginaw, is the author of
an article entitled “Metatarsus Primus Varus and Hal-
lux Valgus,” read before the Section on Orthopedic
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4444 Woodward Avenue. Detroit 1. Mich.
March, 1957
Say you saw it in the Journal of the Michigan State Medical Society
385
NEWS MEDICAL
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Grand Rapids 2. Mich.
Surgery at the 105th Annual Meeting of the American
Medical Association, Chicago, June, 1956, and pub-
lished in AMA Archives of Surgery, January, 1957.
George L. Waldbott, M.D., Detroit, is the author
of an article entitled “Incipient Fluorine Intoxication
from Drinking Water,” published in Acta Medica Scan-
dinavica, Vol. CLVI, fasc. Ill, 1956.
* * *
Elmer Hess, M.D., Immediate Past President of the
A.M A, speaking on the role of the physician in Blue
Shield, at Seattle and the Interim Session of the Ameri-
can Medical Association, said:
“Without Blue Cross and Blue Shield and other in-
surance programs our hospitals and ourselves would be
hard put to render the services that these two organiza-
tions have made possible. Since we have accepted the
insurance principle many patients would previously be
non-paying patients have had their bills at least partly
paid. . . . Today’s professional freedom to be a private
practitioner of medicine instead of a slave of govern-
ment is due solely to Blue Shield, the physician’s answer
to ‘Socialized Medicine.’ ”
* * *
General practitioners are taking an increasingly im-
portant role in the treatment of mental illness. As
more and more patients are able to leave psychiatric
hospitals, due in part to the use of tranquilizing drugs,
much of the follow-up care and maintenance therapy
falls to the family physician. In order to aid co-operation
between the discharged patient and his family physician,
a discharged patient booklet, entitled “A New Chapter,”
has been prepared which the State Mental Hospitals at
their discretion will give to the home-going patient.
(Available from Smith Klein and French.)
* * *
The Centennial Exposition commemorating the 100th
anniversary of the Academy of Medicine of Cincinnati,
February 27-March 5, in Music Hall, included an
exhibit of the Ohio Valley Civil Defense Authority,
illustrating a typical 200-bed emergency hospital.
The exhibit, along with the entire Centennial Exposi-
tion’s 175 booth unit attractions has been obtained from
the national Civil Defense authority for showing in
Cincinnati.
* * *
The American Orthopsychiatric Association will hold
its 34th Annual Meeting at the Hotel Sherman in
Chicago on March 7, 8, 9, 1957.
* * *
Polio Vaccine. — During the 1956 vaccine manufac-
turers brought supply up to meet demand. The 100,-
000,000th cubic centimeter of Salk vaccine was released
by the U. S. Public Health Service in Washington in
mid-September. There are no more priorities on use
of commercial vaccine. It is available for all who want
it.
Performance of the Salk vaccine up to now suggests
a potential effectiveness among persons who have re-
ceived all three shots, properly spaced, of about 90 per
cent. With only one shot, one cannot be sure that one
is safe or that the immunization will last after the first;
a second shot increases’s one’s chance of being among
the immunized. The third shot, given seven months
386
Say you saw it in the Journal of the Michigan State Medical Society
JMSMS
NEWS MEDICAL
DAIRY PRODUCTS
TE 1-7000
after the second, further increases one's chances of
being safe and it prolongs the term of safety, perhaps
for years.
* * *
Lt. Col. Herschel E. Griffin, Chief of the Communi-
cations Branch, in reviewing the cause of non-effective-
ness in the army, reports that three fourths of all deaths
in the army are due to injury. Accidents, as in civil
life, are the greatest cause of time loss. One half of
all injuries are due to automobiles. The army has
cut down the presence of communicable disease, which
naturally has increased the proportion of accidents.
Career Incentive. — The Department of Defense has
found its incentive for retaining medical officers in
the armed forces has been somewhat effective. From
July 1, 1956, to November 30, the medical Corps of
the Army, Navy, and Air Forces showed a net gain in
strength of 251. This compares with a gain of 73 in
the previous year, and a loss the year before of 291.
The Dental Corps shows a like change.
* * *
Any combat veteran awarded the Purple Heart would
be deemed to be 10 per cent disabled from service-
connected causes under a bill (H.R. 330) by Rep.
McDonough (R., Calif.). This disability rating would
be in addition to any other disability rating VA had
established for the veteran. The effect would be to
make every Purple Heart winner a service-connected
case for purposes of medical care; the “availability of
space” restriction and “cannot afford to pay” oath
would not apply to him, and he would be entitled to
home-town as well as hospital care. Rep. Henderson
(R., Ohio) proposes a three-year “presumptive” period
of service-connection for arthritis, psychoses and multiple
sclerosis, as well as tuberculosis. The presumptive period
for arthritis is now one year, for psychosis and multiple
sclerosis, two years. The bill is H.R. 1143. — AM A
Washington Letter.
* * *
Rise of Medical Care Costs. — The January issue of
Economic Indicators, a statistical report published
monthly by Joint Congressional Economic Committee,
contains a table on consumer prices which puts medical
care in a unique light. For it disclsoses that the cost
index for this category (including hospitalization and
drugs, as well as medical services) has gone upward
without interruption since 1939 — a distinction that can-
not be claimed by housing, food, recreation, transporta-
tion or any other consumer item. Still the increase in
medical care costs between 1939 and November, 1956,
is not as great per percentagewise as the price rise for
food, apparel, transportation or personal care, in the
same span of years. — WRMS, 1-21-57.
* * *
The Henry Ford Hospital Medical Bulletin is pub-
lished quarterly and contains papers written by the
Professional Staff. It contains in abstract form the
medical, surgical, and research papers published from
The Henry Ford Hospital and from The Edsel B.
March, 1957
Say you saw it in the Journal of the Michigan State Medical Society
387
NEWS MEDICAL
new
the
B i RTCH E R
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conization
electrodes
designed to meet the
HAWKINS* technic
Built by Birtcher of the finest materials to ex-
actly meet the requirements of the technic of
M. C. Hawltins, Jr., M.D., of Searcy, Arkansas,
described in his paper "Re-Evaluation of Coniza-
tion of the Cervix," published in Southern Medi-
cal Journal.
* Described in his paper which will be sent on request
NOBLE-BLACKMER, INC.
267 W. Michigan 28148
lackson, Michigan
Ford Institute for Medical Research. It is furnished
without charge to medical schools, medical libraries,
medical research laboratories, medical students, internes,
residents and interested practicing physicians, upon
application to The Henry Ford Hospital Publications
Committee.
* * *
The American Academy of Plastic Surgery for Head
and Neck announces a Convention in Otolaryngologic
Plastic Surgery conducted by Samuel Fomon, M.D.,
New York City, N. Y., to be held May 12, 1957
through May 18, 1957. Further information may be
obtained by writing to Secretary, American Academy
of Plastic Surgery, Manhattan General Hospital, 307
Second Avenue, New York 3, N. Y.
* * *
Fifty-nine unclassified life science research contracts
in the fields of medicine, biology, biophysics and radia-
tion instrumentation have been announced by the
Atomic Energy Commission, as part of its continuing
policy of assisting and fostering research and develop-
ment in fields related to atomic energy. One of these
awards has been made to the University of Michigan,
the investigator being A. B. French. The subject of
the research is “Effect of Irradiation on the Pituitary
Adrenal Axis.”
* * *
Fourth International Poliomyelitis Conference. — The
Governments are being invited to send delegates to
the Fourth International Poliomyelitis Conference to
be held in Geneva, Switzerland, on July 8-12, 1957.
Thomas Francis, Jr., M.D., Ann Arbor, is serving
on the Scientific Program Committee.
* * *
Clinoptikons. — The Schering Corporation has pre-
sented The Journal with two Clinoptikons — one on
common rheumatic disorders and the other on arthritis.
The publication of these booklets, the first in a series,
marks the beginning of a new Schering service to the
medical profession.
The Clinoptikons depict anatomic and pathologic
aspects of major diseases frequently encountered in
medical practice. The full color medical drawings
will help the physician to explain to the patient the
nature of his condition. This will prove valuable to
the physician in giving to the patient a fuller under-
standing of his condition and the procedures used to
help him.
* * *
Polio Research. — The University of Michigan School
of Public Health has received a grant from the Na-
tional Foundation for Infantile Paralysis of $153,770,
to attempt to find a chemical compound which can
block the paralytic effects of polio. The research team
working on this project is headed by Thomas Francis,
Jr., M.D. His associates will include Drs. Gordon C.
Brown, Wilber W. Ackerman, Kenneth W. Cochran,
Jr.. Donald E. Craig, R. Bernal Johnson and Richard
E. Hartman.
This group has been studying the polio inhibiting
effects of many chemical compounds with some promis-
ing experimental results.
388
Say you saw it in the Journal of the Michigan State Medical Society
JMSMS
NEWS MEDICAL
Symposiums on three officially selected subjects will
e a leading feature of the program of the Fourth
nterim Congress of the Pan American Association of
)phthalmology, which is to be held in New York City,
ipril 7-10, in joint session with the National Society
Dr the Prevention of Blindness. Official subjects of
iscussion are (1) Diseases of the ocular fundus, (2)
)phthalmic surgery, and (3) Therapeutics in Present-
lay Ophthalmology.
* * *
Two new Ciba publications, State of Mind and Pulse
<nd Pressure, are now being distributed to physicians,
>eginning the first of the year, according to T. F.
iaines, president of Ciba Pharmaceutical Products, Inc.
State of Mind is a monthly review of emotional
md psychiatric problems, while Pulse and Pressure will
eport each month on current views concerning hyper-
ension and related cardiovascular disorders. Both pub-
ications are designed for the general practitioner.
The objective of State of Mind is to cast some light
>n the various mental or emotional disorders which the
general physician may be called on to treat, by pro-
dding a new medium of information and expert opin-
■on.
Pulse and Pressure will serve the general practitioner
is a medium for the opinions of leading cardiologists
md other specialists in heart disease.
* * *
Alfred Whittaker, M.D., Honored. — On January 29,
1957, in its list of honorary degrees, included a Doctor
of Arts degree for Alfred H. Whittaker, M.D., of Detroit.
His citation is as follows:
ALFRED HEACOCK WHITTAKER
Alfred Heacock Whittaker, a native of Ohio; a
graduate of the Ohio State University College of Medi-
cine in 1918, for more than thirty years he has been
engaged in the practice of General Surgery, with special
interest in Industrial Medicine and Surgery.
His true physician’s concern for the arts of healing
has been exemplified and extended to problems of civic
scope. To the Committees and Commissions on City
Planning, Health, Housing, Libraries, and Urban Rehab-
ilitation, he has given vigorous and inspiring leadership.
His strong sense of human relationships has motivated
his lifelong interest in our historical societies whose
developing work he has supported by splendid contribu-
tions of time energy and money.
We have been privileged to share in his vision of a
better community a vision which he has actively helped
us in the present to shape closer to the best historic
dreams and plans of the past.
DOCTOR OF ARTS
The W. K. Kellogg Foundation has made a $401,515
commitment to the University of Pennsylvania School
of Medicine for testing and improving the periodic
health examination as an instrument for the early
detection of disease and the promotion of health. —
Philadelphia Medicine, February 1, 1957.
* * *
The second volume of the recently resumed series
of annual reports of The Surgeon General, titled “Medi-
cal Statistics of the United States Army, 1954,” has
been recently published and is now being distributed.
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Codeine Phosphate gr. Vz
Phenobarbital gr. Va
Acetophenetidin gr. 2Vz
Acetylsalicylic Acid gr. 3Vi
(N) subject to Federal Narcotic Law
BURROUGHS WELLCOME & CO. (U.S.A.) INC.
Tuckahoe, N. Y.
March, 1957
Say you saw it in the Journal of the Michigan State Medical Society
389
NEWS MEDICAL
NOSE COLD
each coated tablet:
Phenacetln (3 gr.) 194.0 mg.
Acetylsalicyllc Acid (2 Vz gr.) . 162.0 mg.
Phenobarbital (V4 gr.) .... 16.2 mg.
Hyoscyamlne Sulfate .... 0.031 mg.
Prophenpyridamine Maleate . . 12.5 mg.
Phenylephrine Hydrochloride . 10.0 mg.
Flint Medical Laboratory
633 Mott Foundation Building
Flint
Phone CE. 4-9312
E. G. Murphy, M.D.
W. T. Hill, M.D.
W. L. Eaton, M.D.
C. J. Flanagan, M.D.
J. D. Wheeler, M.D.
W. Caraway, Ph.D., Biochemist
COMPLETE SERVICES IN LABORATORY
MEDICINE
Tissue diagnosis
Serology
Chemistry
Bacteriology
Protein bound iodine
Exfoliative cytology
Basal Metabolism
Electrocardiograms
Pregnancy tests
Hematology
Urinalysis
Autopsies
This report presents detailed statistics on the incidenc
of disease and injury, mortality, hospitalization, medi
cal resources and similar subjects dealing with th
health of Army troops. The volume is intended pri
marily for use by Army personnel directly concernei
with the work of providing medical care. A limitei
number of copies are available for distribution to othe
military and civilian workers in the health field wh'
have need for data of this kind. Any requests shouh
be addressed to the Office of The Surgeon Genera]
Attn: MEDCS.
* * *
American Board of Obstetrics and Gynecology. — Th
next scheduled Examinations (Part II) oral and clini
cal for all candidates will be conducted at the Edge
water Beach Hotel, Chicago, Illinois, by the entir
Board from May 16 through 25. 1957. Formal notic
of the exact time of each candidate’s examination wil
be sent him in advance of the examination dates.
Candidates who participated in the Part I examina
tions will be notified of their eligibility for the Par
II examinations as soon as possible.
* * *
The Ninth Annual Convention of the Internationa
Academy of Proctology will meet at the Plaza, Nev
York, April 29, 30, and May 1, 2, 1957. Cocktail
and dinner will be served the delegates and trustee
and their wives, Sunday evening, April 28. All phy
sicians are invited to attend the various functions
including the banquet, Thursday evening, May 2
Members and non-members are welcome to the con
vention. There are no fees for attendance.
* * *
Pharmaceutical Progress. — If a 1947 graduate of Th
University of Michigan College of Pharmacy were tc
enroll for his training all over again in 1957, he woulc
not find any courses in pharmacy the same as thos'
he took ten years ago, either in name or content.
According to Dean Tom D. Rowe of the Colleg
of Pharmacy, the reason for this startling change i
the tremendous advance in the field of drugs. “Mor
than 50 per cent of the drugs used today were no
known ten years ago,” he explains. “The job of keep
ing up with developments of new drugs and othe
new products, having to know and be familiar witl
them, gives the pharmacist one of the greatest ‘continu
ing education’ responsibilities of any professional man.1
* * *
Interim Congress. — A special invitation is extende<
to Michigan physicians to attend the Fourth Interin
Congress of the Pan American Association of Ophthal
mology, which will be a joint session with the Nationa
Society for the Prevention of Blindness in New Yorl
City, April 7-10, 1957. Headquarters will be at th'
Hotel Statler.
* * *
Peter B. Rastello, M.D., has been appointed medica
director of the Fisher Body Division of General Motor
to succeed A. F. Lecklider, M.D., who retired in Janu
ary after thirty-four years with Fisher Body. Dr. Ras
tello was born in Hancock, Michigan, and is a gradu
ate of the University of Michigan Medical School.
390
Say you saw it in the Journal of the Michigan State Medical Society
.TMSM!
NEWS MEDICAL
! R. L. Novy, M.D., Detroit, was honored January 22
or sixteen years of outstanding service to Detroit, con-
ributed as a member of the Detroit Board of Health.
The tribute was made to Dr. Novy at a luncheon given
jy the Woman’s Advertising Club in the Ford Audi-
orium.
' Congratulations, Dr. Novy, on a magnificent job in
oehalf of the City of Detroit and the health of its
Deople!
* * *
The Summer Camp for Diabetic Children will be
opened for the eighth season under the auspices of the
Chicago Diabetes Association, Inc., from July 14 to
August 4, 1957, at Holiday Home, Lake Geneva, Wis-
consin.
In addition to the complete camp personnel, the Chi-
cago Diabetes Association furnishes a staff of resident
physicians and dietitians, trained in the care of diabetic
children.
Boys and girls, aged eight through fourteen years, are
eligible. For further information regarding fees, inter-
ested persons should be directed to write or telephone
the office of the Chicago Diabetes Association. Fees
will be set on a sliding scale to meet individual circum-
stances.
Physicians are urged to notify parents of diabetic
children and to enter the names of children who would
like to attend camp. Applications may be obtained from
and inquiries should be addressed to: James B. Hurd,
M.D., Chairman, c/o The Chicago Diabetes Associa-
tion, 5 South Wabash Avenue, Chicago 3, Illinois. AN-
dover 3-1861.
* * *
The Third Annual Nutrition Conference, sponsored by
Wayne State University College of Medicine, will be
held on Thursday and Friday, April 4 and 5, 1957.
Speakers on the general subjects, “Fats — Helpful or
Harmful,” will include Drs. John B. Brown, Ohio State
University; Frederick J. Stare, Harvard University;
Grace A. Goldsmith, Tulane University; and Ancel
Keys, University of Minnesota. Further information
may be obtained by writing the Department of Physio-
logical Chemistry, Wayne State University College of
Medicine, Detroit 7, Michigan. All members of the
Michigan State Medical Society are cordially invited
to attend this conference.
* * ■*
It would appear that there are well authenticated in-
stances where malnutrition was the only probable cause
of a rise in tuberculosis morbidity and mortality, though
in most instances it is one of several associated possible
causes. There are also indications that malnutrition be-
comes operative as an etiological factor in tuberculosis
only when a critical level is reached. On the other hand,
it is recognized that optimum nutrition gives no abso-
lute protection against tuberculosis, if other circum-
stances are unfavorable. — Alton S. Pope, M.D., and
John E. Gordon, M.D., American Journal of Medical
Sciences, September, 1955.
* * *
“The Metabolic Insufficiency Syndrome: Diagnosis and
The Burdick MICROWAVE
DIATHERMY UNIT
Studies by Martin and Herrick* indicate that
microwave diathermy creates "significant” rapid
deep heating of localized tissues for effective
relief of pain and muscular rigidity in such
conditions as:
bursitis fibrositis myositis
strains and sprains pelvic inflammatory disease
neuritis (of varying origin)
Simplified operation, convenience, safety, com-
fort to the patient and the traditionally rigorous
Burdick engineering standards mark the Burdick
Microwave Diathermy unit as a highly proficient
therapeutic agency.
For a review of the advanced features of this
outstanding unit, see your Burdick dealer.
*Martin, G.M., and Herrick, J. F. : Further Evaluation
of Heating by Microwave and by Infra-red as Used
Clinically, J.A.M.A. 159:1286 (Nov. 26) 1955.
For information write —
THE BURDICK CORPORATION, MILTON, WIS.
THE G. A. INGRAM COMPANY
4444 Woodward Avenue, Detroit 1, Michigan
March, 1957
Say you saw it in the Journal of the Michigan State Medical Society
391
NEWS MEDICAL
HEAD COLD
each coated tablet:
Phenacetin (3 gr.) 194.0 mg.
Acetylsallcylic Acid (2% gr.) . 162.0 mg.
Phenobarbital (V4 gr.) .... 16.2 mg.
Hyoacyamlne Sulfate .... 0.031 mg.
Prophenpyrldamine Maleate . • 12.6 mg.
Phenylephrine Hydroohlorlde . 10.0 mg.
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rolling grounds, scientifically prepared tasty
meals, congenial companionship. A real
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Approved by the American Medical Association
and Michigan State Department of Social Wel-
fare—Highly recommended by members of the
Medical Profession who have had patients at
the Lodge.
For further information write to:
SAMM0ND PLEASANT LODGE
124 West Gates Street
Romeo, Michigan
Treatment,” a new medical film, is now available fron
the Medical Film Center of Smith, Kline & Frencl
Laboratories. Particularly oriented towards the physi
cian in general practice, it also is suitable for medica
teaching.
A 16 mm. sound motion picture in full color, the 25
minute film reviews the processes of metabolism am
describes the etiology and diagnosis of hypometabolism
whether due to subnormal activity of the thyroid glam
itself (hypothyroidism) or faulty cellular utilization o
the thyroid hormone (metabolic insufficiency). The clin
ical use of “Cytomel,” a new Smith, Kline & Frencl
Laboratories preparation designed for use in the treat
ment of hypometabolic states, is demonstrated in th
film.
Prints of this film, as well as other medical motioi
pictures, are available on free loan to physicians am
medical groups through SKF professional Service Repre
sentatives, or by writing: Medical Film Center. Smith:
Kline & French Laboratories, Philadelphia 1, Pa. Fou
weeks’ notice and an alternate showing date should h
given whenever possible.
* * *
“The Pennsylvania State Medical Society’s 201 -mem
ber House of Delegates has unanimously voted to voi(
and terminate its nine-month-old UMW Welfare ant
Retirement Fund agreement. Last May, the AM A point
ed out that the agreement might help improve union
physician relations.
“Earlier, members of the medical staff at Citizen
General Hospital, New Kensington, Pa., charged tha
the hospital had been boycotted by the union for refus
ing to accept UM W-sponsored physicians. This, sait
state society delegates, constituted a “plot” to “pack’
the medical staff and seize control of the hospital.
“The delegates further contended that since Octobe
1, the UMW has refused to pay bills incurred by bene
ficaries for non-emergency care and treatment at th<
New Kensington hospital. Dr. Warren F. Draper, out
spoken medical director of the $52 million fund, declaret
that his organization feels “no obligation” to purchasy
medical services from any hospital.
“The evidence indicates that unless the UMW cai
control hospital staff appointments, it doesn’t wan
to play.” — AAGP Secretary’s Letter. January, 1957, GP
* * *
The Cook County Graduate School of Medicine an
nounces an intensive course in Neuromuscular Disease:
of Children with special emphasis on cerebral palsy, tc
be given by Meyer A. Perlstein, M.D., for the two-weel
period from July 8 to 19, 1957. This is an intensive
didactic and clinical course designed for pediatricians
orthopedists, neurologists, psychiatrists and physiatrist:
interested in the care and treatment of children witf
neuromuscular handicaps. Emphasis will be placed or
the practical clinical aspects of treatment and rehabilita-
tion procedures.
The course will include itinerant clinics to round oul
the program in most of its practical aspects. The fee I
for the course, which is $250, will include the cost ol
luncheons during the two-week period, as well as the
392
Say y°u saw it in the Journal of the Michigan State Medical Society
JMSMS
NEWS MEDICAL
sxpense of travel, meals and accommodations during the
trip to the field clinic. For further information, write
to John W. Neal, Registrar, Cook County Graduate
School of Medicine, 707 South Wood Street, Chicago,
Illinois. * * *
“Federal Income Tax Liability of Physicians” is a
thirty-eight page booklet available from the AMA Law
Department. It contains many matters of interest to
physicians in preparing their 1957 income tax returns:
business entertainment expenses, deductions for expenses
incurred in taking postgraduate courses, and deduc-
tions for maintaining an office at home. For a copy of
this booklet write Law Department, AMA, 535 N. Dear-
born Street, Chicago 10.
* * *
Hungarian Physicians. — M. Arthur Cline, M.D., Ex-
ecutive Secretary of the American Medical Society in
Vienna, writes that over 600 native Hungarian refugee
doctors of medicine have been receiving the aid of the
AMA of Vienna. Dr. Cline writes: “There are presently
over 450 Hungarian doctors in Austria who wish to
return to their practice as soon as a change in the
Hungarian political situation permits. In fact, we are
urging these colleagues to remain here (in Vienna)
attending this possibility, for we feel that most of them,
should they ever enter the United States, would en-
counter considerable difficulty with language and state
board requirements. However, to maintain them here
will require our further financial support for several
months to come.” Funds to aid these Hungarian doctors
may be sent direct to Dr. Cline in care of 11 Univer-
sitatsstrasse, Vienna 1, Austria.
* * *
The first annual meeting of the American Association
of Medical Assistants was held in Milwaukee October
26-28, 1956. Miss Hallie Cummins, Caro, Michigan,
was elected as a member of the new Board of Directors;
subsequently, the directors selected Miss Cummins as
Chairman of the Executive Committee.
MSMS was represented by R. W. Shook, M.D., Kala-
mazoo, a member of the MSMS Council. J. E. Manning,
M.D., Saginaw, was speaker at the banquet on “The
Doctor’s Dream Girl.”
* * *
The Michigan Cancer Coordinating Committee’s offi-
cers for the year 1957 are: Chairman, Harry M. Nelson,
M.D., Detroit; vice chairman, James W. Hubly, M.D.,
Battle Creek; and secretary, William J. Burns, LL.B.,
Lansing. A vote of thanks was placed on the record to
C. Allen Payne, M.D., Grand Rapids, for his efficient
chairmanship of the MCCC during the past four years.
* * *
Alfred H. Whittaker, M.D., Detroit, received the
honorary degree of Doctor of Arts from Wayne State
University at its commencement exercises, January 29.
Congratulations, Dr. Whittaker.
* * *
Wayne State University College of Medicine Alumni
Clinic Day and Alumni Reunion will be held May 1,
1957, at the Fort Shelby Hotel, Detroit. Presentations
will include “Returning the Cardiac to Work” by Her-
man K. Hellerstein, M.D., Cleveland: “Clinical Evi-
Protection against loss of income from
accident and sickness as well as hospital
expense benefits for you and all your
eligible dependents.
PHYSICIANS CASUALTY & HEALTH
ASSOCIATIONS
OMAHA 2, NEBRASKA
Since 1902
March, 1957
Say you saw it in the Journal of the Michigan State Medical Society
393
NEWS MEDICAL
MISERABLE JOLD
MISERABLE JOLD
each coated tablet:
Phenacetin (3 gr.) 194.0 mg.
Acetyl8alicylic Acid (2 V4 gr.) . 162.0 mg.
Phenobarbital (Va gr.) .... 16.2 mg.
Hyoscyamine Sulfate .... 0.031 mg.
Prophenpyrldamlne Maleate . • 12.5 mg.
Phenylephrine Hydrochloride • 10.0 mg.
dences of Placental Deficiency” by Clyde L. Randall,
M.D., Buffalo; “Diagnosis and Treatment of Surgical
Lesions of the Stomach” by Campbell M. Gardner,
M.D., Montreal; “Application of Psychiatry in General
Practice” by R. W. Waggoner, M.D., Ann Arbor;
“Emergency Surgery in the New Bom” by William L.
Riker, M.D., Chicago; and “Low-Grade Infections of
the Urinary Tract” by Maurice A. Schnitken, M.D.,
Toledo. The scientific meeting will be followed by a
reception and the annual banquet (Crystal Ballroom
and Coral Room).
* * *
The American Medical Education Foundation com-
pleted its fifth year of operation with a record total
of $1,072,717 in contributions — a 41 per cent increase
over last year’s total. Grants are being made to the
nation’s eighty-three medical schools.
* *
$75,000 in Educational Policies. — In a contest which
closes May 4, 1957, Johnson & Johnson, in co-operation
with the Mutual Benefit Life Insurance Company, will
offer educational policies totaling $75,000 through the
Annual Youth Scholarship Fund. The contest will award
scholarship prizes for the best fifty-word essays that
complete the statement: “A Good Education is im-
portant because . . .” Top prize will be $10,000, with
two prizes of $5,000, six fourth prizes of $1,500 each
and thirty-six prizes of $1,000 each.
* * *
World Flealth Day is April 7 — selected by the World
Health Organization, according to Leroy E. Burney,
M.D., Surgeon General of the Public Health Service.
L. G. Christian, M.D., of Lan-
sing was given the first honorar
lifetime appointment to a State ,
commission — the first in the his-
tory of Michigan — wh. lovernoi
G. Mennen Williams gave him
this signal honor on January 24 in
recognition of his long service r ’
the Michigan Social .re r
mission. Dr. Christie. n serv
this Commission from the tin;,
was first established in 1939 until
October 15, 1956. The Governor, in making the honor-
ary appointment, stated Dr. Christian exemplified “dili-
gence, integrity, compassion and a love for all mankind,
and that his public service brought not only great
credit upon himself but great benefit to the people of
Michigan.”
* * *
The Upper Penins (a Medical Society’s Sixty-Fourth
Annual Meeting will be held June 21-22 in Houghton,
Michigan, under the chairmanship of T. P. Wickliffe,
M.D., Calumet, and Forrest W. Larson, M.D., Hough-
ton, who will serve as secretary. Four excellent facilities
will be used by the UPMS for its functions: the Douglass
House, the Scott Hotel, the Onigaming vacht Cluh and
the Memorial Union Building of Michigan Tech.
* * *
The Bahamas branch of the British Medic" Associa-
tion invites all MSMS members to attend its Bahamas
. 'V •
Medical Conference in Nassau April 23-“”, 1957, at
the British Colonial Hotel and .he U’in .^ss Margaret
Hospital in Nassau. For information and program write
to B. L. Frank, M.D., P O. Box 148, Pu.tLh Colonial
Hotel, Nassau.
* * *
The National Industrial Health Conference will be
held at St. Louis April 20-26. For information write the
Secretary of the Conference, 604 N. Michigan Avenue,
Chicago 11, Illinois.
* * *
The University of Cincinnati’s Institute of Industrial
Health offers graduate fellowships in Industrial Medi-
cine, providing professional training for graduates of
approved medical schools who have completed one year
of internship. This three-year course of instruction in-
cludes stipends for the first two years of between $3,000
and $4,000, depending upon marital status. For infor-
mation write Cincinnati College of Medicine, Eden and
Bethesda Avenues, Cincinnati 19, Ohio.
* * *
“Pediatric Advances for Pediatricians and General
Practitioners” is the title of a short refresher course con-
ducted by the staff of Children’s Hospital, Philadelphia,
May 27-31. Tuition $110.00. “Practical Pediatric
Hematology” course will be held June 3-5 — tuition
$75.00; and “Blood Group Incompatibilities and Ery-
throblastosis Fetalis” on June 6-7 — tuition $50.00. In-
quiries should be addressed to Irving J. Wolman, M.D.,
1740 Bainbridge Street, Philadelphia 46, Pennsylvania.
394
Say you saw it in the Journal of the Michigan State Medical Society
JMSMS
NEWS MEDICAL
“Medicine — A Life Long Study” will be the theme of
■ Second World Conference on Medical Education to
held in Chicago August 30-September 4, 1959, under
e sponsor-hip of the World Medical Association.
* * *
abor Says:
"ter 'th Plans are a labor goal. At the last
meet: 'g of the American Public Health Associa-
-- James Brindle, director of the United Auto Work-
s’ Social Security Department, noted that although
bor unions differ on details of how medical care ought
be provided and financed, most of them have sup-
trted legislation to establish a national health insurance
ogram.
Since Congress has not enacted this legislation all
lions, because of their health and velfare funds gained
rough collective bargaining, ha\ ie task of making
e best use of the dollars set a ^,e for medical care,
abor has used these dollars to purchase mostly hospitali-
.tion coverage and surgical benefits from Blue Cross,
lue oxueld and commercial carriers. Some plans include
ime and office care but these are rare. In about fifty
stances labor groups have established direct service
edical centers where services are actually provided
ther than cash indemnities to cover part of the costs.
The latter type of plan has proven more popular with
embers because there are no barriers to the service,
•eve five services are usually included in the benefits
id the*e art no hidden bi'ls cropping up after the
rvices are <er dered.
Health insurarce In rh last 20 years has had a
lenomenal g owth, mostly as a result of collective bar-
tining. Unfortunately, even at this date, the extent to
hich commonly available insurance programs meet a
mily’s health needs is not too impressive to labor. Among
ie cause for difficulties is the system of indemnity pay-
ents for physicians’ services which is not a satisfactory
ethod of paying for services and are a base upon which
me physicians too frequently add substantial charges.
Iso the emphasis on hospitalization and surgical cover-
;e as in the case of most plans without substantial
ltpatient benefits is frequently a cause for unnecessary
ispitalization. Also as a result of inadequate concern
r operating efficiency in hospitals and an unwillingness
enforce legitimate controls there are unjustified
emium increases.
Labor is beginning to focus more on the following
>jectives:
1 . Complete prepayment for medical care without
i-insurance and deductible features and hidden added
ists.
2. Comprehensive benefits — only if the range of health
rvices is complete will the individual’s health needs be
Fectively and economically met.
3. Rational organization of medical services — on the
isis of group practice, and
4. Control of the quality of medical services which
ust be built into medical care plans. (Dr. Morris
rand in AFL-CIO News, December 22, 1956.)
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All important laboratory exam-
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Tissue Diagnosis
The Wassermann and Kahn Tests
Blood Chemistry
Bacteriology and Clinical Pathology
Basal Metabolism
Aschheim-Zondek Pregnancy Test
Intravenous Therapy with rest rooms for
Patients
Electrocardiograms
Central Laboratory
Oliver W. Lohr, M.D., Director
537 Millard St.
Saginaw
Phone. Dial 2-4100—2-4109
The pathologist in direction is recognized
by the Council on Medical Education
and Hospitals of the A.M.A.
[arch, 1957
Say you saw it in the Journal of the Michigan State Medical Society
395
NEWS MEDICAL
Incompletely treated tuberculosis
patients who leave sanatoriums and
interrupt their drug therapy
threaten the effectiveness of mod-
ern drug treatment for tubercu-
losis. These uncooperative patients
may spread the disease in a form
resistant to drug treatment.
At Maybury Sanatorium in
Northville between 140 and 150
children are admitted annually. Dr. W. Leonard How-
ard, medical superintendent of the sanatorium, reported
31 per cent of the children admitted in 1955 were
resistant to the modern drugs. Lowered death rates can-
not be maintained if large numbers of patients enter
sanatoriums with their tuberculosis resistant to life-sav-
ing drugs.
* * *
British Medics Fight for More Pay. — Average $4,875;
Want $616 More from State: Britain's physicians were
reported to have accumulated a fund to fight their
demand for more money from socialized medicine. They
held meetings over the week end to decide whether t
stage a walkout on the health service.
Britain has nearly 40,000 doctors. All except 700 tak
part in the national health program. Some of the gov
ernment physicians also take private patients but th
number of Britons paying their own doctor bills is les
than a million.
The government admits that doctors, under socializei
medicine, today do not have the living standards o
doctors under private medicine in 1939. But the govern
ment puts this down to demotion of doctors, as om
report puts it, from the class of squire to that of civi
servant. (Chicago Daily Tribune, 12-31-56) — Insuranc,
Economics Surveys, January, 1957.
M.D. LOCATIONS
Through February 1, 1957
Placed by Michigan Health Council
Alvin Ratzlaff, M.D.
Floyd R. Town, M.D.
C. E. Payne, M.D.
Assisted by Michigan Health Council
P. G. Seven, M.D.
Don R. Morrill, M.D.
Opened Practic
Berrien Spring
Hillman
Ann Arbor
Flint
Holt
MEDICAL TELEVISION SHOWS
Produced by Michigan Health Council
Date
Station
Subject
Guests
Jan. 6
WJBK-TV, Detroit
Mickey’s Miracle
Film
Jan. 13
WJBK-TV, Detroit
Tenth Annual Michigan
Rural Health Conference
J. K. Altland, M.D., Lansing
S. E. Chapin, M.D., Dearborn
E. H. Wiard, Lansing
Jan. 17
W K AR-TV , East Lansing
Tenth Annual Michigan
Rural Health Conference
Edward Kiley, East Lansing
Dr. Frank W. Suggitt, Lansing
Bob Starring, East Lansing
Dr. Louis Wolfanger, East Lansing
Fred Kellow, Lansing
Carol Avery, Okemos
Jim Kreider, Okemos
Mary Madzia, Okemos
Ted Warner, Okemos
Jan. 20
WJBK-TV, Detroit
Mental Health
Film — “Roots of Happiness”
Jan. 27
WJBK-TV, Detroit
Fire Safety
Film — “Farm Petroleum Safety”
Jan. 31
W K AR-TV , East Lansing
The Doctor Examines Your Heart
E. A. Irvin, M.D., Detroit
John G. Bielawski, M.D., Detroit
Ernest T. Guy, Detroit
E. H. Wiard, Lansing
|
The HAVEN
SANITARIUM, Inc.
Rochester, Michigan
In operation since 1932
M. O.
Director
Wolfe, M.D.
of Psychotherapy
Ralph S. Green, M.D.
Clinical Director
Graham Shinnick
Manager
A private psychiatric hospital for the intensive treatment
of mental and emotional illnesses.
T elephone : OLive 1 -944 1
396
Say you saw it in the Journal of the Michigan State Medical Society
JMSMS
THE DOCTOR'S LIBRARY
THE DOCTOR’S LIBRARY
Acknowledgment of all books received will be made in this column,
and this will be deemed by us as full compensation to those
sending them. A selection will be made for review, as expedient.
A MAN AGAINST INSANITY. By Paul de Kruif,
Ph.D. 240 pages. New York: Harcourt, Brace &
Co., 1957. Price: $3.95.
Has Michigan a modern Beaumont in its boundaries?
Paul de Kruif answers that question with a sturdy
“Yes” in his latest and most thrilling and emphatic
book. •
Beaumont's resounding research of the 1820’s opened
windows of knowledge about physiology of digestion;
the modern pioneer, who becomes the modest hero of
de Kruif s 1957 opus, whips chronic mental illness and
gives promise not alone to abolishing mental institu-
tions (and changing them into community treatment
centers for abnormal behavior) but to guiding the more
important road of prevention.
John T. Ferguson, M.D., of Traverse City State Hos-
pital, is the central figure in “A Man Against Insanity.”
A zealous lone wolf, like William Beaumont, M.D., Dr.
Ferguson has developed the plain science that insanity
is too often just chemical imbalance that can be brought
on an even keel by the use of certain modern behavior
medicines (chemicals).
The greatest pull in the book is the sanguine hope
for mental disease prevention through the work of the
family physician:
“The family doctor is the father of psychiatry. It is
this man who sees mental illness start. He practices
soft shoe psychiatry with over half of his patients every
day. And the public wants its competent modern gen-
eral practitioners to handle its family mental and emo-
tional problems.”
Hope for the cure and eventual prevention of insanity
pervades this well authenticated document. Scientific
facts abound — but never at the expense of reader in-
terest. de Kruif’s words rush with vigor and intensity
and always with good humor and homey Americanisms
— characteristics that make his labors “best sellers.”
“A Man Against Insanity” has twelve chapters and
240 pages that can be enjoyed by physician and layman
alike. The bright vision enfolded in the final thirty
pages is “must” reading for all general practitioners.
W.J.B.
RECOMMENDATIONS FOR DRIVER LICENSING
AND RE-EXAMINATION. PROPOSED AT SYM-
POSIUM ON MEDICAL ASPECTS OF MOTOR
VEHICLE ACCIDENT PREVENTION Center for
Safety Education, New York University,' Washington
Square, New York. Reprints at $.50 per copy, in
quantities of ten or more, $.40 each.
New driver licensing requirements have been proposed
by 125 leading medical specialists from the United
States and Canada and traffic safety authorities in gov-
ernment and industry, who met at New York University,
May 23, 1956, for an all-day workshop conference on
Medical Aspects of Motor Vehicle Accident Prevention.
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Say you saw it in the Journal of the Michigan State Medical Society
397
THE DOCTOR'S LIBRARY
These recommendations, together with an anaylsis of
research needs, are contained in the thirty-two-page
report of the proceedings, contained in full in the Decem-
ber 15 issue of the New York State Journal of Medicine.
Co-sponsored by the University’s Center for Safety
Education and the NYU-Bellevue Medical Center, this
pioneer conference was held in co-operation with the
New York Academy of Medicine’s Committee on Public
Health, the New York Industrial Medical Society, and
several county medical societies.
SICK CHILDREN. Diagnosis and Treatment. By
Donald Paterson, M.D. (Edin.), F.R.C.P. (Lond.),
F.R.C.P. (Canada), Consulting Physician to the Hos-
pital for Sick Childern, Great Ormond Street, Lon-
don; Consulting Paediatrician, Westminster Hospital,
London; Honorary Consultant to the Department of
Paediatrics at the Vancouver General Hospital; Some-
time Clinical Professor of Paediatrics, Faculty of Med-
icine, University of British Columbia and Senior in
Paediatrics, Vancouver General Hospital. Revised by
Reginald Lightwood, M.D. (Lond.), F.R.C.P. (Lond.)
D.P.H. (Eng.), Director, Paediatric Unit, St. Mary’s
Hospital Medical School, University of London, and
Physician-in-Charge, Children’s Department, St.
Mary’s Hospital, London ; Physician to The Hospital
for Sick Children, Great Ormond Street, London;
Paediatrician to the Research Unit for Juvenile Rheu-
matism, Canadian Red Cross Memorial Hospital,
Taplow; External Examiner in Paediatrics to the Uni-
versity of Wales. With the assistance of F. S. W.
Brimblecombe, M.D. (Lond.), M.R.C.P. (Lond.),
D.C.H., Paediatrician, Royal Devon and Exeter Hos-
pital, and Exeter City Hospital; Consultant Paediatri-
cian, Exeter Clinical Area. Philadelphia, Montreal:
J. B. Lippincott Company. Price $8.75.
This is a very good book considering it has been
written to cover the commoner children’s diseases with-
out being too detailed. It is concise, but yet covers
enough to give a most adequate picture of any subject
being quite complete regarding diagnosis and treatment.
Reading the subject matter is very easy and interesting
because of the manner in which the British authors pre-
sent it. Due to this being a British text there are some
variations and differences occasionally noted in either
type of therapy or agents used. The publisher has
unfortunately bound the book with the index pages
not in order or sequence.
J.L.
ALLERGIC DERMATOSES DUE TO PHYSICAL
AGENTS. Edited by Rudolf L. Baer, M.D., Asso-
ciate Professor of Clinical Dermatology and Syphil-
ology, New York University Postgraduate Medical
School. 101 pages. New York University Press.
Philadelphia and Montreal: J. B. Lippincott Com-
pany (distributors). Price: $3.00.
This is a small book of 101 pages which is an outline
of the present knowledge of this somewhat limited field
of Dermatology. The six contributors, who are well
qualified in this field, have done a good job of present-
ing a subject which is still theoretical to a great extent.
For those interested in these peculiar phenomena which
occur on the skin, this book is a good summary and
guide.
GIVE
CRIPPLED CHILDREN
NEED
YOUR
HELP
SEND YOUR EASTER SEAL CONTRIBUTION
TODAY
MICHIGAN SOCIETY FOR
CRIPPLED CHILDREN AND
ADULTS, INC.
10601 Puritan Avenue, Detroit 38, Michigan
' the
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Treating alcoholism and other problems of addiction.
INSTITUTE
•
REGISTERED BY THE AMERICAN MEDICAL ASSOCIATION -
MEMBER AMERICAN HOSPITAL ASSOCIATION.
DWIGHT, ILLINOIS
. -'r
398
Say you saw it in the Journal of the Michigan State Medical Society
JMSMS
THE JOURNAL
of the Michigan State Medical Society
VOLUME 56 APRIL, 1957 NUMBER 4
Contributors to This Issue
E. A. Bicknell, M.D.
E. R. Jennings, M.D.
J. E. Lofstrom, M.D.
Table of Contents
Cancer Registries. I. Purposes and Functions
Harry M. Nelson, M.D., and E. R. Jennings, M.D. 449
The Michigan Tumor Registry
Isidore Selzer, M.D 451
Cancer and Anoxia
Edgar A. Bicknell, M.D 4-56
Screening for Carcinoma of the Cervix
Norman D. Henderson, M.D., Robert Bucklin,
M.D., and V. K. Volk, M.D 461
Cobalt60 Teletherapy in the Palliation of Advanced
Gastrointestinal Carcinoma
]. E. Lofstrom, M.D., S. L. Balofsky, M.D., and
C. R. Williams, M.D 465
Results of Surgical Management of Carcinoma of
the Thyroid
James L. Sawyer, M.D., Melvin A. Block, M.D.,
Diagnostic Difficulties in Carcinoma of the Colon
Henry A. Chapnick, M.D 471
Cancer of the Stomach
Cameron Morrison, M.D., and Gerald S. Wilson,
M.D 474
Herniation of Abdominal Viscera into the Thorax
through the Foramen of Bochdalek
Herbert L. Fishbein, M.D., and Samuel Fink,
M.D 478
A Page from Medical History. IV. The Hebrews
John E. Summers, M.D 480
Acute Pancreatitis
]. Edward Berk, M.D., Sc.D 489
Development in Prepayment Plans
Jay C. Ketchum 494
St. Luke’s Hospital Clinico-Pathologic Conference
Chandler Smith, M.D., Editor 498
The Detroit Physiological Society
December and January Meetings 501
Editorial 504
President’s Message 505
Code of Procedures and Ethics Relating to Autopsies 509
Michigan’s Department of Health 512
In Memoriam 514
Correspondence 516
Membership Record, 1956, MSMS 518
News Medical 520
The Doctor’s Library 536
Tenth Annual Michigan Rural Health Conference.... 408
Attendance Records Broken at 1957 Seminar 414
You and Your Business 424
Toast to the President 426
AMA Washington Letter 4.30
AMA News Notes 432
PR Report 434
AMA Annual Congress on Medical Education 436
Cancer Comment - 438
National Blue Shield Professional Relations
Conference 440
Joint Blood Council 440
Editorial Opinion 442
© 1957 by Michigan State Medical Society
J. E. Berk, M.D.
H. L. Fishbein, M.D.
Jay C. Kf.tchum
H. M. Nelson, M.D.
I. Selzer, M.D.
April, 1957
403
THE JOURNAL
of the Michigan State Medical Society
= VOLUME 56 APRIL, 1957 NUMBER 4 —
PUBLICATION COMMITTEE
G. B. SALTONSTALL, M.D., Chairman Charlevoix
WILLIAM BROMME, M.D Detroit
B. M. HARRIS, M.D Ypsilanti
O. B. McGILLICUBBY, M.D Laming
W. S. STINSON, M.D Bay City
T. P. WICKLIFFE, M.D Calumet
Office of Publication
2642 University Avenue
Saint Paul 14, Minnesota
Editor
WILFRID HAUGHEY, M.D.
610 Post Bldg., Battle Creek, Michigan
Secretary and Business Manager of THE JOURNAL
L. FERNALD FOSTER, M.D.
Thorne Bldg., 919 Washington Ave.
Bay City, Michigan
Executive Director
WM. J. BURNS, LL.B.
606 Townsend Street, Lansing 15, Michigan
All communications relative to exchanges, books for review, manu-
scripts, should be addressed to Wilfrid Haughey, M.D., 610 Post
Bldg,, Battle Creek, Michigan.
All communications regarding advertising and subscription should
be addressed to Wm. J. Burns, 2642 University Avenue, Saint
Paul 14, Minnesota, or 606 Townsend Street, Lansing 15, Michigan.
Telephone Ivanhoe 57125.
_ © 1957, by Michigan State Medical Society.
Published monthly by the Michigan State Medical Society as its
official journal at 2642 University Avenue, Saint Paul 14, Minnesota.
Entered at the post office at Saint Paul, Minnesota, as second
elass matter. May 7, 1930, under the Act of March 3, 1879.
Acceptance for mailing at special rate of postage provided for
in Section 1103 Act of October 3, 1917, authorized August 7, 1918.
Yearly subscription rate, $6.00; single copies, 60 cents. Additional
postage; Canada, $1.00 per year; Pan-American Union, $2.50 per
year; Foreign, $2.50 per year.
PRINTED IN U.S.A.
OFFICERS OF THE SOCIETY
1956-1957
President ARCH WALLS, M.D Detroit
President-Elect G. W. SLAGLE M.D Battle Creek
Secretary L. FERNALD FOSTER, M.D Bay City
Treasurer W. A. HYLAND, M.D Grand Rapids
Speaker K. H. JOHNSON, M.D Lansing
Vice Speaker J. J. LIGHTBODY, M.D Detroit
Editor WILFRID HAUGHEY, M.D Battle Creek
THE COUNCIL
D. BRUCE WILEY, M.D., Chairman, Utica
W. B. HARM, M.D., Vice Chairman, Detroit
L. FERNALD FOSTER, M.D., Secretary, Bay City
Term
District Expires
A. E. SCHILLER, M.D 1st Detroit 1961
O. B. McGILLICUDDY, M.D.. .. 2nd Lansing 1960
H. J. MEIER, M.D 3rd Coldwater 1960
RALPH W. SHOOK, M.D 4th Kalamazoo 1961
C. ALLEN PAYNE, M.D 5th Grand Rapids 1961
H. H. HISCOCK, M.D 6th Flint 1961
H. B. ZEMMER, M.D 7th Lapeer 1957
L. C. HARVIE, M.D 8th Saginaw 1957
G. B. SALTONSTALL, M.D 9th Charlevoix 1957
W. S. STINSON, M.D 10th Bay City 1957
W. M. LeFEVRE. M.D 11th Muskegon 1958
B. T. MONTGOMERY, M.D 12th Sault Ste. Marie .,1958
T. P. WICKLIFFE, M.D 13th Calumet 1959
B. M. HARRIS, M.D 14th Ypsilanti 1959
D. BRUCE WILEY, M.D 15th Utica 1960
G. THOMAS McKEAN. M.D 16th Detroit 1960
W. B. HARM, M.D 17th Detroit 1958
WILLIAM BROMME, M.D 18th Detroit 1959
ARCH WALLS, M.D President Detroit
G. W. SLAGLE, M.D President-Elect Battle Creek
K. H. JOHNSON, M.D Speaker Lansing
J. J. LIGHTBODY, M.D Vice Speaker Detroit
L. FERNALD FOSTER, M.D Secretary Bay City
W. A. HYLAND, M.D Treasurer Grand Rapids
W. S. JONES, M.D Past President Menominee
EXECUTIVE COMMITTEE OF THE COUNCIL
D. BRUCE WILEY, M.D Chairman
W. B. HARM, M.D Vice Chairman
W. M. LeFEVRE, M.D. Chairman, County Societies Committee
G. B. SALTONSTALL, M.D Chairman, Publication Committee
RALPH W. SHOOK, M.D Chairman, Finance Committee
K. H. JOHNSON, M.D Speaker, House of Delegates
J. J. LIGHTBODY. M.D Vice Speaker, House of Delegates
ARCH WALLS, M.D President
G. W. SLAGLE. M.D President-Elect
L. FERNALD FOSTER, M.D Secretary
W. A. HYLAND, M.D Treasurer
Dermatology and Syphilology
Wm. T. Kruse, M.D Grand Rapids
Chairman
Coleman Mopper, M.D Detroit
Secretary
Gastroenterology and Proctology
N. B. Nigro, M.D Detroit 1
Chairman
E. J. Tallant, M.D. Detroit
Secretary
General Practice
F. P. Rhoades, M.D Detroit 2
Chairman
F. G. Brace, M.D Grand Rapids
Secretary
Gynecology and Obstetrics
J. H. Beaton, M.D Grand Rapids
Chairman
R. W. McClure, M.D Detroit 26
Secretary
Medicine
J. M. Kaufman, M.D Detroit 26
Chairman
J. W. Hall, M.D Traverse City
Secretary
SECTION OFFICERS
Nervous and Mental Diseases
W. R. Slenger, M.D Ann Arbor
Chairman
S. C. Mason, M.D Ann Arbor
Secretary
Occupational Health
O. J. Johnson, M.D Bay City
Chairman
P. B. Rastello, M.D Detroit 9
Secretary
Ophthalmology and Otolaryngology
B. C. Wildgen. M.D Muskegon
Chairman (Ophth.)
W. K. Locklin, M.D Kalamazoo
Co-Chairman (Oto.)
H. A. Dunlap, M.D Detroit 14
Secretary (Ophth.)
H. L. LeVett, M.D Lansing
Co-Secretary (Oto.)
Pediatrics
C. E. Booher, M.D Grand Rapids
Chairman
A. M. Hill, M.D Grand Rapids
Secretary
Public Health and Preventive
Medicine
J. D. Monroe, M.D Pontiac
Chairman
J. K. Altland, M.D Lansing 4
Secretary
Radiology, Pathology, Anesthesiology
R. B. Sweet. M.D Ann Arbor
Chairman (Anes.)
E. R. Jennings, M.D Detroit
Vice-Chairman (Path.)
E. O. Pearson, M.D Kalamazoo
Secretary (Rad.)
Surgery
E. T. Thieme. M.D Ann Arbor
Chairman
H. M. Bishop, M.D Saginaw
Secretary
Urology
R. P. Lytle, M.D Detroit 1
Chairman
J. F. Harrold. M.D Lansing
Secretary
Delegates DELEGATES
W. A. Hyland, M.D., Grand Rapids, Chairman 1957
J. S. DeTar, M.D., Milan 1957
G. I. Owen, M.D., Detroit 1957
W. D. Barrett, M.D., Detroit 1958
W. H. Huron, M.D., Iron Mountain 1958
R. L. Novy, M.D., Detroit 1958
Section
G. C. Penberthy, M.D. (Surgical
TO A. M. A. Alternates
W. W. Babcock, M.D., Detroit
E. F. Sladek, M.D., Traverse City
O. J. Johnson, M.D., Bay City
William Bromme. M.D.. Detroit
J. R. Rodger, M.D., Bellaire
G. W. Slagle, M.D., Battle Creek
Delegate
Section) Detroit
.1957
.1957
1957
.1958
1958
1958
404
JMSMS
NO OTHER
ANTIRHEUMATIC
PRODUCT
PROVIDES AS MANY
BENEFITS AS
I
MEPROl BAMATE
predniso I LONE, buffered
THE ONLY
ANTIRHEUMATIC,
ANTI ARTHRITIC
THAT SIMULTANEOUSLY
RELIEVES:
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2. JOINT INFLAMMATION
3. ANXIETY AND TENSION
4. DISCOMFORT
AND DISABILITY
MERCK SHARP 6e DOHME
DIVISION OF MERCK ft CO.. INC. PHILADELPHIA I, PA.
UEPBOLONE ii die trade-mark of Merck L Co., lac
you saw it in the Journal of the Michigan State Medical Society
Tenth Annual Michigan Rural Health Conference
The following report was submitted to the
Midland County Medical Society by G. Fred
Moench, M.D., official delegate of the Society to
the three-day meeting. The Editor feels this is
an outstanding example of reporting by a county
society delegate and might well serve as a guide
for other delegates when they wish to inform their
members of meetings they attend.
The Conference theme centered around serious
health problems developed as people move out of
cities into newly settled sections called “fringe
areas.”
The purpose of this conference was to seek
solutions to the health problems which develop in
these new areas.
General Conference chairman, Brooker L.
Masters, M.D., Fremont, chairman MSMS Com-
mittee on Rural Medical Service, presented
“Theme for the Day.”
More than 100 representatives from dozens of
Health Councils and 104 important health groups
co-sponsoring the conference attended the three-
day session.
The first day, called “Professional Day,” was
devoted almost entirely to meetings of doctors,
nurses and health officials. Emphasis was placed
on these problems:
1. How to get political bodies to appropriate
enough money for suitable adequate health de-
partments.
2. How to meet the problem from mental hos-
pitals, develop preventive aspects and how to find
facilities and personnel to treat mental cases in
hospitals and as out-patients with services that fol-
low the patient back to his home community.
3. How to care for the chronically ill ojd
person.
4. How to develop more emphasis on preven-
tion of disease rather than cure after the disease
has struck. This includes mental health as well
as physical health.
5. How to force more planning on sewage
needs and refuse disposal before they become dire
problems difficult to solve.
The workshop series, medical, dental, public
health, nursing and hospital administration
brought the professionals and people together
on problems unique to rural areas. Rural med-
icine is an entirely new field that is appearing
in today’s health picture.
Four professional papers on medical health
topics were presented and will appear in Michigan
State Medical Society Journal in the near future.
The titles were “Diseases Transmitted from
Animals to Man,” “The Management of the In-
jured Extremity,” “Dentistry in Rural Michigan,”
and “The Management of Acute Chest Injuries.”
The second day was called “Rural Health
Day” and was devoted to a “Composium” on
fringe areas health problems. “Composium” is a
word coined for this conference which means a
controlled “rhubarb.” Each expert leader had a
table where guests gathered to present their
questions.
Subjects covered included Sanitation, Water
Supply and Zoning, Fluoridation and getting a
dentist to locate, Hospitals and prepayment plans,
and School Health and Recreation.
After a coffee break and visit to the exhibits in
Big 10 room, morning session No. 2 was staged.
The four tables highlighted questions on the fol-
lowing subjects: Resort problems and the Tourist
Industry; Accidents and Traffic Control; Migra-
tory Labor; Getting an M.D. to Locate.
At the noon luncheon a group of high school
students and their physical education teacher
presented, in spirited fashion, the viewpoint of
various youth organizations on health problems
confronting our young people in 1957.
Problems and comments presented were : ( 1 )
Recreation and nutrition for healthy bodies. Need
for controlled use of cars and TV. (2) Problem
of how to have a clear complexion. (3) Problem
of youth in meeting the social alcoholic beverage
drinking, drug, and smoking practices. (4) Need
for education and guidance in personal health
and sex education. Opinion was that sex educa-
tion lacked organization and should be done by
qualified people. (5) There was general agree-
ment of youth representatives that parents should
be a little more strict in parental discipline regard-
ing health, recreation and safety, especially with
diet, sleep and car driving.
The afternoon session general assembly entitled,
“Harvesting the Crop of Questions,” featured full
audience participation.
The Annual R.H.C. banquet, with Hugh Bren-
neman representing the MSMS serving as toast-
master, highlighted the presentation of service
recognition certificates to certain individuals and
groups. The Chesaning Community Service
Group, Saginaw County, were awarded a plaque
for their activities in health work in the field of
TB and Cancer case finding surveys, organization
of Visiting Nurse Association and school health
programs.
A component of the Michigan State University
Glee Club presented an entertaining program.
(Continued on Page 410)
408
JMSMS
a penetrant emulsion
for chronic
constipation
COLLOIDAL EMULSION OF MINERAL OIL AND IRISH MOSS
permeales ihe hard, stubborn stool of chronic
constipation with millions of microscopic
oil droplets, each encased in a film of Irish moss
makes it more movable
KONDREMUL (Plain)— Pleasant-lasting and
non-habit-forming. Contains 55% mineral oil.
Supplied in bottles of 1 pi.
KONDREMUL (With Cascara)— 0.66 Gm. nonbitter
Ext. Cascara per tablespoon. Bottles of 14 fl.oz.
KONDREMUL (With Phenolphthalein) — 0.13 Gm.
phenolphthalein (2.2 gr.) per tablespoon. Bottles of 1 pt.
When taken as directed before retiring, KONDREMUL
does not interfere with absorption of essential nutrients.
THE E. L. PATCH CO. — STONEHAM, MASSACHUSETTS
April, 1957
Say you saw it in the Journal of the Michigan State Medical Society
409
KONDR
MICHIGAN RURAL HEALTH CONFERENCE
(Continued from Page 408)
This group departed for Washington after the
banquet to sing at the ceremonies for the Presi-
dential Inauguration.
The third and last day was Community Health
Day and highlighted four workshops designed to
study and plan community lead programs, each
staffed with community local-state level resource
people.
The title of this session was “RX— Prescription
for Community Health.”
Group I — “Diagnosis of Symptoms,” — the
recognizing of need by exploration of ways to
“take the pulse of the community, diagnose its
health problems, discuss the value and use of com-
munity surveys and studies, and consider how to
best tackle community health problems.”
Group II — “The Prescription” — studying the
community resources.
Group III — “Filling the Prescription” — or or-
ganizing for action which means developing a
program by utilizing all resources.
Group IV — “The Prognosis” — or what are the
prospects?
A complete report of this conference will be
available at a later date as a release of the Michi-
gan Health Council and its co-sponsoring agencies.
A brief summary and suggestions for local con-
sideration from your representative delegate
follow :
1. This conference was a well organized and
executed action which presented a means for
communication between professional leaders,
agencies and the public as consumers of health
services.
It provided factual health education.
It is a live medical society, public relations
activity by providing an opportunity for physicians
to learn directly the problems of people and for
people to learn the problems of the physician in
rendition of medical services.
2. Community Health is a leadership respon-
sibility of medical, dental, public health and other
health agencies working with citizen consumer
groups.
3. Good medical, dental and public health
community service to consumers is one of the best
public relations a local county medical society can
develop.
4. Continued study and evaluation of com-
munity needs is a must and recognization of
“fringe area” and new rural health problems must
be met with.
5. Medical, dental and public health can serve
as leaders in the community approach. The pro-
gram must be designed and implemented at local
level by local people, for local people.
6. The procedure for developing the program
is:
(a) Determine the presence and extent of the
community need.
(b) Survey and identify community resources
available to meet the need.
(c) Go into an action program toward utiliza-
tion of all resources and to find new and additional
resources not available in the community.
(d) Evaluation and continuous study of com-
munity programs in relation to old and new
community health needs.
7. As delegate to the Michigan Rural Health
Conference, it is recommended that the Public
Relations Committee of the Midland County
Medical Society explore and study the possibility
of sponsoring a Midland County Health Con-
ference patterned after the program of the
Michigan Rural Health Conference, sponsored by
the Michigan Health Council. The reasons for
this recommendation are:
(a) Midland County is growing, progressive
and is developing many new needs.
(b) It has qualified medical, dental and public
health leaders with many other health, education
and welfare agency leaders as resource personnel.
(c) Modem day problems are no longer solved
by any one agency. A united team approach in a
positive action program is necessary to meet the
threats implied in the criticism of Blue Cross and
Blue Shield, and the attempts to organize pro-
grams of medical and hospital service care without
the advice and counsel of organized medical, hos-
pital and public health agencies.
(d) With its many resources, Midland County
is in an excellent position to accept the challenge
of modern health problems with modern research
methods to maintain high standards of service and
care for all the people in the community by
methods in tune with the principles of private
competitive system in a democracy.
(e) While we have been actively engaged in
fighting Federal government controlled plans,
there is danger in overlooking the threats implied
from attempts to organize group practice sub-
sidized by neither the medical profession or the
Federal government. Patterns for meeting these
growing threats must be developed on the local
level.
MSMS ANNUAL MEETING
September 25-26-27, 1957
Civic Auditorium, Pantlind Hotel
Grand Rapids
Make your hotel reservation now. <—
410
JMSMS
AFTER ALMOST
FIVE YEARS OF
INVESTIGATION
AND EXTENSIVE
CLINICAL USE
(MILLIONS OF
PRESCRIPTIONS)
THERE HAS NOT
BEEN A SINGLE
REPORT OF
A SERIOUS OR
FATAL REACTION
TO ERYTHROCIN
This remarkable safety record stands un-
paralleled in systemic antibiotic therapy
today. In addition to being an unusually
well-tolerated drug . . . erythrocin (com-
pared to most other commonly-used anti-
biotics) is virtually free of side effects.
Still, with this virtual freedom from tox-
icity, erythrocin is effective in the great
majority of common, bacterial respiratory
infections. In speaking of pneumonia, Her-
l-ell said, “the lack of toxic manifestations
following administration of erythromycin
today actually favors its use over that of
the broad-spectrum antibiotics in the treat-
ment of this infection.” 1
While discussing purulent cellulitis and
sepsis due to staphylococci, Eastman, et al.,
mentioned erythromycin as a drug of first
choice in treating these conditions.2
Meanwhile, Solomon and Johnston stated,
“in the staphylococcic and streptococcic in-
fections, other than pneumonias, without
exception the results of treatment ivith ery-
thromycin were excellent.” 3
IN ANTIBIOTIC THERAPY
You, too, can have these same good results
in your everyday practice-plus the assur-
ance of prescribing a drug proved to be
exceptionally well-tolerated in almost five
years’ use. Filmtab erythrocin Stearate
(100 and 250 mg.), in bottles of 25 and 100.
1. Herrell, W. E., Erythromycin, Antibiotics Mono-
graphs, No. 1, p. 34, New York, Medical Encyclopedia
Inc., 1955. 2. Eastman, G., Cook, E. and Bunn. P.,
N. Y. State J. Med., 56:241, 1956. 3. Solomon, S. Cl
and Johnston. B.,Amer.J. Med. Sc., 230:660. 1955. V^U/OtMX
Film-sealed tablets, Abbott; pat. applied for.
Attendance Records Broken at 1957 Seminar
“What’s your future as a professional man?”,
“Today’s trends in medicine,” and “Your organi-
zational opportunities” were the three main topics
of discussion at the 1957 Annual County Secre-
taries-Public Relations Seminar held January 25-
26-27 in Detroit.
L. Howard Schriver, M.D., of Cincinanti, past presi-
dent of the Blue Shield Commission, addressing guests
at the concluding luncheon Sunday on “The Job is
Yours.”
Meeting Co-chairmen C. D. Selby, M.D., Port
Huron and R. W. Teed, M.D., Ann Arbor, said
in a post-meeting announcement that previous reg-
istration marks had been shattered.
The Seminar, running from Friday evening to
Sunday noon, played host to nearly 150 guests
representing nearly every component county medi-
cal society in Michigan.
The Friday banquet speaker was L. Fernald
Foster, M.D., MSMS secretary, who spoke on
“Your Future as a Professional Man.” Doctor
Foster outlined the problems faced by medicine
in protecting the heritage of freedom in medical
practice.
Doctor Foster’s remarks set the stage for the
following day’s session which diagnosed Today’s
Trends and sought solutions for the problems
raised.
Discussing the trends of today from the stand-
point of prepaid medical care plans was Jay C.
Ketchum, Detroit, Executive Vice President of
Michigan Medical Service. Representing Labor
on the panel was John Reid, East Lansing,
Commissioner, Michigan Department of Labor.
Medical care plans through the eyes of manage-
ment was discussed by James M. Gillen, Detroit,
Director of Personnel Research, General Motors
Corporation. The government’s interest was de-
scribed by Donald H. Stubbs, M.D., president of
Medical Service of Washington, D. C.
During the afternoon session, the same four
panelists served as “experts-at-bay.” Impromptu
questions were thrown at the experts by guests in
the audience as well as the on-sta?e devil’s advo-
cates’: James R. Doty, M.D., Luther R. Leader,
M.D., Walter A. Meier, M.D., George N. Petroff,
M.D., and John M. Wood, M.D.
Summarist for this session was John R. Rodger,
M.D.
Mr. Jay Ketchum and Donald H. Stubbs, M.D., two
of the Saturday morning panelists who outlined their
appraisal of “Today’s Trends.”
Sunday morning speakers on “Our Organiza-
tional Opportunities” included Wm. M. LeFevre,
M.D., Indoctrination; W. S. Jones, M.D., and
William J. Burns, LL.B., The Organization’s Ad-
ministration; C. Allen Payne, M.D., and Hugh W.
Brenneman, Public Relations; R. J. Hubbell,
M.D., Mediation and Grievance, and Horace
Wray Porter, M.D., Ethics.
The concluding luncheon on Sunday was
sparked by guest speaker L. Howard Schriver,
M.D., of Cincinnati, past president of Blue Shield
Commission, who told the audience that “The
Job Is Yours.”
Elected Chairman of the 1958 Seminar to be
held next January was John M. Wood, M.D.,
(Continued on Page 416)
414
JMSMS
■ Relieves cough quickly and thor-
oughly ■ Effect lasts six hours and
longer, permitting a comfortable
night’s sleep ■ Controls useless
cough without impairing expecto-
ration ■ rarely causes constipation
■ And pleasant to take
Syrup and oral tablets. Each teaspoon-
ful or tablet of Hycodan* contains 5 mg.
dihydrocodeinone bitartrate and 1.5 mg.
Mesopin.t Average adult dose: One tea-
spoonful or tablet after meals and at
bedtime. May be habit-forming. Avail-
able on your prescription.
ATTENDANCE RECORDS BROKEN
(Continued from Page 414)
Mt. Pleasant, Secretary of the Gratiot-Isabella-
Clare County Medical Society. Those present
included :
County Secretaries. — J. E. Mahan, M.D., Allegan
(Allegan) ; Harold Kessler, M.D., Alpena (Alpena-
Alcona-Presque Isle) ; E. L. Phelps, M.D., Hastings
(Barry) ; H. T. Knobloch, M.D., Bay City (Bay-Arenac-
Iosco ) ; John C. Heffelfinger, M.D., Coldwater (Branch) :
T. B. Mackie, M.D., Sault Ste. Marie (Chippewa-
Mackinac) ; Norman Lindquist, M.D., Escanaba (Delta-
Schoolcraft) ; R. D. Cecconi, M.D., Iron Mountain
(Dickinson-Iron) ; J. M. Cook, M.D., Charlotte (Ea-
ton) ; J. B. Rowe, M.D., Flint (Genesee) ; J. M. Wood,
M.D., Mt. Pleasant (Gratiot-Isabella-Clare); H. W.
Porter, M.D., Jackson (Jackson) ; E. O. Pearson, M.D.,
Kalamazoo (Kalamazoo) ; G. A. Mulder, M.D., Grand
Rapids (Kent) ; James Doty, M.D., Lapeer (Lapeer) ;
A. J. Phelan, M.D., Tecumseh (Lenawee) ; Ray M.
Duffy, M.D., Pinckney (Livingston); Dan Zavela,
M.D., E. Detroit (Macomb); Ruth E. Laline, M.D.,
Bear Lake (Manistee) ; James R. Acocks, M.D., Mar-
quette (Marquette) ; L. Grant Glickman, M.D., Me-
nominee (Menominee) ; Walter A. Meier, M.D., Monroe
(Monroe) ; H. Clay Tellman, M.D., Muskegon (Muske-
gon) ; Edward Crippen, M.D., Mancelona (Northern
Michigan); J. Paul Klein, M.D., Fremont (Newaygo);
G. N. Petroff, M.D., Pontiac (Oakland) ; W. F. Strong,
M.D., Ontonagon (Ontonagon); Charles G. Kramer,
M.D., Saginaw (Saginaw) ; Norman F. Bach, M.D.,
Owosso (Shiawassee) ; C. D. Selby, M.D., Port Huron
(St. Clair); Clark G. Porter, M.D., Three Rivers (St.
Joseph); A. E. Parks, M.D., Lawton (Van Buren) ;
B. C. Payne, M.D., Ann Arbor (Washtenaw); Wm. W.
Moon, M.D., Cadillac (Wexford-Missaukee) .
County Presidents. — Bert VanDerKolk, M.D., Hopkins
(Allegan) ; J. N. Asline, M.D., Bay City (Bay-Arenac-
Iosco) ; John E. McEnroe, M.D., Ironwood (Gogebic) ;
Robert F. Hall, M.D., Mt. Pleasant (Gratiot-Isabella-
Clare) ; T. P. Wickliffe, M.D., Calumet (Houghton-
Baraga) ; John F. Tannheimer, M.D., Ionia (Ionia-
Montcalm) ; L. F. Thalner, M.D., Jackson (Jackson) ;
(Continued on Page 420)
RECORD OF ATTENDANCE AT MSMS COUNTY SECRETARIES-PUBLIC RELATIONS SEMINAR
January 25-26-27, 1957
County or District
Medical Society
Pres.
Pres.-
Elect
Secy.
P.R.
Chairman
Editor
MSMS
Councilor
MSMS P.R.
Committee
Exec.
Secy
Others
Allegan
X
X
X
o
N
o
o
N
Alpena-Alcona-Presque Isle
o
o
X
X
N
o
o
N
o
o
X
X
N
o
X
N
Bay-Arenac-Iosco
X
o
X
o
o
X
xo
N
X
Berrien
o
o
o
X
o
o
o
N
X
o
o
X
o
N
o
o
N
Calhoun
o
o
o
o
o
X
o
N
o
o
o
N
N
o
o
N
Chippewa-Mackinac
o
o
X
o
N
o
xo
N
Clinton
o
o
o
o
N
o
o
N
Delta-Scboolcraft
o
o
X
o
N
o
N
N
Dickinson-Iron
o
o
X
o
N
o
N
N
Eaton
o
o
X
o
N
o
N
N
Genesee
o
X
X
X
X
o
xxo
X
Gogebic
X
o
o
N
N
o
N
N
Grand Traverse- Leelanau-Benzie.
o
o
o
o
N
o
X
N
Gratiot-Isabella-Clare
X
o
X
X
N
o
o
N
Hillsdale
o
o
o
o
N
o
N
N
Houghton-Baraga-Keweenaw
X
o
o
o
o
o
o
N
Huron
o
o
o
X
N
o
o
O
Ingham
o
o
o
X
N
X
ooo
N
Ionia-Montcalm
X
o
o
o
N
o
N
N
Jackson
X
o
X
X
N
o
N
N
Kalamazoo
X
o
X
X
X
X
X
N
Kent
X
X
X
X
o
X
ooo
X
Lapeer
X
o
X
o
N
X
N
N
Lenawee
X
o
X
o
N
o
N
N
Livingston
o
o
X
o
N
o
N
N
Luce
o
o
o
N
N
o
N
N
Macomb
X
X
X
o
N
X
O
N
Manistee
o
o
X
o
N
o
N
N
Marquette-Alger
o
o
X
o
N
o
N
N
Mason
o
o
o
o
N
o
O
N
Mecosta-Osceola-Lake
o
o
o
X
N
o
N
N
Menominee
o
o
X
X
N
o
N
N
Midland
o
o
o
o
N
o
N
N
Monroe
X
o
X
X
N
o
O
N
Muskegon
X
o
X
X
O
o
O
X
Newaygo
X
o
X
o
N
o
N
N
North Central
o
o
o
N
N
o
O
N
Northern Michigan .....
o
o
X
o
N
o
X
N
Oakland
o
X
X
X
X
o
ooo
X
Oceana
o
o
o
o
N
o
N
N
Ontonagon
o
o
X
N
N
o
o
N
Ottawa
o
o
o
X
N
o
N
N
Saginaw
X
X
X
o
O
o
N
O
X
St. Clair
X
o
X
o
N
o
X
N
St. Joseph
o
X
X
X
N
o
o
N
Sanilac
o
o
o
o
N
o
N
N
Shiawassee
o
o
X
o
N
o
O
N
Tuscola
o
X
o
N
N
o
N
N
Van Buren
X
X
X
X
N
o
O
N
X
Washtenaw
o
X
X
o
O
X
XOO
O
Wayne
X
o
o
o
O
XX
XXXOO
OOOOO
X
XXX
Wexford-Missaukee
o
o
X
o
N
X
N
N
O — Not represented; X — Present; N — None.
Others, present at the Seminar were; Woman’s Auxiliary representatives, 4; Michigan State Medical Assist-
ants Society representatives, 3; Michigan Medical Service representatives, 13; Seminar speakers, 22; guests, 18.
416 JMSMS
frozen
shoulder
Bursitis and tenosynovitis are new terms to home-
makers, but they are not uncommon sequels to over-
exertion. Early antirheumatic therapy is to be
encouraged in the treatment of these conditions, as
it is in more serious rheumatic conditions, to allevi-
ate pain and prevent progression of the disorder.
With adequate therapy the prognosis of bursitis in
its acute stage is good. Delaying therapy may result
in extension of the inflammation and gross anatom-
ical changes that tend to incapacitate the patient.
Sigmagen provides doubly protective corticoid-sali-
cylate therapy— a combination of Meticorten® (pred-
nisone) and acetylsalicylic acid providing additive
antirheumatic benefits as well as rapid analgesic
effect. These benefits are supported by aluminum
hydroxide to counteract excess gastric acidity and by
ascorbic acid, the vitamin closely linked to adreno-
cortical function, to help meet the increased need for
this vitamin during stress situations.
protective corticoid -salicylate therapy
SlGMAG€> 1
corticoid-analgesic compound "J*clblstS
for patients
who go beyond
their physical
capacity
*T.M. QO'J-217
ATTENDANCE RECORDS BROKEN
(Continued from Page 416 )
John Fopeano, M.D., Kalamazoo (Kalamazoo) ; D. B.
Hagerman, M.D., Grand Rapids (Kent) ; Thomas Kay
Buchanan, M.D., Imlay City (Lapeer) ; George C.
Wilson, M.D., Clinton (Lenawee) ; E. G. Siegfried,
M.D., Mt. Clemens (Macomb); John P. Flanders, M.D.,
Monroe (Monroe); E. J. Lauretti, M.D., Muskegon
(Muskegon); Robert E. Paxton, M.D., Fremont (Ne-
waygo) ; J. E. Manning, M.D., Saginaw (Saginaw) ;
Charles N. Hoyt, M.D., Port Huron (St. Clair) ; M. W.
Buckborough, M.D., South Haven (Van Buren) ; Luther
R. Leader. M.D., Detroit (Wayne).
County Presidents-Elect. — James I. Clark, M.D.,
Fennville (Allegan); Clayton K. Stroup, M.D., Flint
(Genesee); Howard Benjamin, M.D., Grand Rapids
(Kent) ; J. H. Jewell, M.D., Roseville (Macomb) ; John
n Monroe. M.D.. Pontiac (Oakland) ; E. C. Galsterer,
M.D., Saginaw (Saginaw) ; Olin L. Lepard, M.D.,
Sturgis (St. Joseph); Versa V. Cole, M.D., Caro
(Tuscola); Henry A. Scovill, M.D., Ypsilanti (Wash-
tenaw) .
County Bulletin Editors. — Philip K. Stevens, M.D.,
Flint (Genesee) ; Wilfred N. Sisk, M.D., Kalamazoo
(Kalamazoo) ; Walter J. Zimmerman, M.D., Royal Oak
(Oakland) .
County Society Public Relations Chairmen. — John W.
Bunting, M.D., Alpena (Alpena) ; A. B. Gwinn, M.D.,
Hastings (Barry) ; Robert E. Reagan, M.D., Benton
Harbor (Berrien); Evan L. Copeland, M.D., Decatur
(Van Buren); George E. Anthony, M.D., Flint (Gen-
esee) ; E. S. Oldham, M.D., Breckenridge (Gratiot-
Isabella-Clare) ; W. J. Herrington, M.D., Bad Axe
(Huron); David Kahn, M.D., Lansing (Ingham); Ed-
ward C. Lake, M.D., Jackson (Jackson); Glen Callan-
der, M.D., Kalamazoo (Kalamazoo); Jack Hoogerhyde,
M.D., Grand Rapids, (Kent) ; F. A. Merlo, M.D., Big
Rapids (Mecosta-Osceola-Lake) ; W. S. Jones, M.D.,
Menominee (Menominee) ; R. A. Frary, M.D., Monroe
(Monroe) ; Victor Curatolo, M.D., Mt. Clemens (Ma-
comb) ; Harold Dykhuizen, M.D., Muskegon (Muske-
gon) ; Edgar J. Geist, Jr., M.D., Rochester (Oakland);
John H. Kitchell, M.D., Grand Haven (Ottawa) ; John
M. Jacobowitz, M.D., Three Rivers (St. Joseph).
MSMS Council. — W. S. Stinson, M.D., Bay City (Bay
Arenac-Iosco) ; Wilfrid Haughey, M.D., Battle Creek
(Calhoun) ; G. B. Saltonstall, M.D., Charlevoix (Char-
levoix) ; Kenneth H. Johnson, M.D., Lansing (Ingham) ;
O. B. McGillicuddy. M.D., Lansing (Ingham) ; Ralph
W. Shook, M.D., Kalamazoo (Kalamazoo) ; C. Allen
Payne, M.D., Grand Rapids (Kent) ; H. B. Zemmer,
M.D., Lapeer (Lapeer); D. Bruce Wiley, M.D.. Utica
(Macomb) ; W m. M. LeFevre, M.D., Muskegon (Mus-
kegon): G. Thomas McKean, M.D.. Detroit (Wayne);
A. E. Schiller, M.D., Detroit (Wayne); B. M. Harris,
M.D., Ypsilanti (Washtenaw).
Executive Secretaries of County Medical Societies. —
Sara M. Warren. Flint (Genesee) ; Robert O. Kinsman,
Grand Rapids (Kent) ; Lucy W. Bartlett, Muskegon
(Muskegon) ; James O. Devereaux, Pontiac (Oakland) ;
Else Kolhede, Detroit (Wayne).
Woman’s Auxiliary Representatives. — Mrs. R. E. Rea-
gan, Benton Harbor (Berrien); Mrs. A. C. Stander,
Saginaw (Saginaw) ; Mrs. C. Allen Payne, Grand
Rapids (Kent).
Michigan State Medical Assistants Society Repre-
sentatives.— Mrs. Eileen DeWent, Holland (Ottawa);
Doris E. Jarrad, Lansing (Ingham); Marlouise Redman,
Detroit (Wayne).
MSMS Public Relations Committee. — James Millard,
M.D., Middleville (Barry); W. G. Gamble, M.D., Bay-
420
City (Bay- Arenac-Iosco) ; Tony J. Trapasso, M.D.,
Sault Ste. Marie (Chippewa-Mackinac) ; W. Z. Rundles,
M.D., Flint (Genesee) ; J. L. Leach, M.D., Flint
(Genesee) ; R. L. Thirlby, M.D., Traverse City (Grand
Traverse-Leelanau-Benzie) ; S. E. Andrews, M.D., Kala-
mazoo (Kalamazoo) ; L. E. Grate, M.D., Charlevoix
(Northern Michigan) ; C. L. Weston, M.D., Owosso
(Shiawassee); F. E. Ludwig, M.D., Port Huron (St.
Clair) ; R. W. Teed. M.D., Ann Arbor (Washtenaw) ;
Sidney E. Chapin. M.D., Dearborn (Wayne) ; Edwin
H. Fenton, M.D., Detroit (Wayne) ; E. C. Long, M.D.,
Detroit (Wayne).
Participants on the Program. — L. Fernald Foster,
M.D., Bay City; G. W. Slagle, M.D., Battle Creek;
John M. Wood, M.D.. Mt. Pleasant; C. Allen Payne,
M.D., Grand Rapids; James Doty, M.D., Lapeer;
D. Bruce Wiley, M.D., Utica: Walter A. Meier, M.D.,
Monroe ■ Wm. M. LeFevre, M.D., Muskegon; W. S.
Jones, M.D., Menominee; G. N. Petroff, M.D., Pontiac;
B. M. Harris, M.D., Ypsilanti; R. W. Teed, M.D.,
Ann Arbor; Luther R. Leader, M.D., Detroit; Jay C.
Ketchum, Detroit; John Reid, East Lansing; James M.
Gillen, Detroit, Donald H. Stubbs, M.D., Washington,
D. C.; Arch Walls, M.D., Detroit; Clyde F. Cairy,
DVM, East Lansing; John R. Rodger, M.D., Bellaire;
R. J. Hubbell, M.D., Kalamazoo; L. Howard Schriver,
M.D., Cincinnati, Ohio; C. D. Selby, M.D., Port Huron.
Guests. — W. W. Boyles, Detroit; Donna Marie Bu-
chanan, Imlay City; R. J. Burns, Ann Arbor; Mrs.
Dorothy Callander, Kalamazoo; Verne Collett, Detroit;
Kenneth Cook, Sault Ste. Marie; Arthur Clements, De-
troit; R. H. McDonough. Grand Rapids; Mrs. John V.
Fopeano, Kalamazoo; L. H. Freye, Detroit; Mrs. W. G.
Gamble, Bay City : Louis Graff, Detroit ; L. Gordon
Goodrich, Detroit: Jack Kantner, Lansing; Mrs. Wanda
M. Lake, Jackson; Mrs. Wm. M. LeFevre, Muskegon;
Mrs. N. L. Lindquist, Escanaba; Mrs. F. E. Ludwig,
Pt. Huron; John Nelson, Pontiac; Harry Parke, Lansing;
Thomas Paton, Detroit; Mrs. Edwin Pearson, Kalama-
zoo; Jeannette Phillips. Kalamazoo; Charles Rickett,
Detroit; Mrs. Howard Robinson, Detroit; Miss Helen
Schick, Detroit; Mrs. Lynn Stinson, Bay City; Mrs.
H. C. Tellman, Bay City; Franz Topol, Kalamazoo: Miss
Kay Topp, Detroit; John E. Verbiest, Detroit; E. H.
Wiard, Lansine.
MSMS ANNUAL MEETING
September 25-26-27, 1957
Civic Auditorium, Pantlind Hotel
Grand Rapids
Make your hotel reservation now *—
JMSMS
“Tom” had tuberculosis. And in this latest Parke-Davis message on
the cost of medical care, "Tom’s case” is used as a specific example
of the heartening progress being made against sickness and disease.
The ad points out that, thanks to earlier detection, improved
surgery and the anti-tuberculosis drugs, tuberculosis has fallen from
first to sixth place among the ten leading causes of death.
Unfortunately, most people do not appreciate the priceless value
of today’s more effective medical care until they come face to face
with a dread disease— like "Tom”. And that’s why, with a colorful
new series of advertisements,* Parke-Davis is helping to give your
patients a new and clearer understanding of what modern medical
care can do for them — in terms of getting them well quicker, back
on the job again, and even saving their lives.
In short, we’re continuing to tell your patients that prompt and
proper medical care may well turn out to be the biggest bargain
ever to come their way.
PARKE, DAVIS & C O IVI P A N Y
Detroit 32, Michigan
Now in eye-catching color in life, time,
SATURDAY EVENING POST and TODAY’S HEALTH.
t
April, 1957
Say you saw it in the Journal of the Michigan State Medical Society
423
You and Your Business
AMERICAN BOARD OF OBSTETRICS
AND GYNECOLOGY
Applications for certification (American Board
of Obstetrics and Gynecology), new and reopened,
for the 1958 Part I Examinations are now being
accepted. All candidates are urged to make such
application at the earliest possible date. Deadline
date for receipt of applications is September 1,
1957. No applications can be accepted after that
date.
Candidates for admission to the Examinations
are required to submit with their application, a
typewriten list of all patients admitted to the
hospitals where they practice, for the year preced-
ing their application, or the year prior to their
request for reopening of their application. This
information is to be attested to by the Record
Librarian of the hospital or hospitals where the
patients are admitted and submitted on paper
8/2 x 11". Necessary detail to be contained in the
list of admissions is outlined in the Bulletin and
must be followed closely.
Current Bulletins outlining present require-
ments may be obtained by writing to the Secre-
tary’s office: Robert L. Faulkner, M.D., American
Board of Obstetrics and Gynecology, 2105 Adel-
bert Road, Cleveland 6, Ohio.
PERSONNEL EXPERIENCE AS WELL
AS PROFESSIONAL
Career medical officers of the Army could profit
from an assignment in the Personnel Division of
the Office of The Surgeon General of the Army,
says Col. Joseph H. McNinch who concluded a
nineteen-month tour as chief of that division,
January 24, 1957.
He has been named Chief Surgeon, U. S. Army
Forces in the Far East and his parting message to
his co-workers was that this personnel tour had
been the most enjoyable and profitable he has ex-
perienced in the Army.
I came to W ashington with misgivings because I
had thought I was to continue in preventive medicine,
a field I like very much, but I have learned so much
about the effect of good personnel administration on the
success of our medical mission that I now wish that
every Army Medical Service officer could have a simi-
lar detail as part of his or her career.
“It is the best method I know for introducing the
medical service officer to the importance of clear com-
munication lines between himself and those upon whom
he depends to carry out his health objectives. Such an
officer comes to understand the value of recognizing the
individual problems of his military or civilian staff, pro-
fessional or otherwise, and I believe very firmly that he
or she will be a better medical officer as a consequence.”
“Each one of us has already personally benefited
from your accomplishments but the benefits to be real-
ized by the Army Medical Service and the Army itself
are even more important. Improved assignment and
personnel policies result in happier people and better
medical care for those we serve.”
ARMY’S FIRST INTERNS FOR
CLASS ONE HOSPITALS
Fourteen June graduates of medical schools ap-
proved by the American Medical Association will
report for duty at the U. S. Army Hospital, Fort
Benning, Georgia, July 1, 1957, to inaugurate the
first internships yet instituted for the Army’s Class
I hospitals.
This will be a “pilot” program directed toward
the introduction of such training in other hospi-
tals of this classification.
Applications for Army medical internships have
exceeded by far in recent years the number of
openings available at the Army’s named teaching
hospitals. This has brought about a need to ex-
pand the intern training programs to accommo-
date more of the young physicians interested in
Army professional training.
A total of 150 medical school graduates are
now admitted to the established intern training
programs at the Army’s named teaching hospitals
but for current training years, many more than
this number have been received by The Surgeon
General.
Army educational authorities indicate that the
conduct of an intern training program helps im-
prove the quality of patient care at the hospitals
concerned.
MEDICAL MEETINGS AND CLINIC DAYS
A list of known medical meetings and clinic days, sponsored by county
other physician groups in Michigan, follows:
1957
Spring
May 2
May 5-10
June 21-22
July 11-13
Sept. 25-27
MSMS Postgraduate Extramural Courses
Ingham County Clinic Day
Sixth International Congress of Otolaryngology
Upper Peninsula Medical Society
Mid-Summer Session of The Council, MSMS
MSMS Annual Session
medical societies and
Statewide
Lansing
Washington, D. C.
Calumet
Mackinac Island
Grand Rapids
424
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Sprains
Tendinitis
Trigger finger
Peritendinitis
Trigger points
Tennis elbow
Lumbosacral
Capsulitis
Frozen shoulder
Coccydynia
Rheumatoid nodules
Fibrositis
Tensor fascia lata
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Collateral ligament
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Radiculitis
Osteochondritis
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Hydrocortisone Acetate'
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6 7 6 0 IO II 12 13 14 15 DAT9
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ranges from 20 to 30 mg. depend-
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t.b.a. — 20 mg. /cc. of predniso-
lone r^rHzzry-butylacetate, in
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1. Hollander, J. L., Paper read at conference in New York City , May 31 and June 1 , 1955
April, 1957
Say you saw it in the Journal oj the Michigan State Medical Society
425
Toast to the President
5»
The Saginaw Club for forty-five years has held
a New Year’s banquet for the members and their
sons at which a Toast is given to the President.
This year J. Edward Manning, M.D., President of
the Saginaw County Medical Society, had the
honor, and made such an outstanding contribution,
we are pleased to make the speech available to our
members. The text of Dr. Manning’s toast
follows :
Mr. President, members of the Saginaw Club, your
sons and guests.
First, I would like to wish all of you a healthy, happy,
and prosperous New Year.
I would also like to ask you to give thought to our
members and friends who have left us during the past
year; particularly poignant to me is the loss of Geoffrey
Childs but a few weeks ago. He, incidentally, to the
best of my knowledge, was the only member to have
given the New Year’s Toast two times.
This is the 45th consecutive New Year’s Day that
the members of this Club and their sons have met to
toast the President of the United States. The fact that
this splendid tradition has continued through the years;
that so many men and their sons should be willing to
leave warm homes on cold winter days to assemble
here to toast the President caused me to wonder why
they did ; what force, beliefs or loyalties caused them
to pay their respects on the first day of each New Year.
It seemed to me that it must be a deep and compelling
attachment to the Presidency rather than loyalty to
the man occupying the office at the moment alone.
There have been years when the political climate of
this room would have offered small solace to the holder
of the office as an individual although the loyalty to
the Presidency was of highest titer. The more I thought
of this continuing phenomenon the more intrigued I
became with the actual institution that is the presidency.
While the following is without doubt familiar knowl-
edge to the members here gathered, I feel that the
sons may enjoy following my musings. I thought about
the origin of the Presidency; about the men who have
held the office, of the growth of the office as each holder
added some impress to it; some little, others more, but
nine, I think, detracting. The Presidency has grown
in stature and in power through the years and it is
the men who have held the office that have made it
the splendid institution we toast here today.
After having declared their independence from Eng-
land on July 4, 1776, the 13 original states had had
their fill of strong government and were in no appetite
for more of the same despite the fact that they had
signed the Articles of Confederation and Perpetual
Union confusion grew worse confounded and chaos
reigned. Ultimately even these rugged individualists
realized that some union must come on Sept. 17, 1787,
after 16 weeks of debate, the Constitutional Convention
adopted the Constitution and in so doing brought forth,
with sincere doubts and misgivings, the office of Presi-
dent of the United States.
The Constitution, as you know, is an amazingly simple
document regarding the Presidency. It says mainly
that, “the Executive Power shall be vested in a Presi-
dent” and that he “shall be commander in chief of the
Army and Navy,” and he could also make treaties,
but only with the consent and advice of the Senate.
Certainly a benign definition of an almost empty
sounding office. As a matter of fact the Constitution
426
was almost not ratified by Pennsylvania because of the
“contemptible weakness” of the office of President —
he would be merely a pageant of state, they said, and
a ceremonial officer rather than a help in the quest for
a more perfect union.
President Washington’s main task was to erect and
staff the governmental structure and to get it going.
The problems were chiefly domestic; establishment of
public revenue and credit: creation of a military estab-
lishment and the encouragement of commerce and
manufacturing as an aid to agriculture. All this, of
course, in a small area of the Eastern Seaboard con-
taining four million people.
Traveling Presidents are not new, it seems, for
Washington traveled over all of New England and made
a 1,900-mile tour of the deep South by coach. Thus,
long before the age of “mikes” and nationwide hookups
he saw the face of the people and made the coach-and-
four his channel for communication.
When Washington left office he had had eight hard
years and in them had founded the office of the
President, discovered the chief of its powers and made
them into tools for those who would follow.
When Thomas Jefferson took office on March 4,
1801, we had in him the master politician of his day
and generation and it is probable that, with Lincoln,
he remains to this day the consummate practitioner of
that art.
The Louisiana Purchase was the outstanding event
of Jefferson’s Presidency and besides doubling the size
of the United States it brought about the first downfall
of the policy of strict interpretation of the Constitution.
Before Napoleon’s moody irascibility caused him to
change his mind about selling this huge plot for a
pittance, Jefferson had to move fast; he had no time
to call Congress to amend the Constitution to make
legal such a purchase and so, casting caution to the
four winds, he bought it and then called Congress to
ratify the act. It was the first example of administration
by “trust and discretion” rather than by definition and
all decisions of later American history have been in
some way affected by this action.
Jefferson also established the importance of party
leadership and was probably the most skillful “Chief
of Party” among all the Presidents. This leadership
was translated through its majority in Congress into the
fact of control of the National Government. It was his
example of the employment of this power which Wood-
row Wilson and Franklin D. Roosevelt studied and put
to good use.
Andrew Jackson brought immense new strength to the
office in 1829 for there was no more determined creator
of Executive Power than he. He greatly expanded the
powers of President in his two greatest battles — one in
which he defeated the privately-owned Bank of the
United States and in the other defeated South Carolina’s
notion that the State could veto the will of the Nation.
It was he who then proposed the famous toast “Our
Union, it muse be preserved.” Old Hickory, with his
great moral courage, added luster and power to the
office by bringing the banking of Federal funds under
Government control and by holding the well-being of
the Union above individual State’s rights.
Abraham Lincoln faced problems more formidable
than any other President when he entered office. In
meeting these problems no other President ever found so
many sources of executive power nor so expanded and
perfected those already in use. With the Nation’s great
(Continued on Page 428)
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White, scored 5 mg. tablets (bottles of 20 and 100) and pink,
scored 1 mg. tablets (bottles of 100).
PFIZER LABORATORIES Division, Chas. Pfizer & Co., Inc. Brooklyn 6, New York
Say you saw it in the Journal of the Michigan State Medical Society
TOAST TO THE PRESIDENT
(Continued from Page 426)
troubles before him he seized upon the Presidential
designation as Commander in Chief and coupled to it
the first sentence of Article II of the Constitution:
“The Executive Power shall be vested in a President
of the United States” and joined them as the “War
Power” which authorized him to do many things beyond
power of Congress. In two years what had begun as a
transition device grew into an independent power under
which Lincoln felt authorized to suspend the execution
of the writ of habeas corpus, issue the Emancipation
Proclamation and restore reoccupied States. The above
and much more by Lincoln added, obviously tre-
mendously to Presidential power.
At the end of Theodore Roosevelt’s l/i years in the
White House the American people had quite a new
concept of the Presidency for few men have conditioned
it more!
Theodore Roosevelt felt that the executive power “was
limited only by the specific restrictions and prohibitions
appearing in the Constitution or imposed by Congress”
and rejected the theory that what was necessary for the
nation could be done by the President if he could find
some specific authority to do it. He insisted it was not
only his right but his duty “to do anything that the
needs of the nation demanded unless specifically for-
bidden by the constitution or laws.” It was this broad
and positive concept that he as President could do a
thing unless specifically forbidden to do so rather than
the previous relatively negative stand that he could
only do it if he had definite authorization that added
tremendous power to the Presidency and also character-
ized Theodore Roosevelt’s incumbency.
He also brought to the office the conviction that the
United States could no longer hold herself safe in the
cocoon of isolation and he took America into the world.
He felt that we should take action in the organization
of the affairs of the world. This meant colonies, a
canal in Panama and thrusting the weight of this
nation onto the scales that measured out the balance of
power in Europe.
It was left for Woodrow Wilson, however, to finally
commit this country to major use of Military Power
outside of the United States and when in January, 1918,
he made his famous speech on the Fourteen Points, for
the first time in history arrangements had been made
so that his speech appeared simultaneously in all the
newspapers of all countries. This caused enormous
pressure to be brought for this charter for a new world.
This instant marked the first time that the utterances
of the President of the United States had had impact
upon and vital importance to all the people in the
world. Surely the power and the influence of the
office had gone far since Washington struggled with
his 13 states and four million people.
The history of the Presidency presents no exact
counterpart to Franklin D. Roosevelt's first 100 days
in the White House. That his influence upon the
Presidency during this acutely critical period and during
the war years was great is unquestioned. However, his
period in office is too recent and the emotional tides
regarding him personally still run too high for the
amateur (and, indeed, the professional) to sum up with
justness his expansion of the power. It can be safely
said, however, that Franklin D. Roosevelt added to the
many Presidential roles that of World Strategist.
Thus, on looking back over the 168 years of this
office one must certainly agree with the great Grover
Cleveland when, with his heavy hand, he wrote: “Sir,
it is a solemn thing to be the President of the United
States and we cannot help but think, too, how blessed
we have been by the choices the people have made for
this great honor. Even those men, who in history’s
mercdess and often unjust light are considered to have
428
been weak or inadequate, were all great patriots doing
the best they could and in most cases are seen, on
closer study, to have been caught up in circumstances
beyond their power or abilities to control. Never has
there been question of Presidential loyalty or sincerity.
For 168 years our Presidency has been being built
and molded by great hands, it has been watered by
blood and tears, tempered by time and crises and
warmed by the sun of patriotism until we have in it
today the greatest power the world has ever known — -
being used as the greatest instrument man has yet
devised for peace and individual freedom.
History will show us too that to the really great
Presidents we are now adding another. We are even
more fortunate than we know to have at this time as
our President, controlling the almost unbelievable power
that the office has become, a man of great ability, great
honesty, great sincerity and dignity, great morals and
great heart.
Gentlemen, I think I know why we meet here each
New Year’s Day and I would like to propose a toast
to the Presidency and to the President of the United
States.
AIN’T GOT TIME
Ain’t got time to go a-fishing
Ain’t got time to relax
Ain't got time to sit a-wishing
Got to pay my income tax.
Ain’t got time for my family
Hardly know the children’s names
Ain’t got time to sit and listen
To their tales of childish games.
Ain’t got time to romp and play
Ain’t got time to go to church
Got to work 14 hours every day
Can’t leave my business in the lurch.
Ain’t got time for mirth or laughter
Ain’t got time to take a drink.
Ain’t got time for the hereafter
Ain’t got time to sit and think.
Ain’t got time to hit a golf ball
Ain't got time to sink a putt.
Got to give my very all
To keep the wolf from my hut.
Ain’t got time for a vacation
That’s all foolishness anyway.
I can get my recreation
Doing things that bring in pay.
Ain’t no one can take my place
Ain’t got time for story or fable.
Think I’ll have to step up my pace
Got to make it while I’m able.
Ain’t got— GOOD MORNING, GABRIEL'
C. F. Holton, M.D.
— Journal of the Medical Association
of Georgia, October, 1955.
JMSMS
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prolonged antibacterial action — emollient effect
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~7T (P
AMA Washington Letter
THE MONTH IN WASHINGTON
The Army’s Office of Dependent Medical Care,
handling the new program that offers private
medical care to service families, is working on
some long — and some short-range plans of im-
portance to state societies.
To meet a problem coming up in the next few
months, the office is notifying states that contracts
for physicians’ services, negotiated through the
state societies last fall, will be extended auto-
matically when their expiration date of July
1 arrives. However, there is no definite time
period set for any of the extensions; each contract
will be continued in effect until that particular
state’s agreement has been renegotiated.
When the contract is extended, according to
Maj. Gen. Paul I. Robinson, head of the Office
of Dependent Medical Care, it will be possible
to make necessary adjustments, but he hopes not
too many changes will be asked at that time.
Then, after July 1, each state will be given
60 days’ notification before Defense Department
makes its final audit covering the period from
December 7, 1956, when the program went into
effect, through June 30, 1957. This audit has
been promised in each state before renegotiation
starts.
Both the state fiscal agents and Gen. Robinson’s
staff should be well prepared for renegotiations
when the time arrives. No renegotiations will
be undertaken until January, 1958. They will
continue for most of next year, on a tentative
schedule that calls for handling about five con-
tracts per month.
Under this tentative arrangement, the contract
with the Michigan State Medical Society will be
renegotiated during the month of August.
* * *
If any large-scale health and medical program
is to be pushed through Congress this year, most
of the pushing will be done by the Democrats,
who, in control on Capitol Hill, can get what they
want, in theory at least.
Announcing that the idea of a special presi-
dential health message had been dropped for
this year, Secretary Folsom also said the Republi-
can administration would press for only three
major health-medical bills. All three, incidentally,
were before Congress last year but were not acted
upon. They are:
1. Federal assistance to medical, dental, and
public health schools to help them build and
equip new teaching facilities or improve and ex-
pand existing classrooms or labs.
2. Waiver of the anti-monoply laws to permit
430
small companies (none doing more than one
per cent of the total business) to pool some of
their funds for experimental work in expanding
voluntary health insurance.
3. Authorization for construction of sanitary
facilities on Indian reservations.
In outlining these legislative objectives of the
administration, the Secretary took the opportunity
to make clear he doesn’t think much of one bill
that has the ardent support of some Democrats
and of some labor leaders. It would have the
U. S. pay for sixty days’ free hospitalization an-
nually for persons aged sixty-five and over who
are under social security, and their dependents
if also over sixty-five.
Mr. Folsom said the social security administra-
tion has all it can do administratively to put into
effect the major amendments passed last year,
and that besides the “hospitalization at sixty-five”
plan skirts so close to the area of compulsory
health insurance that it should be regarded cau-
tiously.
NOTES:
A House committee, making a survey of the
cost of veterans’ programs, has been asked by
VA Administrator Harvey Higley to ponder this
question: Should more VA hospitals be con-
structed when we know beyond doubt that they
will be largely for the benefit of non-service-oon-
nected cases? * * *
As anticipated, pressure already is on Congress
to drop or lower the age 50 limit for OASI pay-
ments because of disability. Many bills have been
introduced on the subject.
* * *
Congressmen are hearing again from the friends
of the “Hoxsey cancer cure,” which has been un-
der constant attack by Food and Drug Admin-
istration but still manages to stay in business.
Form cards, carrying space for a name and ad-
dress, are being received on Capitol Hill, each
asking Congress to investigate FDA for the way
that agency has pressured the Hoxsey people.
* * *
An addition to the top echelon of the Depart-
ment of Health, Education, and Welfare is a
young (thirty-three) assistant to Secretary Folsom,
who holds both medical and law degrees. He is
Dr. Robert H. Hamlin, of Brookline, Mass. An-
other HEW addition is John A. Perkins, Ph.D.,
president of the University of Delaware, the new
Under Secretary.
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promoting growth and stimulating
appetite in poorly nourished children.
(Not intended for treatment of perni-
cious anemia.)
Dosage: 1 or 2 teaspoonfuls t.i.d.
Supply: Bottles of 8 ounces and 1 pint.
1 teaspoonful (5 cc.) supplies:
Elemental Iron 38 mg.
(as ferric ammonium citrate and colloidal iron)
Vitamin B,, activity concentrate 4 meg.
Thiamine mononitrate 1.0 mg.
Riboflavin 1.0 mg.
Niacinamide 5 mg.
Pantothenic acid (Panthenol) 1.5 mg.
Pyridoxine hydrochloride 0.5 mg.
Alcohol content: 12 per cent
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April, 1957
Say you saw it in the Journal of the Michigan State Medical Society
431
AMA News Notes
OUTSTANDING MEDICAL MEETING PLANNED
Physicians attending the AMA’s 106th Annual Meet-
ing in New York City June 3-7 will find a star-studded
revue of exhibits, scientific lectures, medical films and
color television programs lined up for their pleasure and
enlightenment. Approximately 18,000 physicians from
all over the country are expected to participate in this
world-famous “short course” in postgraduate medical
education. Focal point of the scientific program will
be the Coliseum — New York’s new exhibition hall —
with four floors devoted to technical and scientific ex-
hibits, many of the scientific meetings and the color tele-
vision program. A number of section meetings plus the
scientific film program will be held in hotels near the
exhibit hall. Headquarters for the House of Delegates
will be the Waldorf Astoria.
An outstanding scientific lecture program is being
arranged by the Council on Scientific Assembly. Kicking
off the general scientific program on Monday morning,
June 3, will be a review of recent progress in surgery
while the afternoon session will deal with recent ad-
vances in medicine. Tuesday morning’s general meet-
ing will feature a discussion on the use and abuse of
mood-altering drugs in daily practice.
Formal section meetings will run from Tuesday after-
noon through Friday morning. Many of the sections
will combine to present special symposiums and panel
discussions. The Section on Miscellaneous Topics is ar-
ranging sessions on allergy, legal medicine with a
mock trial involving the testing of drinking drivers, and
methods of improving communication in medicine. A
number of exhibit-symposiums and question-and-answer
conferences also will be held. Special exhibits on frac-
tures, diabetes, perinatal mortality, pulmonary' function
testing, fresh tissue pathology, arthritis, and nutrition
also will be presented.
The color television program presenting live surgical
procedures from Roosevelt Hospital will again be spon-
sored in co-operation with Smith, Kline & French
Laboratories.
A foreign air is being added to the regular medical
film program for the first time. More than twenty
foreign countries are sending special films dealing with
many aspects of medical science to the “international
medical film program.” Both the international and reg-
ular film programs will be held at the Barbizon Plaza
Hotel.
Registration officially opens at the Coliseum Monday
at 8:30 a.m. and closes Friday noon. Advance regis-
trations will be accepted Sunday from 12 noon to 4:00
p.m. The exhibit hall will be open to “doctors only”
on Tuesday and Wednesday mornings to give physicians
an opportunity to circulate more freely among the
technical and scientific exhibits. For your comfort, the
new Coliseum has many facilities, including air con-
ditioning, escalators, elevators, a cafeteria, and snack
bars.
Physicians and their wives should plan now to attend
this worthwhile medical conclave. Further details will
be published in the Journal of the AMA.
FIRST INTERNATIONAL FILM PROGRAM
A unique selection of foreign-made medical films will
be shown for the first time at the American Medical
Association’s 106th Annual Meeting June 3-7 in New
York City. So far, twenty countries have submitted ap-
plications to this “international medical film program.”
Chief purpose of the program is to bring to the atten-
tention of doctors attending the convention some of the
outstanding motion pictures produced abroad dealing
with many aspects of medicine and surgery. A great
many foreign physicians have already indicated an in-
terest in the program.
Another aim will be to afford representatives of the
United States and foreign countries the opportunity of
discussing the possibilities of lifting existing customs
barriers which make it practically impossible to exchange
such motion pictures.
This program has been arranged by the AMA in
co-operation with Johnson and Johnson, New Bruns-
wick, N. J. Mr. Ralph Creer, director, AMA Motion
Pictures and Medical Television, and a special commit-
tee have been screening more than 75 applications with
an eye to selecting the most unusual and varied program
for physicians.
The international exhibition and the regular program
of domestic scientific films will be held in separate rooms
of the Barbizon Plaza Hotel, located within two blocks
of the Coliseum.
AUXILIARY WINNERS IN “TODAY’S
HEALTH” CONTEST
Winners in the Today’s Health “Operation Christmas”
subscription contest recently received ten dollar checks
as prizes for their outstanding efforts. The 1956 win-
ning auxiliaries include: Group I — Washington County,
Oregon; Group II — Indiana County, Pennsylvania;
Group III — Escambia County, Florida; Group IV — Los
Angeles County, California.
TWO NEW EXHIBITS AT JUNE MEETING
Two new AMA scientific exhibits designed primarily
for physicians will be unveiled at the Annual Meeting
in June in New York City. These displays are being
prepared jointly by the Bureau of Exhibits and ( 1 ) the
Bureau of Health Education and (2) the Council on
Foods and Nutrition. Both will be available on a loan
basis to medical societies after the Annual Meeting.
1. “Health Appraisal of the School Child”- — presents
five factors involved in a complete appraisal program,
including teacher observation, screening procedures, den-
tal and medical examinations, and the follow-through. A
(Continued on Page 438)
432
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April, 1957
Say you saw it in the Journal of the Michigan State Medical Society
43 3
PR REPORT
NATION APPLAUDS MUSKEGON’S
ACTION
On Wednesday, February 27, the entire nation
heard the story of how the Muskegon County
Medical Society had come to the aid of one of its
members. This is the story.
Edward V. Williams, M.D., became ill on
Sunday, February 24. It was tuberculosis. The
next day he was sent to a sanitarium where it
was expected he would spend at least six months.
This meant that Dr. Williams’ large practice
would have to be covered by others during his
absence.
A special meeting of doctors — members of the
Muskegon County Medical Society — was called
for Monday night and the entire Society met in
special session Tuesday evening to consider what
might be done for their colleague and for his
patients. The president, Emil J. Lauretti, M.D.,
appointed a special committee which was
scheduled to meet the following night.
The committee, composed of R. T. Allen, M.D.,
H. Clay Tellman, M.D., Norbert W. Scholle,
M.D., Norman A. Fleishman, M.D., and Ralph
V. August, M.D., took this action:
1. The Society has made this committee avail-
able to Dr. Williams and through it desires to
help him on all problems, including personal
finances, which he wishes to present to it.
2. The committee recommends that Dr.
Williams consider the placement of his office
finances and collections with a professional or-
ganization.
3. The committee recommends that the mem-
bers of our society on a voluntary basis forward
to the County Society treasurer a sum equal to
twenty-five per cent (25%) of their collections
from the care of Dr. Williams’ patients during
the ensuing six (6) months. This total sum to
be forwarded by the County Society to Dr.
Williams.
4. The committee recommends that the Presi-
dent of our Society forthwith appoint a committee
for the express purpose of inducing negro
physicians to settle here and practice in our midst.
5. The committee recommends that the Society
investigate the availability of financial assistance
to newly situated practitioners in our community.
And as a quick public relations follow-up, the
Committee issued the following press release:
The Muskegon County Medical Society regrets
the sudden illness of Dr. Williams and sympathizes
with his patients in their loss from active practice
of an able physician and a friend. We also will
miss the work of a fine colleague and friend. The ■
medical society through the individual physicians
offices, the emergency services of Mercy and
Hackley Hospitals and the emergency medical
telephone service will provide medical service for
Dr. Williams’ patients.”
As a result of the Society’s speedy and con-
siderate actions, the nation’s attention was focused
on Muskegon. The NBC radio network, AP and
UP wire services, local newspapers and large
dailies all carried the story.
The Detroit Free Press, on March 4, 1957,
made this editorial comment in tribute to the
humanitarian principle for which the medical pro-
fession stands.
MUSKEGON GIVES A TELLING REBUKE
The press of the entire country has carried the story
about members of the Muskegon County Medical Society
taking over the practice of a Negro doctor who has
been stricken with tuberculosis.
Eighty Muskegon doctors, most of them white, have
agreed to look after the patients of Dr. Edward Williams
for the year in which he will be confined in a sanitarium.
They are working out a schedule to handle his office j
calls, and the fees will go to the ill physician.
This wouldn’t particularly be news if the chief figure
in the story wasn’t a Negro and the other doctors white.
That sort of thing under somewhat different circum-
stances is common practice in the medical profession
as well as in other categories of human relationships.
The incident attracted attention only because it
revealed that decent feelings of humanity know no
barrier of race or creed. It stands as a sharp rebuke to
the purveyors of hate wherever they may be plying
their insidious trade. — Reprinted from The Detroit Free
Press.
OPERATION ARMOR
Early in March, the MSMS Operation Armor
spotlight turned its focus to the fourteen to forty
age group, when appeals went to all county
medical societies for help in overcoming this seg-
ment of the public’s apathy towards polio im-
munization.
Latest reports indicate paradoxically that the
overwhelming success of this second phase of
the Michigan M.D.s’ campaign to stamp out polio
might have replaced a January glut of Salk
vaccine with a March shortage.
The component county medical societies pro-
posed various publicity and immunization plans,
reflecting divergent needs and conditions in
different parts of the state. In the majority of
cases, however, such as in Lapeer, Shiawassee,
Macomb, Van Buren, Wayne and Ingham
counties, patients were urged, through the press,
radio and TV, to get their shots in their doctors’
(Continued on Page 442)
434
JMSMS
Proper formula for treating “Rheumatism" patients
With TEMPOGEN, many patients obtain adequate
relief from immobilizing “rheumatic” pain with
lower hormone dosages than are ordinarily
required, because of the enhanced antirheumatic
effect provided by the prednisolone-salicylate
combination. In addition, the likelihood of the
occurrence of gastric distress or adrenal ascor-
bic acid depletion is minimized.
INDICATIONS: Early rheumatoid arthritis, rheu-
matoid spondylitis, osteoarthritis, Still’s disease,
psoriatic arthritis, bursitis, synovitis, tenosynovi-
tis, myositis, fibrositis, and neuritis.
Supplied: TEMPOGEN® and TEMPOGEN® Forte-in bottles of 100 Multiple Com-
pressed Tablets. (TEMPOGEN Forte provides 2 mg. of prednisolone.) TEMPOGEN
and TEMPOGEN Forte are trademarks of Merck & Co., Inc.
*present as 60 mg. sodium ascorbate
MERCK SHARP & DOHME
DIVISION OF MERCK ft CO.. INC. PHILADELPHIA 1. PA.
April, 1957
Say you saw it in the Journal of the Michigan State Medical Society
435
AMA Annual Congress on Medical Education
At the recent meeting of the Congress on
Medical Education, held February 9-12, 1957, at
the Palmer House, Chicago, both H. G. Weis-
kotten, M.D., chairman, and Edward L. Turner,
M.D., secretary, Council on Medical Education
and Hospitals of the American Medical Associa-
tion, stressed the urgency and desirability of pro-
viding more adequate graduate education for
General Practice. It was evident from their
language that they were stating the official policy
of the AMA. William Hildebrand, M.D.,
Menasha, Wisconsin, former president, American
Academy of General Practice, outlined what he
believed to be adequate graduate education for
the generalist. The traditional year of rotating
internship, followed by an intensified year of
residency with the same status accorded the
general practitioner as the residents in the various
specialties enjoy, is projected as a start. He
stressed the necessity of developing a degree of
clinical judgment that would enable the generalist
to recognize his limitations as well as his
capabilities. Hospital privileges must be increased
as the demonstrated abilities of the generalist
increase.
A very interesting panel discussion followed on
what should constitute graduate education for
general practice today, from the point of view
of the leading specialties. William B. Bean, M.D.,
Professor of Medicine, State University of Iowa,
College of Medicine, spoke for Internal Medicine.
Charles B. Puestow, M.D., Clinical Professor of
Surgery, University of Illinois College of Medi-
cine, presented the attitude of Surgery. Pediatrics
was represented by Philip S. Barba, M.D.,
Associate Professor of Pediatrics, School of Medi-
cine and Graduate School of Medicine, Univer-
sity of Pennsylvania. Obstetrics and Gynecology
had their point of view explained by Lawrence
M. Randall, M.D., Professor of Obstetrics and
Gynecology, Mayo Foundation, Graduate School
of Medicine, University of Minnesota; chairman,
Section on Obstetrics and Gynecology, Mayo
Clinic. M. Ralph Kaufman, M.D., Clinical Pro-
fessor of Psychiatry, Columbia University College
of Physicians and Surgeons; Chief of Psychiatry,
Mount Sinai Hospital, New York City, spoke for
Psychiatry.
Most of the panelist expressed the opinion that
a relatively large share of their specialty could be,
more or less, adequately covered in the available
time. The exceptions were the surgeon and the
psychiatrist. Dr. Puestow stated he was un-
alterably opposed to any program that contem-
plated anything less than four years of surgical
training. He voiced strenuous opposition to turn-
ing out half-trained surgeons. Dr. Kaufman was
doubtful that his specialty could contribute enough
436
of its discipline to be worthwhile in the projected
residency for the generalist.
Since the majority of patients will, in the fore-
seeable future, continue to be cared for by the
generalist, it is imperative that ways and means
be found to more adequately prepare our gradu-
ates who are entering general practice. The
specialties, particularly surgery and psychiatry,
should become more realistic. At the present
time 80% of surgery is done by generalists, there-
fore, any amount of training is bound to improve
the situation. There will never be enough
psychiatrists, in all probability, to treat the ever
increasing load of mentally disturbed, so even a
minimum of instruction in this field will improve
patient care.
This entire subject of more adequate training
in general practice residencies, as well as sub-
sequent hospital privileges will, without doubt, be
incorporated in numerous resolutions to be intro-
duced at the forthcoming House of Delegates
Meeting of the AMA in New York in June.
F. P. Rhoades, M.D.,
Member MSMS Postgraduate
Medical Education Committee
PR DOCTOR TIP OF THE MONTH
Many county medical societies have found interpro-
fessional meetings with other health groups to be in-
valuable in solving mutual problems or settling be-
tween-profession conflicts. Instead of waiting for the
suggestion of a meeting to come from another group —
why not evaluate your 1957 PR agenda right now.
Have you scheduled meetings with local lawyers, dentists
and pharmacists?
AMA ADVANCE REGISTRATION CARDS
Invitations, including a request form for an advance
registration card for the American Medical Association
New York meeting, June 3-7, have been mailed to
44,000 member physicians in seven eastern states —
Connecticut. Delaware, Massachusetts, New Jersey, New
York, Pennsylvania, and Rhode Island.
A total of 1,513 requests for advance registration cards
have been received from AMA members to date and
it is expected that 4,000 more requests will be received
between now and April 20 when the convention program
will be published in the AMA Journal.
Physicians are reminded that they can speed up their
trip through the registration area by requesting and
receiving an advance registration card before May 10.
The technical and scientific exhibits at the New York
Coliseum will be open from 8:30 a.m. Monday, June 3,
and daily thereafter from 8:30 to 5:30, closing at noon
on Friday, June 7.
On Tuesday, June 4, and on Wednesday, June 5, the
technical and scientific exhibits will be open ONLY to
AMA member physicians from 8:30 a.m. until 12 noon.
JMSMS
Knox “Choice of Foods” Diet Can Help Your
CARDIAC Patients Lose Weight Successfully
1. Color-coded diets of 1200, 1600 and 1800 calories are
based on nutritionaHyrSound Food Exchanges.1
2. Easy-to-use Food Exchanges (referred to in the Knox
booklet as Choices) eliminate calorie counting by patient.
3. Diets promote accurate adjustment of caloric levels to
the special needs of the patient yet allow each individual
considerable latitude in the choice of foods.
4. More than six dozen appetizing, low-calorie recipes are
presented on the last 14 pages of each diet booklet.
1. The Food Exchange Lists referred to are based on material in
“Meal Planning with Exchange Lists” prepared by Committees of
the American Diabetes Association, Inc., and The American Dietetic
Association in cooperation with the Chronic Disease Program, Public
Health Service, Department of Health, Education and Welfare.
Chas. B. Knox Celatine Co., Inc.
Professional Service Dept. Sl-24
Johnstown, N. Y.
Please send me dozen copies of the new illus-
trated Knox Reducing booklet based on Food Exchanges.
Your Name and Address
April, 1957
Say you saw it in the Journal of the Michigan State Medical Society
437
Cancer Comment
MICHIGAN CANCER CO-ORDINATING COMMITTEE
MAKES PROGRESS THROUGH UNITY
The Michigan Cancer Co-ordinating Committee
was created November 12, 1953, as a voluntary,
co-operative effort of representatives of the fol-
lowing State agencies interested in cancer control:
For further information and copies of publica-
tions, write Michigan Cancer Co-ordinating Com-
mittee, attention of William J. Burns, Secretary,
Box 539, Lansing 3.
American Cancer Society, Michigan Division, Inc.
American Cancer Society, Southeastern Michigan
Division
Michigan Department of Health
Michigan Health Officers Association
Michigan State Dental Society
Michigan State Medical Society
During its early years, the Cancer Co-ordinating
Committee justified its existence by encouraging
more cancer education — both professional and
public. It also urged each of its component mem-
bers to further their endeavors in a co-ordinated
non-overlapping program in line with its purpose
to help develop and maintain a more efficient and
effective, complete dynamic cancer control pro-
gram in Michigan.
The Michigan Cancer Co-ordinating Committee
activates its member organizations to greater effort
in the fight against cancer. It is in effect a
“stimulator” of activity on the part of the for-
malized groups which compose it.
Publications of the Michigan Cancer Co-
ordinating Committee for the public include:
The Story of Cancer For High Schools
Strength Through Unity Against Cancer
The personnel of the Michigan Cancer Co-
ordinating Committee for 1957 is:
Name
H. M. Nelson, M.D.,
Chairman
Charles F. Arnold
,T. A. Cowan, M.D.
M. A. Darling, M.D.
Mr. W. F. Doyle
J. D. Heaslip, M.D.
L. E. Holly, M.D.
W. A. Hyland, M.D.
J. W. Hubly, M.D.
W. A. Irwin, M.D.
B. E. Luck, D.D.S.
C. Allen Payne, M.D.
E. T. Thieme, M.D.
438
Organization
S.E. Mich. Div., American
Cancer Society
S.E. Mich. Div., American
Cancer Society
Michigan Department of Health
S.E. Mich. Div., American
Cancer Society
Michigan Div., Inc., American
Cancer Society
Michigan Health Officers Asso-
ciation
Michigan Div., Inc., American
Cancer Society
Michigan State Medical Society
Michigan State Medical Society
Michigan State Medical Sociep
Michigan
tion
Michigan
State Dental Associa-
Div., Inc., American
Cancer Society
Michigan State Medical Society
AMA NEWS NOTES
(Continued from Page 432)
series of colored slides demonstrating each of these major
phases also will be presented. This exhibit will be of
interest not only to the medical profession but also to
educators and other allied health leaders.
2. “Foods in Oral Electrolyte Therapy” — designed
primarily for the general practitioner who is concerned
with electrolyte therapy in the non-hospitalized patient.
Purpose of the display is to remind physicians that
foods are useful in electrolyte replacement. The exhibit
is diveded into three major categories: (a) common
clinical conditions causing deviation from the normal;
(b) examples of foods useful for replacement therapy,
and (c) advantages of oral administration of these
elements.
HEALTH EXHIBIT GOOD DRAWING CARD
The first public showing of AMA’s new health ex-
hibit “We Hear” brought an enthusiastic response from
visitors at the Florida State Fair in Tampa, January 29
through February 9. Most popular feature of the ex-
hibit was the “test your hearing” booth which drew
some 27,000 participants. Both the “We Hear” and
“We See” exhibits were sponsored jointly by the
Florida Medical Association and the Hillsborough Coun-
ty Medical Association. Other medical societies inter-
ested in showing health exhibits at local fairs should
contact the AMA’s Bureau of Exhibits as soon as possi-
ble. Many spring and summer bookings have already
been arranged.
The most important single technique in brain tumor
diagnosis is ophthalmoscopic examination, but before
it or any other diagnostic procedure is undertaken
suspicion of tumor must be planted in the physician’s
mind.
* * *
Only by employing adequate diagnostic measures
can the offices of physicians and dentists become effec-
tive cancer detection centers.
* * *
In many cases of bladder tumor, symptoms of pros-
tatitis and prostatic hypertrophy are frequently encoun-
tered.
* * *
Seminomas of the testes usually occur during the years
of greatest sexual potency.
JMSMS
new physiologic iron chelate for
.
hematologic
response — avoids interruption, of
therapy
due to g. i. irritation
guards against iron
TT
poisoning from accidental overdosage
FERROUP
(Iron Choline Citrate*)
for the clinical and
experimental proof, write for
complete literature
chelated iron for effectiveness
plus “built-in” tolerance and safety
TABLETS — 3 tablets supply 120 mg. of iron DROPS-Each cc. provides 16 mg. of iron
and 360 mg. of choline base. Adults: 1 or 2 and 48 mg. of choline base. M.D.R. for in-
tablets t.i.d.: Children, 1 tablet t.i.d. fants and children up to 6 years is 0.5 cc.
SYRUP — 6 teaspoonfuls supply 120 mg. of Supplied: Tablets: Bottles of 100 and 1000;
iron and 360 mg. of choline base. Adults: 2 Syrup: Pints and gallons; Drops: 30-cc.
to 4 teaspoonfuls t.i.d.: Children, 2 tea- dropper bottles,
spoonfuls t.i.d.
EATON <£ COMPANY
*U. S. Pat. 2,575,611
April, 1957
Say you saw it in the Journal of the Michigan State Medical Society
439
National Blue Shield Professional Relations Conference
“A strong Blue Shield is vital to the freedom
of medical practice, and an understanding physi-
cian is vital to Blue Shield.” This was the under-
lying theme of a highly successful “professional
relations conference” held by the national asso-
ciation of Blue Shield Medical Care Plans in
Chicago, February 11-13, 1957.
Some 110 Blue Shield professional relations di-
rectors and staff members were joined by more
than seventy physician-trustees of local Blue Shield
Plans and thirty-five executive secretaries of spon-
soring county and state medical societies. The
conference was conducted by the national Blue
Shield Professional Relations Committee, whose
Chairman is Dr. Fredrick H. Good of Denver,
President of the Colorado Blue Shield Plan.
Keynoter of the conference was Dr. Robert L.
Novy, of Detroit, national President of Blue
Shield Medical Care Plans who emphasized that
the ideals and purposes of Blue Shield are pre-
cisely the same as the age-old ideals and purposes
of medicine: to serve people singlemindedly, re-
gardless of personal profit.
“Blue Shield safeguards the basic freedoms of
medical practice which are fundamental to good
medical care,” Dr. Novy said. “Blue Shield hopes
to strengthen the doctor’s traditional way of
practicing medicine, not to change it or destroy it.
Blue Shield protects the patient’s right to choose
his doctor, the doctor’s right to accept or reject the
patient, and their common right to an inviolate
confidential relationship.”
Dr. Novy pointed out that in the fifteen years
since Blue Shield was created, a whole new gen-
eration of doctors has come into practice who
know nothing of the struggle and sacrifice of its
founders. Many of these doctors take Blue Shield
for granted, and the success of Blue Shield has
even led many of their older colleagues to take
it for granted, too.
Indifference, apathy and complaisancy can be
fatal to Blue Shield and to the whole voluntary
medical care prepayment program. “Blue Shield
deserves the doctor’s wholehearted support be-
cause it is fashioned in the doctor’s own image;
it is his own creation; and it is designed to
strengthen the freedoms that he and his patients
want to keep strong and safe,” Dr. Novy con-
cluded.
Joint Blood Council
Frank E. Wilson, M.D., Washington, D. C.,
executive vice president of Joint Blood Council,
announced launching of a nationwide survey of
blood transfusion services. The two-year study,
made possible by a Public Health Service grant
of $50,000. will collect, analyze and disseminate
information of vital importance in normal peace-
time blood banking as well as in civil and military
defense planning.
A census of the country’s blood collection and
distribution facilities will be only one phase of this
survey, the most comprehensive in its field ever
conducted. Among its objectives are preparation
of guidelines and standards for accreditation of
blood banks, development of a glossary of terms
and solution of numerous nomenclature problems,
inventory of research in blood and blood deriva-
tives, and the assembling and analysis of needed
data appertaining to these objectives.
Questionnaires and field sampling will be the
principal media of the survey.
Dr. Wilson will serve as study director, with
Mr. Paul T. Rees as associate director. The latter,
a resident of Arlington, Va., was for nine years
sales manager and director of trade relations for
a national pharmaceutical house following his re-
tirement from the Navy. During World War II
he was in charge of the materiel section of the
Navy’s whole blood program.
A national postal card survey, which is a pre-
liminary screening for the main study, already is
under way and the response has been excellent,
said Dr. Wilson. In January nearly 10,000 cards
were sent to hospitals, clinics and other institutions
asking how many transfusions were given to pa-
tients. In each instance information was requested
on sources of blood used — that is, whether it was
obtained from Red Cross, a community blood col-
lection agency, or some other facility, or whether
or not procured by the using institution.
A project advisory committee of representatives
from the Council’s member institutions and re-
search consultants will guide the survey.
Joint Blood Council, established in 1955 with
headquarters in Washington, D. C., is a voluntary
organization incorporated by five nonprofit agen-
cies. These are American Medical Association,
American Association of Blood Banks, American
Hospital Association, American National Red
Cross and American Society of Clinical Pathol-
ogists.
440
JMSMS
symptomatic relief. . . plus!
ACHROCIDIN
TETRACYCLINE-ANTI HISTAMINE- AN ALGESIC COMPOUND
tablets and syrup
Achrocidin provides early effective therapy for
undifferentiated upper respiratory infections, espe-
cially in the very young and very aged; nephritics;
susceptibles to recurrent middle ear and sinus in-
fections; those with diabetes, chronic pulmonary
diseases, bronchial asthma of the infectious type,
rheumatoid or rheumatic disorders.
In addition to rapid symptomatic improvement,
achrocidin offers prompt, potent control of the
bacterial component frequently responsible for com-
plications leading to prolonged disability in sus-
ceptible individuals.
Adult dosage for achrocidin Tablets and new,
caffeine-free achrocidin Syrup is two tablets or
teaspoonfuls of syrup three or four times daily.
Dosage for children according to weight and age.
Available on prescription only
Each tablet contains:
Achromycin® Tetracycline
Phenacetin
Caffeine
Salicylamide
Chlorothen Citrate
‘Trademark
125 mg.
120 mg.
30 mg.
150 mg.
25 mg.
LEDERLE LABORATORIES DIVISION.
April, 1957
Say you saw it in the Journal of the Michigan State Medical Society
COMPANY, PEARL RIVER.
NEW YORK
441
AMERICAN CYANAMID
Editorial Opinion
THE IDEAL PHYSICIAN
What makes “an ideal physician?” Dr. P. H.
Woutat of Grand Forks, North Dakota, has pro-
vided his answer, and it’s a compelling one.
The ideal physician, first, must he a man of
top abilities, faultless personal habits, and the
talent to inspire confidence and respect in others.
He must be active in community affairs of all
kinds, and a frequent church goer.
He must be available to service, educational,
religious and other groups which are seeking
reliable information on medical subjects.
He must work on and contribute liberally to
fund raising campaigns for hospitals, young
peoples’ organizations, homes for the aged,
charities and other good works.
He must be active in local and state medical
societies and must be faithful in attendance at
hospital staff meetings, as a participant and
educator.
He must be a good family man, “with a gracious
and tactful wife who abhors mink coats and other
vulgar extravagances ...”
Finally Dr. Woutat says: “But above all this, he
must never fail to give his patients the finest
possible medical service, keeping abreast of medical
progress by reading, attendance at medical meet-
ings, and taking frequent postgraduate courses.
He must be a tireless worker and improve his
public relations by spending adequate time with
his patients, answering urgent calls promptly, day
or night, and by not keeping his patients waiting.
This must all most certainly be done for what
has been vaguely defined as a reasonable fee.”
All over the country, thousands of doctors are
doing a splendid job of living up to such high
standards as these. — Grandville Star & Alliance,
January 18, 1957.
HAVE YOU THOUGHT OF THIS?
This page has been used to protest certain prac-
tices indulged in by insurance companies. It
should be a welcome change to commend a few
of the many sound principles that have made their
existence so necessary to all segments of our
Society.
Our national economy has as an important cor-
nerstone the tremendous investments of its citizens
in insurance. The wage earner is attracted to life
insurance as a means of current protection for
himself and his family, and the anticipated future
benefit of assured income in retirement. Means
of current protection, aside from life insurance, are
442
hospital and health and accident policies. These
facts are obvious, and there is no intent to repeat
what every insurance agent can do much more
thoroughly and competently.
The impact of compulsory health insurance
upon this structure is a cause for real concern.
It is not one that has been widely publicized. As
an aside, the word “compulsory” is the only honest
word in that phrase. It is not “health” but sick-
ness,— as it is not “insurance” but taxes. The in-
surance principle is decidedly within the frame-
work of our system of government. It helps our
country and our country helps it. The adoption
of an alien philosophy would lead to an inferior
quality of patient care.
It would also seriously weaken the financial
position of actuarial companies. This could bring
about government control. Thus it is the patient
and policyholder who will suffer. This is the rea-
son our profession has fought this issue. Alas,
there is a widespread opinion — in and out of the
profession— that doctors oppose this type of legis-
lation for the selfish motives of curtailed income
and privilege. If this were true, we would be false
to our heritage and singularly naive. Our system
of government can only thrive on the principle of
the greatest good to the greatest number. This
adage was true at the dawn of our country; it is
equally valid today. In the wide area of defense
of democratic principle, the leaders of the medical
profession and the leaders of the insurance profes-
sion are dedicated to a common goal.
— Ralph A. Johnson in Detroit Medical News
OPERATION ARMOR
(Continued from Page 434)
offices; and special “Immunization Days, or
Weeks” were set aside, during which all applicants
would get immediate consideration.
In other areas, such as in Wexford, Missawkee
and Saginaw counties, M.D. -staffed clinics were
set up in factories, schools and churches, operated
on a mass basis.
In all cases, as reported above, the public re-
sponse to Operation Armor has been phenomenal.
There is every indication that close to 100 per
cent “coverage” will be achieved by year-end as
a result of this all-out drive. M.D.s and their
patients are again proving the adage: “An ounce
of prevention is worth a pound of cure.”
JMSMS
H'kt JOU R M A t
of the Michigan State Medical Society
Issued Monthly Under the Direction of The Council
VOLUME 56 APRIL, 1957 NUMBER 4
Cancer Registries
I. Purposes and Functions
By Harry M. Nelson, M.D. and E. R. Jennings, M.D.
Detroit, Michigan
TNTEREST in the development of individual
hospital cancer registries has been stimulated
by the requirement of the American College of
Surgeons that institutions, to meet the minimum
standard for approval of a cancer program, must
maintain a registry of all patients on whom a
diagnosis of cancer is made.
In the manual published by the American Col-
lege of Surgeons on such activities, the following
appears :
“It shall be a requirement (after December 31,
1955) for approval that a properly functioning cancer
registry be in operation which records every patient,
private and public, inpatient and outpatient, upon
whom a diagnosis of cancer is established. This may
be the only formal cancer activity conducted.
“Each year a report will be made to the medical
staff of the current work of the registry, including five-
year end results as they become available through con-
tinuing follow-up.”
This is an extension of the original require-
ments for an approved clinic (i.e., the consultative
principle as related to the diagnosis and treatment
of cancer) as carried out by the College during
the past two decades. This addition makes it man-
datory that the records of all cancer patients be
reviewed periodically, from the standpoint of
diagnosis, therapy and follow-up, by a committee
of the medical staff of the hospital.
Dr. Nelson is Chairman of the Michigan Cancer Co-
ordinating Committee.
Dr. Jennings is President-elect of the Michigan Path-
ological Society.
April, 1957
In 1 956, the American College of Surgeons ap-
proved 713 cancer clinical facilities. This is an
increase of fifteen programs over 1955 and has
been achieved in spite of the mandatory require-
ment that an operating cancer registry has been
a prerequisite for survey since January 1, 1956.
Several large institutions in Michigan have con-
ducted tumor registries and follow-up services for
years. The purposes of these registries are to ob-
tain information on the incidence and results of
treatment on all cancer cases within the institu-
tion. Generally, these registries provide only the
simple basic information which serves as a guide
to find those cases on which detailed research is
to be done.
The philosophy of the individual hospital regis-
try as now required by the American College of
Surgeons, is essentially that of a medical audit for
cancer patients; i.e., it provides a tool for
measuring the quantity and quality of medical
care provided for cancer patients in a given in-
stitution.
The cancer registry is interested primarily in
helping the patient who has cancer. It does this
in several ways. First, it provides assistance for
periodic follow-up examinations. Second, it
makes possible the early detection of recurrent or
metastatic disease which might have been missed
or ignored. Third, it leads to the evaluation of
results of treatment and in the end helps to deter-
mine the best method of cancer therapy.
By requiring accurate information about his-
tologic diagnosis, clinical extent of the disease,
449
CANCER REGISTRIES— NELSON AND JENNINGS
methods of treatment and other data, the cancer
registry encourages better medical records. In
simplest terms, it may be thought of as a mirror
which reflects to the hospital staff what is good
and what is bad with respect to the diagnosis and
treatment of cancer in their institution.
Those institutions that have conducted cancer
registries for years, and the many which started
their registries recently, are already aware of its
advantages and shortcomings. However, it pro-
vides only an appraisal of its own activities; i.e.,
a comparison with itself over a period of years.
The central registry, which provides for the
pooling of records from a group of hospitals, per-
mits not only evaluations within its participating
institutions but also between these institutions. It
is apparent from the experiences of several cen-
tral registries now in operation that this type of
evaluation is an important stimulus to the im-
provement of medical care for cancer patients.
Without any hindrance or censure or undue con-
demnation, the central registry can simply file the
facts as they prevail, hospital by hospital, and a
mere distribution of these facts to the hospitals
provides the stimulus for advancement in cancer
control activities.
The primary purpose of a central registry is to
serve as a foundation for the cancer control pro-
gram of the geographic area covered by the par-
ticipating hospitals. It is a basic tool for measur-
ing the magnitude of the cancer problem and
for evaluating the effectiveness of control meas-
ures. It is clear that only in such measure as the
program approaches 100 per cent participation on
the part of the hospitals in the area can it achieve
its full value and purpose. The development of
a system in which the cancer records from a group
of participating hospitals are pooled in a central
registry provides for more uniformity in reporting
and operating procedures than would be possible
if each hospital were to develop its own registry
individually and independently. The quantity of
material available for analysis will be such as to
greatly enhance the value of the findings.
The basic objectives of a central registry are:
( 1 ) to provide a readily available source of con-
sultative and supervisory assistance in the estab-
lishment and maintenance of the registries in the
individual hospitals participating in the program;
(2) to establish a clearing house and cross-refer-
ence file of information which will facilitate the
follow-up of cancer patients in each of the par-
ticipating hospitals, and (3) to compile data and
prepare analyses on an area-wide, as well as on
an individual hospital, basis.
The central registry does not presume to take
the place of or carry out any of the major re-
sponsibilities of the individual hospital registry.
However, it can be a real asset to the successful
functioning of a group of hospital registries. For
example, the authority and responsibility for the
development of a hospital registry rests with the
Cancer Committee of that hospital. The experi-
ence of a small central registry staff, derived from
assisting in the development of a number of hos-
pital registries, is of value in the month-by-month
maintenance and operation of such facilities. In
the matter of follow-up, the individual hospital
registry is responsible for maintaining contact with
each of its patients. A central registry, however,
can provide for each participating hospital a
routine periodic list of cancer deaths, as well as
information on other individual cases (received
from various sources), thus facilitating the work
of a follow-up in the individual hospital. If the
central registry is developed to the point of in-
cluding IBM equipment for the mechanical
handling of mass data, it can prepare summaries
not only of its total operation, but analyses of in-
dividual hospitals, that would be extremely time-
consuming, if not entirely impossible, for the in-
dividual hospitals to undertake.
There are a few basic principles which should
be considered in the development of a successful
central registry program : ( 1 ) that it must have
complete backing and active participation of all
organized medical groups; (2) that it have the
continuing counsel and guidance of a committee
representing these groups for setting policy and
ground rules on the responsibility and authority
for the collection, maintenance, use, and final dis-
position of cumulative records, and (3) that the
important work of a central registry should not be
allowed to become snarled up in such tangles of
the legal implications involved in reporting in-
formation.
The Michigan Cancer Coordinating Committee,
which consists of six major groups primarily in-
terested in the control of cancer, has endorsed the
work of the American College of Surgeons Com-
mittee on Cancer Program in Hospitals. The or-
ganizations represented in the Coordinating Com-
(Continued on Page 470)
450
JMSMS
The Michigan Tumor Registry
An Historical Survey
Isidore Selzer, M.D.
Detroit, Michigan
TTTHILE the Michigan Tumor Registry was
* * founded in 1949, its actual operation be-
gan in 1950. With a six-year-experience, it was felt
that an historical review of the Registry’s organiza-
tion and a survey of its operations would prove of
interest to the medical profession of Michigan
and serve as a small contribution to the history
of medicine in Michigan, especially as it relates
to cancer control in this state.
The formation of a Tumor Registry in Michi-
gan followed a pattern, which had already been
established on both a state and national level.
With the development of state cancer control
programs, the importance of having information
concerning the incidence of cancer became readily
apparent. It was in conjunction with the or-
ganization of its cancer control program in 1926
that Massachusetts became the first state to estab-
lish a tumor registry. Since then tumor registries
have been developed as an adjunct to, or as a
fundamental part of, the cancer control program
in such states as Alabama, Connecticut, New
York, New Jersey, Kentucky, Rhode Island,
Washington, Pennsylvania and Utah.
Although all of these state tumor registries
have in common, as one of their chief aims, some
form of case-finding or case reporting, they never-
theless exhibit certain fundamental differences in
their underlying philosophy, especially those per-
taining to organization, method of operation and
administrative control.
In Connecticut1 and Massachusetts,2 reporting
of cases is carried out by hospitals and tumor
clinics. The accumulated data is centralized in
the state health department, division of cancer
and other chronic diseases. This is encouraged
in part by state aid to the hospitals and tumor
clinics.
In Kentucky,3 Rhode Island4 and New York
State5 (exclusive of New York City), data are
accumulated by direct reporting of cases to the
state health department by practicing physicians
and hospitals. In these states, reporting of cancer
has been made mandatory by a legislative act
(New York, Rhode Island), or state board of
health regulation (Kentucky).
In 1939, the Pennsylvania Plan6 of the state
department of health established a division of
cancer control and declared tumors reportable
diseases. Since mere reporting of the tumors was
considered inadequate, it was decided to obtain,
on a voluntary basis, clinical information as well
as pathologic material concerning the tumors re-
ported. It is this latter feature, i.e., the voluntary
registration of tumor specimens and clinical his-
tories, which made this plan unique, and it is this
feature which has been followed in New Jersey,7
Alabama8 and Washington.9 The Pennsylvania
Tumor Registry ceased to function in 1941.
In Utah,10 cancer was declared a reportable
disease in 1947. However, due to the inadequate
response to compulsory reporting, the Tumor
Registry was organized in 1951 to undertake active
case-finding through hospital and laboratory
records and through data of the state health de-
partment statistics division. The Utah Tumor
Registry also is no longer functioning.
On the national level, the registries which have
developed are tissue, i.e., Pathology Registries, in
contrast to the state registries which are concerned
chiefly with case-finding and statistical analysis.
The national registries, the first of which was
formed in 1922, represent almost every branch
of medicine and surgery. They are sponsored by
national medical and professional organizations
and are maintained at the Armed Forces Institute
of Pathology. These registries are supervised by
the American Registry of Pathology11 which is a
department of the Armed Forces Institute having
liaison with the National Research Council and
National Academy of Sciences.
The Michigan Tumor Registry follows that
aspect of the Pennsylvania Plan dealing with the
voluntary registration of tumor specimens, i.e.,
its policy is to collect and register specimens of
tumor tissue and related clinical data submitted
Dr. Selzer is Director of the Michigan Tumor Registry.
April, 1957
451
MICHIGAN TUMOR REGISTRY— SELZER
voluntarily by the practicing pathologists in the
state. Thus, it incorporates on a statewide level,
some features of the national specialty registries.
The organization is unique in that its support has
come entirely from voluntary nongovernmental
agencies. It is important to emphasize that the
Michigan Tumor Registry is a tissue registry and
that registration of cases is entirely voluntary.
The Michigan Tumor Registry was organized
upon the initiative of the Michigan Pathological
Society after a report to the Society by Dr. A.
James French, Professor of Pathology at the Uni-
versity of Michigan Medical School, based upon
information gained from his experiences as Con-
sultant at the Army Institute of Pathology (now
Armed Forces Institute of Pathology). In 1947,
a committee was appointed by the president of
the society to study existing state and national
registries and to recommend a plan for a registry
to be sponsored by the Michigan Pathological
Society. Following a comprehensive survey by this
committee under the direction of Dr. French,
plans were presented to the Society for its con-
sideration. The study and consideration of these
plans extended over a period of nearly two years,
following which the plans were approved and
adopted by the Society.
In February, 1949, the Pathological Society, at
the suggestion of its Tumor Registry Committee,
voted to accept the invitation extended by Dr.
William L. Simpson and Dr. William Murray, on
behalf of the boards of trustees of the Detroit
Institute of Cancer Research and the American
Cancer Society, Southeastern Michigan Division,
to locate the Registry in the Detroit Cancer
Center. Since these two organizations as well as
the Cancer Control Center (now Yates Memorial
Clinic) were also located in the Cancer Center,
this decision provided the Registry with office and
laboratory space in the same building with its
affiliated organizations and thus gained for the
Registry the use of their facilities as well as the
co-operation and guidance of Dr. Simpson,
Scientific Director of the Cancer Research
Institute, and Mr. Edward L. Tuescher, Executive
Director of the American Cancer Society, South-
eastern Michigan Division. At the same time
the Registry has been able to reciprocate by co-
operating in some of the work of the other
agencies.
In June, 1949, the Michigan Cancer Founda-
tion approved an appropriation of $10,000 for the
establishment and first year’s operation of the
Tumor Registry. These funds were made avail-
able with the approval of the Cancer Control
Committee of the Michigan State Medical Society.
The organization, administration, aims and pur-
poses of the Tumor Registry were outlined in a
plan which was drawn up and titled “Method of
Organization.” This document has since acted
both as a charter and a constitution.
The following organizations were listed as
sponsors: (a) Michigan Pathological Society; (b)
Detroit Institute of Cancer Research; (c) Michi-
gan State Medical Society, through its Cancer
Control Committee; (d) American Cancer
Society, Southeastern Michigan Division; and (e)
Michigan Cancer Foundation.
The responsibility for the administration of the
Registry was placed in the hands of an adminis-
trative committee which was constituted as
follows: (a) Four members of the Michigan
Pathological Society; (b) the Scientific Director
of the Detroit Institute of Cancer Research; (c)
the Executive Director of the American Cancer
Society, Southeastern Michigan Division; and (d)
one member of the Cancer Control Committee of
the Michigan State Medical Society.
The purposes of the Tumor Registry may be
summarized as follows :
I. General
a. To maintain a tumor registry composed of
microscopic sections submitted on a voluntary
basis by Michigan pathologists and augmented
by clinical and follow-up data.
II. Educational
a. To supply pathologic material for professional
education at all levels.
b. To assist pathologists in stimulating interest
in cancer among the medical profession.
c. To supply pertinent data for lay education.
d. To evaluate present day diagnosis and tech-
niques in tissue pathology in terms of earlier
diagnosis.
e. To implement research.
III. Statistical
a. To collect and interpret data regarding inci-
dence, prevalence and mortality rates of cancer
by site, pathologic type, age, sex, occupation
and other pertinent variables.
IV. Follow-Up
a. To assist and encourage the physician through
the local pathologists to follow cancer cases.
V. Tumor Consultant Board
a. This board is appointed by the Administrative
Committee and carries the responsibility of re-
viewing sections of all controversial cases as
submitted by the Director of the Tumor
452
JMSMS
MICHIGAN TUMOR REGISTRY— SELZER
Registry. Although the Registry was not and
is not intended to be a diagnostic service,
pathologists are encouraged to submit problem
cases for consultation.
Considerable credit is due to the sponsoring
organizations and especially their representatives
to the Administrative Committee, all of whom
serve voluntarily and who give freely of their
time and energy to this project. A special debt
of gratitude is owed to the late Dr. Donald C.
Beaver; Dr. Osborne A. Brines, Chairman, De-
partment of Pathology, Wayne State University
College of Medicine; Dr. A. James French; and
Dr. Frank W. Hartman, Emeritus Pathologist-in-
Chief, Henry Ford Hospital, for their guiding
interest in the organization and operation of the
Michigan Tumor Registry.
At this point it would be appropriate to name
the members of the first Administrative Commit-
tee, which held its initial meeting on November
30, 1949. At the time of this first meeting the
Administrative Committee consisted of the late
Dr. Donald C. Beaver, Chairman; Dr. Osborne
A. Brines, Dr. A. James French, Dr. Frank W.
Hartman and Dr. William L. Simpson. In the
following year the Committee was completed by
the appointment of Dr. Harry M. Nelson, Detroit,
Chairman, Southeastern Michigan Division of the
American Cancer Society, to represent this or-
ganization and of the late Dr. A. B. McGraw to
represent the Cancer Control Committee of the
Michigan State Medical Society.
Dr. Harry M. Nelson was replaced late in 1950
by Dr. John Locke as representative of the Ameri-
can Cancer Society, Southeastern Michigan Divi-
sion. The latter was in turn replaced by Mr. Ed-
ward W. Tuescher, who became Executive Sec-
retary of the American Cancer Society, South-
eastern Michigan Division, in the latter part of
1951, and who has been a member of the
Committee since that date. Dr. McGraw re-
mained a member of the Committee until his
death in 1953, and in 1954 Dr. John Wellman
of Lansing was designated by the Michigan
Cancer Co-ordinating Committee to fill the
vacancy created by the death of Dr. McGraw.
Dr. Wellman was a member of the Committee
for approximately one year when pressure of other
duties forced him to resign. Following his
resignation in 1955, Dr. Harry Nelson was
designated as representative of the Cancer Co-
ordinating Committee to the Administrative Com-
mittee of the Tumor Registry.
Of the pathologist members of the original
Committee, Dr. French served until the end of
1950, Dr. Beaver through 1951, Dr. Brines through
1952, and Dr. Hartman through 1953. Beginning
with 1951, the Michigan Pathological Society has
each year designated a new member to represent
the Society on the Committee. This member
serves for a term of four years, and becomes the
chairman of the Committee during the fourth
year of his term.
Since this rotation began, Dr. Arthur A.
Humphrey, Battle Creek, Drs. Donald H. Kaump,
Lawrence W. Gardner and William L. Brosius, all
of Detroit, Dr. R. E. Olsen of Pontiac and Dr.
Viola Brekke, Highland Park, have been elected
to the Administrative Committee. Dr. Humphrey
completed his four-year term in December, 1954,
and Dr. Kaump at the end of 1955. Dr. Gardner
completed his term in December of 1956.
Dr. Simpson was the first secretary of the Ad-
ministrative Committee. In 1951, Mr. Locke
served a term as secretary, and since 1952 Dr.
Simpson has been re-elected to this office each
year.
After the Administrative Committee was or-
ganized its first official act was to utilize the
funds allocated by the Michigan Cancer Founda-
tion for the purchase of equipment and supplies
for the Registry laboratory and office, space for
which had been provided on the first floor of
the Cancer Center at 4811 John R Street in
Detroit. News releases were issued and the an-
nouncement was made that the Registry was
officially opened.
About mid-year in 1950 tumor specimens began
to be submitted to the Registry by various
pathologists. After being processed in the Registry
laboratory, these cases were reviewed and classi-
fied by the pathologist members of the Adminis-
trative Committee. It was not until early in
1951 when Dr. Henry Tesluk was appointed
Director of the Tumor Registry that the Adminis-
trative Committee was relieved of the many
routine duties which its members had voluntarily
taken upon themselves.
In 1952, Dr. Tesluk resigned as Director, and
it was not until 1954 when the author assumed
April, 1957
453
MICHIGAN TUMOR REGISTRY— SELZER
the post that the Registry again had a full-time
director.
In the year 1950, only 280 specimens were re-
ceived and recorded by the Tumor Registry. This
TABLE I. NUMBER OF ACCESSIONS TO
MICHIGAN TUMOR REGISTRY
1950
1951
1952
1953
1954
1955
Total
280
495
1192
782
1301
2021
6071
is shown in Table I, which also includes the
number of accessions for each of the following five
years. The decrease in the number of accessions
for the year 1953 is undoubtedly due to the fact
that the Registry was then operating with only a
part-time director brought about by the resigna-
tion of Dr. Tesluk. In 1954, this downward trend
was reversed and the number of new cases has
increased each year.
The hospitals participating in the Registry pro-
gram and the number of accessions credited to
each hospital for the years 1950-1955 are listed in
Table II. This table points up the fact that not
only are all sections of the state represented to
some degree, but also that certain hospitals,
notably some in Detroit, are conspicuously absent.
This latter fact, of course, tends to diminish the
value of our statistics.
Since a complete analysis of the Registry
material does not fall within the scope of this
paper, only a partial classification of this material
is included in Table III.
In addition to its main function of collecting,
classifying and coding tumor specimens, the
Registry has conducted other activities:
1 . Provision of a consultation service for unusual
controversial cases.
2. Preparation of histologic sections for the Slide
Seminars of the Michigan Pathological Society.
3. Processing of biopsy specimens for the Yates Me-
morial Clinic (Cancer Detection Clinic of the
American Cancer Society, Southeastern Michigan
Division)
4. Participation in the research program of the De-
troit Institute of Cancer Research.
5. Co-operation with American Cancer Society,
Southeastern Michigan Division, in lay and pro-
fessional education.
6. Co-operation with the American Cancer Society
in its Smoking-Lung Cancer Survey.
7. Co-operation with the American Cancer Society,
Southeastern Michigan Division, in encouraging
and assisting the formation of hospital cancer
registries.
TABLE II. ACCESSIONS TO MICHIGAN TUMOR
REGISTRY BY HOSPITALS
Location
Hospital
1950-1955
Detroit and
Alexander Blain
27
Wavne County
Children’s Hospital
Dearborn Veteran’s Hospital
2
119
Detroit Memorial
393
Grace Hospital
2
Harper Hospital
10
Henry Ford Hospital
1200
Herman Kiefer
2
Highland Park General
59
Mt. Carmel Mercy
706
Providence
97
Receiving
715
Wayne County General
268
Woman’s Hospital
545
Sinai Hospital
119
Yates Memorial Clinic
65
Ann Arbor
St. Joseph’s Mercy
73
Battle Creek
Leila Y. Post Montgomery
Community
204
Bay City
Mercy and General
108
Flint
Hurley
333
McLaren
110
St. Joseph’s Hospital
Women’s Hospital
115
11
Grand Rapids
Blodgett Memorial
10
Butterworth Hospital
169
St. Mary’s Hospital
172
Jackson
Foote Memorial
16
Mercy
10
Kalamazoo
Borgess
7
Bronsen
1
Lansing
Edward W. Sparrow
77
St. Lawrence
2
Marquette
St. Luke’s
12
Muskegon
Hackley
49
Mercy
1
Pontiac
Pontiac General
63
Saginaw
Saginaw General
164
Ypsilanti
Beyer Memorial
23
Miscellaneous
12
T otal
6071
Except for 1953, due to the reasons mentioned
above, the Registry has shown continued growth
in respect to the number of specimens submitted
for registration. This fact is an indication of the
growing awareness on the part of the pathologists
of the importance of the Tumor Registry. How-
ever, in order to fulfill its purposes, the Registry
is attempting to achieve its goal of a minimum
of 3,000 specimens annually for the next several
years. Although most hospitals and pathologists
are co-operating to some extent in this effort, the
Registry is hampered by the fact that some hos-
pitals still are remaining aloof and unco-operative.
Although pathologists are most directly involved
with the activities of the Registry, its success is
of direct or indirect concern to all members of
the medical profession in Michigan and of course
to their patients.
In addition to our continued efforts to en-
courage registration of increasing numbers of
cases, our plans call for the preparation of ade-
quate varieties of slide study sets to be available
for loan purposes. We are also encouraging the
use of our permanent slide collection for study
and reference purposes.
454
JMSMS
MICHIGAN TUMOR REGISTRY— SELZER
At the present time, specialty registries within
the Michigan Tumor Registry are being formu-
lated with the co-operation of various specialty
groups in the State of Michigan.
References
1. Macdonald, Eleanor J.: The state-wide cancer rec-
ord registry in Connecticut. M. Woman’s J., 51:26
(April) 1944.
2. Lombard, Herbert L.: Twenty-six years of cancer
TABLE III. CLASSIFICATION OF ACCESSIONS TO MICHIGAN TUMOR
REGISTRY BY ORGAN SITE OR SYSTEM AND SEX FOR THE
period 1950-1955
Primary Site
Male
Female
Sex Not
Stated
Total
M/F
Mouth and Oropharynx
142
36
1
179
Esophagus
67
14
81
Stomach
214
87
301
Intestinal Tract
455
374
829
Pancreas
38
23
61
Liver, Gallbladder and Bile Ducts
33
49
82
Nose, Larynx, Trachea and Luna
338
56
394
Urinary Tract
237
103
340
Male Reproductive System
316
316
Female Reproductive System
829
829
Breast
7
704
711
Skin
286
238
3
527
Brain and Spinal Cord
97
74
171
Bone
73
71
144
Thyroid
24
127
151
Lymphatic and Hematopoietic Systems
166
86
252
Salivary Glands
77
74
151
Soft Tissue
46
45
91
Miscellaneous Sites (Spleen, Adrenal, Eye, etc.)
37
38
75
Primary Site Unknown
94
50
1
145
Total Neoplasms
2747
3078
5
5830
252
Non-neoplastic lesions, errors, etc
6082*
♦The apparent discrepancy between the total figures of Tables I and III is due to the fact
that in some cases, the same accession number included more than one neoplasm.
A constantly growing reprint collection dealing
chiefly with the morphologic aspects of cancer,
and selected texts and cancer journals are avail-
able for reference.
In addition, in accordance with the stated
Registry program, follow-up studies on selected
groups of cases are now being undertaken.
Although the Registry was initiated by the
Michigan Pathological Society and members of
this Society provide the chief basis for its scientific
endeavors, the support and co-operation of mem-
bers of all branches of medicine in Michigan
would be welcomed. In turn, the facilities of the
Registry are available to all members of the
medical profession in Michigan.
Acknowledgment
Dr. Lawrence W. Gardner, President of the Michigan
Pathological Society, has kindly reviewed the manuscript
and has offered valuable criticism and suggestions.
control in Massachusetts. Pub. Health Rep., 68:
647-655 (July) 1953.
3. Hall, Homer K., Kentucky Department of Health.
Personal Communication.
4. Murphy, Thomas H. : The role of the state depart-
ment of health in cancer control. Rhode Island
M. J., 37:512-515 (Sept.) 1954.
5. Handy, Vincent H., and Gehrhardt, Paul R.: New
York state cancer control program. Pub. Health
Rep., 67:1225-1232 (Dec.) 1952.
6. Reimann, Stanley P. : An Outline of the Plan and
Work of the Division of Cancer Control of the
Pennsylvania Department of Health, Philadelphia,
Pennsylvania.
7. Shaffer, E. L. : New Jersey State Department of
Health. Personal Communication.
8. Scott, Walter F., Jr.: Alabama Tumor Registry.
Personal Communication.
9. Lipincott, Stuart W. ; Dewey, Leonard A.; and
Spielholz, Jess B.: Report of the First Five Years
of the Teaching- Research Activities of the Wash-
ington State Tumor Registry.
10. Eichwald, E. J. ; Carlquist, J. H.; and Jenkins,
A. A.: Utah Tumor Registry — first 1000 cases.
Rocky Mountain M. J., 51:204-206 (Mar.) 1954.
11. Austin, T. R., Capt. MC., U.S.N.: American Reg-
istry of Pathology, Washington, D. C. Personal
Communication.
April, 1957
455
Cancer and Anoxia
A Further Evaluation of Clinical
and Experimental Trends
By Edgar A. Bicknell, M.D., Detroit, Michigan
IN 1950 1 advanced a new theory for the cause
of cancer (Journal MS MS, 49:1179-1184,
1950), namely, anoxia of a cell, goading it into
cancerous change, by diverse actions, such as the
carcinogens and their ilk on the one side, and cell
factors on the other. Enzymes were suggested as
possible agents. Reversion of the cell to a former,
more primitive, type of metabolism requiring less
oxygen, which allowed it to escape from physio-
logic control, I believed was cancer.
Last fall I decided to try once again to clarify
this issue. There seems to me to be proof enough
for all but the modus operandi. I knew of Otto
Warburg’s work on the excess lactic acid in cancer
cells, but his recent report in Science (123:3191,
Feb. 24, 1956), caused me to rewrite my paper
to incorporate his theory. He lists the following
sequence :
1. Injury to cellular respiration by interference
with the oxygen supply.
2. Attempts of the cell to survive by shifting
to anaerobic fermentation as an alternate source
of energy.
3. Development of a transitional or sleeping
phase, a precancerous state whose cells look like
cancer but have not yet fully replaced respiration
by fermentation.
4. Loss of cellular differentiation upon repeated
substitution of respiration by fermentation. Subse-
quently these cells grow wild as cancer. This
action parallels that of Torula yeast cells. Not
even they can maintain structure permanently by
fermentation alone without degeneration. Since
these respiratory insults are irreversible, their ef-
fect is cumulative. Massive effect kills. Lesser
amounts lead to cancer.
All other supposed causes of cancer are second-
ary and Warburg feels that stress on virus, chemo-
therapy and other research is futile and hinders
the outlook.
I agree most heartily with the basic premises
because this is further proof of my theory, al-
though we differ on some points. Precancer cells
can revert to normal if the carcinogenic agent is
removed. Also, I will show that cancer cells,
though they seem to be growing entirely wild,
may be under the influence of growth stimuli as
well as hormone influence which, if enough energy
is made available through glycolysis, may allow
the cell to resume lost patterns of form and work.
Energy not used for growth and reproduction can
be shunted to the latter effects.
What is the opinion of others? Many, like Lud-
wig Gross, indict the virus as the cause of cancer.
I knew Dr. Gross while in the service and respect
his work very much, but I believe that though
he has shown evidence in leukemia as well as in
breast cancer, his virus theory applies to animals
only and the viruses may be only co-carcinogens.
The work of training viruses to attack cancer,
while ingenious, I fear is a will-o-the-wisp. Can-
cer is so protean in its manifestations, due to the
variety of tissue from which it springs, that this
and a single magic bullet are doomed by the great
variety of malignancies.
Heredity is the other main cause offered. A
recent case report by Lt. Commander Ende in
Cancer (Sept. -Oct., 1955), makes both heredity
and virus as “the” cause of cancer untenable. He
reported the delivery of identical twin girls at the
thirty-second week of gestation to a healthy
twenty-four-year-old primigravida. The one child
was normal and stayed so through thirteen months.
The other was stillborn, death being due to a
large brain tumor, a medullo blastoma and epen-
dymoma. Anoxia by cord torsion or compression
is tenable. Transplacental carcinogenic activity
can occur through hormones or other agents. We
know that the placental barrier is far from com-
plete. I know of no other theory than mine that
can explain this.
In order to evaluate the whole field of clinical
and research I have read much current literature
456
JMSMS
CANCER AND ANOXIA— BICKNELL AND BICKNELL
and delved into the basic sciences to strengthen my
background in biology, genetics, biochemistry, en-
zymes, physics (especially isotopes and other radia-
tion) as far as possible. My present evaluation
follows.
Chronic lack of oxygen causes cancer. Cell
resistance to carcinogenic activity varies. When
cells are normal greater amounts of carcinogens
are required. Even a normal cell can become can-
cer if enough carcinogenic activity is exerted on it.
Depleted cells require far less. Especially if
forced to work by nerve or hormone stimulation.
How is this brought about? Many things have
been shown to be carcinogenic. We know that
ionizing radiation causes cell changes in the
chromosomes and that mutations occur. We also
know that malignancy follows many types of ra-
diation. It can follow repeated small doses or one
blast from atomic energy. Ultra violet light can
be trained on portions of chromosomes and one
can watch microscopically the definite changes
which occur. Further study is being carried on by
R. E. Zirkle. Cells in growing bone are more
sensitive than in resting. Reserve cells in mitosis
are the ones most affected. End cells never be-
come cancerous, but may end up as giant cells.
Where is the action on the cell of radiation and
other carcinogens? This is the “toughie.” Even
though radiation effects are visible and aromatic
hydrocarbon carcinogenicity may not be, the latter
seems to be the best carcinogen, displacing thoro-
trast. Jacob Furth and John L. Tullis have a
masterful article in Cancer Research (January,
1956) on “Carcinogenesis by Radioactive Sub-
stances,” that all should read.
The work of the Pullmans on electronic struc-
ture and carcinogenic activity of aromatic mole-
cules is very trite. They have devised a method
for measuring the molecular orbit of these sub-
stances, and show that there are static and active
molecules present in these hydrocarbons. In order
to be carcinogenic they must have an active K
region, and if there is also an L region it must
be somewhat inactive. A region is an assembly of
two carbon atoms placed in such a way that they
may undergo an additional reaction. A reaction
center is a single reactive carbon atom particularly
able to undergo a substitution reaction. Nagata
and co-workers tried to elaborate on this by a so-
called “frontier electron method,” but the Pull-
mans have shown error in their interpretation.
These hot areas on the cells are measurable and
show the degree of carcinogenic activity expected.
I believe the Pullmans’ work will be productive in
solving the final link in interference with the cells’
oxygen. Men like Pullman, Warburg or Theorell
should be able to solve this.
I believe these hot atoms act like radiation in
their effect on the cell but seem to require less
time to cause the same end result. Drs. E. J. Am-
brose, A. M. James and J. H. B. Lowick of Lon-
don just reported in Nature that cancer cells have
about twice the electric charge of normal cells.
Work with bacteria has shown how easy it is to
produce changes that can be handed on for gen-
erations. Growing organisms resistant to an anti-
biotic with sensitive ones in culture has caused
the latter to become resistant for several genera-
tions. Likewise, bacteria grown in culture with
enzymes and glucose have changes that are dif-
ferent if the glucose is added later. The descend-
ants perpetuate this for plus or minus twenty
generations. When the difference in the time of
adding the glucose is so impressed on the cell,
how easy it must be for lack of so vital an element
as oxygen to cause changes in cells that last for
generations and finally forever. Fibroblasts grown
in culture in partial anoxia from a nitrogen at-
mosphere change to sarcoma. This should be a
fertile field for research.
The enormous desoxy ribosenucleic acid mole-
cule is made up of large numbers of purine and
pyrimidine bases and pentoses linked in long chains
by phosphates. Our hereditary traits are deter-
mined by the exact structure of this molecule. Its
size and complexity allows infinite genetic possi-
bilities. The cell also contains RNA in the nucleo-
lus, the mitachondria, and the smaller particles of
the cytoplasm. The genes are made of DNA.
Viruses and bacteriophages also are DNA in ani-
mal and some vegetable species. These are the
only subcellular substances that can reproduce.
This is why virus study is so intriguing. The DNA
controls the cell and most workers think that it
controls the making of RNA. Some think that
RNA, like DNA, is self-perpetuating; at any rate,
it is agreed that the DNA controls cell type and
functions, while RNA controls enzyme formation.
The importance of this in cancer is readily seen.
Anything that injured either the DNA or the
RNA could interfere with enzymes or with respi-
ration of the cell causing anoxia. This is what
causes cancer. Injury to respiration short of per-
manent is precancer. I believe removing the car-
April, 1957
457
CANCER AND ANOXIA— BICKNELL AND BICKNELL
cinogenic influence will reverse this, but after the
cell has turned cancerous it cannot be reversed.
Warburg feels, and so do I, that this is a case of
survival of the fittest; that is, cells most able to
turn to fermentation for energy when deprived of
oxygen survive. Finally, after continual goading
by anoxia, often produced by carcinogens, we get
cells able to produce a large share of their energy
aerobically, i.e., by fermentation. These cells are
cancer. Warburg has shown that they may pro-
duce half of their energy this way, while a normal
cell produces only about one per cent by fermenta-
tion and 99 per cent by respiration, that is, aero-
bically. Some of the effects may be due to changes
in the cell membrane itself.
The use of hypotonic solutions has caused great
spreading of the chromosomes so they can be
counted under the microscope. Cancer cells show
a very high number of these and fragments of
shattered ones. This points to changes in the
DNA. The fact that many carcinogens have been
proved mutagens also fits. Many are known to
depolymerize DNA. The fact that ontogeny tends
to recapitulate phylogeny may account for the
ability of some of the cells to reactivate fermenta-
tion processes. Maybe this was indelibly, if faint-
ly, etched on the DNA as a gift from a remote
ancestor. The ones who survive in this new form
show how great an influence self-preservation can
exert and also that the fittest survive. This new
cell being forced to get its energy the hard way
has to give up some of its former activities in or-
der to survive. The degree of change ranges from
grade 1 where there is little, to grade 4 where there
is such great change that the former identity may
be lost. The fact that grade 4 cancers of this
type, when grown in a guinea pig’s eye, may
change enough to be identified is very significant.
I believe this is due to the fact that the cancer
cell still responds to certain stimuli. I think that
the cell is removed from an influence that has
been goading it into rapid growth and reproduc-
tion. When this is missing in the new locale, en-
ergy that was lacking is now available for use in
restoring some of its former characteristics. I
will elaborate on this further in regard to thyroid
cancer. Research men with this lead may unravel
this mystery.
The new micro techniques of dissection may-
aid in finding changes in structure before and
after this change. Also it should be easy to see
what effect traces of carcinogens or hormones or
both may have on this phenomenon.
There are several types of cancer:
1 . Mucosal or skin epitheliomas.
2. Simple sarcomas of any tissue.
3. Simple adenocarcinoma of a sweat gland or anv
mucous gland.
4. Central nervous system tumors.
5. Respiratory tumors.
6. Urinary tumors.
7. Bone marrow, lymph and reticuloendothelial
tumors.
(All of the above are simple, being under the
influence of no known substance but the nervous
system and any carcinogenic influence present.)
8. The endocrine tumors are under the influence of
the pituitary except it, itself, which is influenced
by the hypothalamus.
9. Sex tissues, less the gonads, are under the influ-
ence of the gonads and the pituitary and, also at
times, the adrenals.
It is obvious that there are many forms of can-
cer under varying influences. It is hard to see how
any one test can be devised for cancer per se.
There are many important factors in cell re-
sistance to carcinogens.
Heredity. Some protoplasm must excel geneti-
cally.
Environment. Heat, cold, weather, sunlight and
trauma with its edema are obvious factors.
Diet. Deficiency, especially of protein or vita-
mins; excess, especially of fat.
Blood supply, if impaired.
Nervous or tension states. May jangle our endo-
crines.
Aging — in many ways.
Many agents exert carcinogenic influences.
These may be co-carcinogens or real carcinogens;
they are often associated and additive. Among
the most important are:
Radiation — X-rays, radium, radium water, ra-
dium chloride, thorotrast. ultraviolet, isotopes and
other atomic energy.
Metals — arsenic, cobalt, chromium, to list a few.
Hydrocarbons — in vapor or fumes from chemi-
cals; combustion gasoline and oils, raw or burned;
factories; furnaces; cleaning fluids; paint solvent
and tar roads.
Foods and chemicals ingested, absorbed from
surfaces or injected accidentally or deliberately.
Analine dyes. Even foods may contain them.
458
JMSMS
CANCER AND ANOXIA— BICKNELL AND BICKNELL
Water may be polluted by industrial wastes.
Tobacco, especially cigarette smoking.
Viruses, possibly.
Bacterial toxins, possibly.
Liver disease may accent the titre of some of
these by failure to detoxify them normally. Tissue
repair per se has been accused, but the small gut
and the cornea where this is greatest rarely are
malignant. Experimentally, most cancers have
been produced in animals. Cancer of the colon
has been produced by feeding Y91 and 3-3' di-
hydroxybenzidine.
The clinical features of cancer described by
great men of the past are not to be lightly re-
garded. Osier, Mackenzie and Sydenham were
very accurate in their observations.
Nasopharyngeal cancer from radioactive mate-
rials has been known for years. The effect of heat
and tobacco in oral and esophageal cases is im-
portant. The stomach and pancreas are often
affected by food and drink so seasoned and so hot
that no animal could be induced to touch it. Lung
bronchiogenic cancer has been elucidated so well
by Ochsner that I wonder that any one still
smokes. His statistics are so dramatic that it
amazes me that some doctors make light of them.
The recent showing of epithelial metaplasia of
bronchial mucosa in smokers at postmortem and
by biopsy which reverted to normal on discontinu-
ation of smoking should convince any but those so
blind they will not see. I believe tobacco may
have a dual role in lung cancer. The nicotine may
produce a vasospasm of the vessels supplying the
bronchial mucosa. This, plus the known carcino-
gens, may be why it is so deadly. New work
indicts a neutral fraction of the tars which the
manufacturers are trying to eliminate.
The story of the pituitary and the thyroid are
very illustrative. The pituitary makes trophic hor-
mones for all the endocrines as well as the soma-
trophic hormone. This latter is a factor in
goading cancers to grow and should be checked.
The thyroid having a good hormone easily used
in treatment, as well as I131, is perfect to show
some aspects of cancer not formerly stated.
The normal gland and cancer, plus its metasta-
ses, pick up I131 if the latter are not too wild.
When the level of thyroid hormone falls, TSLI
is made by the pituitary. Crile showed recently in
the Cleveland Clinic Quarterly that lung metasta-
ses regressed when thyroid extract was fed in
large doses, probably due to suppression of the
TSH. Lung metastases too wild to pick up the
istotope have regained this ability after total thy-
roidectomy and have thus destroyed themselves.
One explanation for this is that when all other
thyroid was gone, the pituitary kept making more
TSH and when the titre was high enough stopped
growing and reproducing. Energy so liberated was
used to return the cell enough towards its former
state that it recovered the ability to pick up the
iodine. Absence of the thyroid hormone eased the
cancer cells as lack of sex hormone allows regres-
sion in cancer of the prostate. After total thy-
roidectomy, thyroid extract should be given, if not
contraindicated, or the pituitary' will get tumorous
from overwork.
Breast and prostate cancers that regress with
the opposite hormones are somewhat similar. In
this case, I think that either hormone suppresses
the gonadotropic hormones in either sex. I don’t
think the pituitary distinguishes between them. I
believe that this suppression of the pituitary re-
moves the drive from the gonads and hence no
sex hormones are formed and this lack is what
allows them to regress. This is similar, I believe,
to what happens in the guinea pig’s eye. There
could, of course, be other factors in the latter
because it is a transfer to a different species. I
prefer to think they are the same. Tissue from
breast or prostate cancer, if analyzed before and
after this therapy, might show a down-grading of
these tumors, too. The adrenal takes over some-
times in these cases and upsets the balance. Adre-
nalectomy has been done as has hypophysectomy.
I believe that hormone therapy may make surgery
unnecessary in some cases. Some of the effects
from cortisone may be from adrenal suppression,
predisone or prednisolone should be as efficacious
and less troublesome.
The fact that thyroid extract in large doses was
used empirically for ovarian dysfunction with fair
success may be due to a cross-over suppression
from contiguous areas of the gland. I am using
this along with stilbestrol and Meticorten in an
eighty-four-year-old man who relapsed after 9
years’ control on stilbestrol alone. The tumor al-
most disappeared in the first instance. Using this
pattern, any endocrine-fed tumor can be treated.
The pituitary is affected by the emotions through
the hypothalamus.
Because of the importance of early diagnosis
we must alert the public still further. If cancer is
April, 1957
459
CANCER AND ANOXIA— BICKNELL AND BICKNELL
found early many can be completely removed and
cured.
I find our pure scientists more interested in
the unknown minutae than in trying to foster use
of the present material. I believe with Warburg
that we have all but one or two pieces of the
jigsaw puzzle. What we learn from now on may
avail us little in cure. We should use the
tremendous knowledge we have. Remember qui-
nine and digitalis saved thousands of lives before
much was known about them.
Prophylaxis is of the essence. The public should
be educated by all available media in the impor-
tance of good living habits. Diet, rest, and vaca-
tions should be explained to all, starting with the
tots. We should set examples, especially the doc-
tors, by our lives and habits. I think all doctors
should cease cigarette smoking even if they doubt
the figures until they are proven one way or
another. I am convinced now, as are many others.
Moderation in everything from tobacco and al-
cohol to caffeine-containing drinks should be re-
peatedly stressed. All known carcinogenic influe-
ences should also be made known. Smoke and
fumes should not be allowed to pollute our air,
nor should anything else be put in our food and
drink unless unavoidable. Government regulations
should be strict because these are killers.
Chemotherapy has been helpful in a few iso-
lated cases. We may get occasional results from
the alkylating agents or the antimetabolites and
hormones and isotopes in certain types. Dr. S.
H. Jones of the Lahey Clinic has had some
startling results with a NH2 mustard regime not
yet published. Because of the short wavelength of
isotopes they must be localized like I131 to be
effective. They help bone and body cavity cases
best. Colloidal isotopes are trapped in the reticulo-
endothelial cells.
I am sure our real gain is to be made in pre-
vention. I feel so sure of this that I think that
the great age of the biblical patriarchs may have
been due to living as I have outlined in a world
less teeming with carcinogens and tensions.
Maybe their periodic fasts purged them of the
ones that were present. They stressed milk and
honey. We want the fat of the land and are
paying for this and other sins.
Metastatic cancer to the liver from the gastro-
intestinal tract is rapid and deadly. The rich
portal blood feeds our livers better than any other
organ. The cancer gets the same. Knowing the
liver’s great need for food, I started a patient on
a diet deficient in protein hoping to reduce the
body pool of building blocks for protein synthesis.
If the cancer fails to get enough, it may fail to
grow and stop reproducing. I hope that the high
priority of the liver may let it out-compete the
cancer for this scarce material. If the cancer
stops growing, the liver may treat it as any other
foreign substance and wrap it in fibroblasts till
it is smothered in scar. This may also limit the
intake of carcinogens. Also the endocrines may
be suppressed. In addition, I suggest suppression
of the endocrines empirically. The risk of stress
in adrenal suppression must be understood and
appropriate measures used when indicated.
Summary
A review of cancer has been attempted.
Anoxia as the cause has been stressed again.
The need to educate the public in all its aspects
is urged.
Stricter regulation of all carcinogenic materials
must be insisted upon.
More harm than good may come from radiation
and hormone therapy if we are not vigilant. All
anticarcinogenic agents are carcinogenic them-
selves, and may precipitate more cancer than they
cure. We may be sowing the wind to reap a
later hurricane. Every physician should realize
the great latency as exemplified by bronchiogenic
cancer from smoking. Hormones may give us a
flood of gonadal cancer later if used promiscuously.
There is evidence of this in increased fundal
cancer of the uterus.
Acknowledgment
The author gratefully acknowledges the assist-
ance of Joseph McCall Bicknell, A.B., of Ann
Arbor, in the preparation of this article.
460
JMSMS
Screening for Carcinoma of the Cervix
The Use of the Cytological
Smear in Office Practice
By Norman D. Henderson, M.D., Lansing, Michigan;
Robert Bucklin, M.D., and V. K. Volk, M.D., Saginaw, Michigan
f'' ANCER produced 16.6 per cent of all reported
deaths in Michigan in 19541 Malignant
neoplasms are the second most common cause
of death in both sexes at all ages from one to
sixty-four. After age sixty-five, deaths due to
cancer are the third ranking cause of death in
Michigan.
Gastrointestinal tract
24.5
per
cent
Breast
. 19.3
per
cent
Uterus
13.3
per
cent
Leukemia
4.2
per
cent
Respiratory tract
3.1
per
cent
Skin
1.0
per
cent
Buccal cavity and pharynx..
0.7
per
cent
All other sites
33.9
per
cent
TABLE I. DEATHS DUE TO CANCER OF THE UTERUS
IN MICHIGAN AND SAGINAW COUNTY SINCE 1940
Year
Michigan
Saginaw County
Rate
Other
Rate
Other
T otal
Per
Cervix*
Parts of
Total
Per
Cervix*
Parts of
100.000
Uterus
100,000
Uterus
1940
660
11
1941
657
18
1942
643
15
1943
675
12
1944
705
16
1945
704
16
1946
710
21
1947
695
25
1948
685
14
1949
653
20
1950
594
9.3
316
278
9
5.9
3
6
1951
678
10.4
373
305
15
9.6
9
6
1952
631
9.4
334
297
18
11.3
8
10
1953
644
9.4
351
293
18
11.2
13
5
1954
621
8.9
358
263
15
**
11
4
♦Deaths due to cancer of the cervix and other unspecified parts of the uterus not available prior to 19C0.
♦♦Saginaw County population figures not available.
Prior to 1947, malignancies of the uterus were
the most common cause of death from cancer in
Michigan women, followed by cancer of the
breast, intestines, stomach and duodenum, female
genital organs other than the uterus, rectum,
respiratory tract and skin. There have been
several changes in the frequency of cause of death
since 1947, due in part to the regrouping and
reclassification of causes of death. Malignancies
as a cause of death of Michigan women were
reported in the following order in 1954:
This study was supported with cancer funds allotted
to the Michigan Department of Health by the Depart-
ment of Health, Education and Welfare, United States
Public Health Service.
Dr. Henderson is from the Michigan Department of
Health; Dr. Bucklin is Director of Laboratories, Saginaw
General Hospital; Dr. Volk is Director, Saginaw County
Health Department.
April, 1957
Table I is a summary of the deaths due to
cancer of the uterus as reported in Michigan and
Saginaw County since 1940.
Detection of carcinoma of the cervix in the
early or pre-invasive stage has been greatly
assisted by the inclusion of exfoliative cytology in
the examination of the female pelvis. The
simplicity of the method of collecting and fixing
the smear lends itself well to use in the prac-
titioner’s office.
A co-operative study was undertaken by the
Saginaw County Medical Society, the Michigan
Department of Health*, and the Saginaw County
Health Department. Publicity directed at the
lay public was not attempted. The study was
organized with three main objectives in mind.
•Division of Tuberculosis and Adult Health.
461
CARCINOMA OF THE CERVIX HENDERSON ET AL
First, this survey was designed to gain informa-
tion as to whether a screening technique of this
nature could be included as a part of the cancer
control program of the Michigan Department of
bered daily. They were then submitted in rota-
tion to three Saginaw pathologists in groups of
twelve cases. Two of the pathologists elected
to stain the fixed smears with hematoxylin and
TABLE II. AGE, RACE AND ETHNIC GROUP DISTRIBUTION AND MARITAL
STATUS PER 1000 PATIENTS EXAMINED IN THE SAGINAW
COUNTY CERVICAL CANCER SURVEY
Age
Groups
White
Negro
Mexican
Total
s
M
W
D
S
M
W
D
s
M
w
D
15-19
4
1
5
20-24
6
41
1
1
4
1
2
56
25-29
5
109
2
6
3
1
126
30-34
3
117
8
1
2
1
132
35-39
3
121
2
3
4
1
1
135
40-44
5
145
3
3
3
1
1
161
45-49
4
138
2
3
3
1
1
152
50-54
1
87
4
5
3
1
101
55-59
4
49
4
2
1
60
GO-64
3
31
4
2
40
65-69
2
10
5
17
70-74
11
4
15
Total
36
863
28
21
i
33
2
3
1
10
0
2
1,000
S — Single M — Married W — Widowed D — Divorced
Health. Second, it was felt that a survey of this
type would serve as a supplement to the program
of physician education in cancer detection. Third,
it was considered desirable to determine how
successful a routine screening procedure was
when carried out in several physicians’ offices.
The project was first discussed with the members
of the Saginaw County Medical Society and its
Committee on Cancer Research. Participating
physicians were encouraged to make a smear from
the cervix of female patients routinely seen in the
office during the course of the survey.
This report deals with an attempt to conduct
a survey of women for carcinoma of the cervix by
using the cytological smear technique on a routine
basis in the physician’s office.
Methods and Materials
Prior to the start of the survey in February,
1955, kits were delivered to the office of each
participating physician in Saginaw County. Each
kit contained a six-ounce bottle of ether alcohol
fixative, several glass slides, mailing containers,
labels and sets of instructions for taking, fixing,
and mailing the smears. A data form for in-
formation about each patient was required to be
completed by the physician and returned with
the fixed smear. Single specimens taken with
a wooden spatula produced satisfactory specimens
in the great majority of cases.
The smears were mailed to the local health
department where they were recorded and num-
eosin, while the other used the staining technique
of Papanicoloau. Each smear was examined by
only one pathologist.
Each pathologist surveyed the stained smears
without the use of preliminary screening per-
sonnel. Reports were made as follows:
“No tumor cells found”
“Atypical cells found”
“Cancer cells found”
The criteria of atypia and neoplasia accepted
by cytologists in general were used. A discussion
of these criteria is not within the scope of this
paper.
Results
Thirty-five physicians in Saginaw County elected
to participate in this study. Specimens were sub-
mitted as follows:
20 general practitioners 108 specimens
9 gynecologists 756 specimens
3 internists 37 specimens
Cancer Detection Center 99 specimens
Total 1,000 specimens
A total of 1,000 specimens was examined
(Table II). Smears containing atypical cells
were reported in fifty instances (Table III). No
definite diagnoses of cancer were made from the
smears, although in one instance, very highly
suspicious cells were noted. The remaining 950
462
JMSMS
CARCINOMA OF THE CERVIX— HENDERSON ET AL
TABLE III. FINDINGS IN THE SAGINAW COUNTY
CERVICAL CANCER SURVEY
February — July, 1955
Findings
Number
1. Patients examined
1,000
2. Patients found to have atypical cells by
smear
50
3. Biopsies recommended
50
4. Patients on whom biopsy was performed
42
a. Cervical cancers found by biopsy
2
1. Previously unknown case
i
2. Previously known case
1
b. Squamous metaplasia found
10
c. Chronic cervicitis found
30
5. Patients found to have atypical smears but not biopsied
8
a. Patient did not return
2
b. Physician decided against biopsv
5
1. Physician saw no abnormality
2
2. Previous diagnosis of cancer
of cervix
3
c. Patient refused biopsy
1
smears were reported as “No tumor cells found.”
In each of the fifty instances where atypical
cells were found, the physician who submitted the
specimen was contacted and requested to obtain
a biopsy of the suspected cervix. Table III shows
the disposition of these fifty cases. The one
proven case of carcinoma of the cervix may be
summarized as follows:
Case 1. Smear No. 688 — Sixty-one-year-old white
woman, four pregnancies. No history of menstrual ir-
regularities, cervical lesions or hormone therapy. Dis-
covered during a routine physical examination.
Diagnosis: Squamous cell cervical carcinoma.
Smears from four previously known and treated
cases of carcinoma of the cervix were submitted by
physicians without the pathologists being aware
of the diagnosis. In each case atypical cells were
found. These four patients are not included as
having been discovered as a result of this survey.
In three of these cases, the attending physician
decided that a biopsy was not indicated (Table
III).
Discussion
The age and marital status of the surveyed
group are given in Tables IV and V. Thirty-seven
atypical smears (74 per cent) were found in the
age group thirty-five to seventy-four, thirteen
atypical smears (26 per cent) were found in the
group less than thirty-five, while two atypical
smears (4 percent) were taken from women under
twenty-five. However, 4.2 per cent of the women
twenty-five to thirty-four, 5 per cent of the women
thirty-five to forty-four, and 4.3 per cent of the
women forty-five to fifty-four had atypical smears.
Married women, making up 90 per cent of the
TABLE IV. NUMBER OF ABNORMAL CASES FOUND
PER 1000 PATIENTS EXAMINED IN THE
SAGINAW COUNTY CERVICAL CANCER
SURVEY BY AGE
Age
Groups
Total
Number
of Smears
Received
Number
of
Atypical
Smears
Per Cent of
Atypical
Smears by
Age Group
Per Cent of
Atypical Smears by
Age Group and in
Relation to Total
Abnormal Findings
15-24
61
2
3.2
4.0
25-34
258
11
4.2
22.0
35-44
296
15
5.0
30 0
45-54
253
11
4.3
22.0
55-64
100
10
10.0
20.0
65-74
32
1
3.1
2.0
Total
1,000
50
—
100.0
TABLE V. NUMBER OF ABNORMAL CASES FOUND
PER 1000 PATIENTS EXAMINED IN THE
SAGINAW COUNTY CERVICAL CANCER
SURVEY BY MARITAL STATUS
Marital
Status
Total
Number
of
Smears
Received
Number
of
Atypical
Smears
Per Cent of
Atypical
Smears by
Marital
Status
Per Cent of
Atypical Smears by
Marital Status and in
Relation to Total
Abnormal Findings
Single
38
3
7.0
6.0
Married
906
42
4.6
84.0
Widowed
30
3
10.0
6.0
Divorced
26
2
7.6
4.0
Total
1,000
50
—
100 0
total, contributed 84 per cent of the atypical
smears. Only 4.6 per cent of the married women
had reportable smears, while 10 per cent of the
widowed group had detectable atypical cells.
Wynder2 observed that abnormal cytological
smears correlate better with the duration of sexual
activity than with the number of pregnancies.
Table II shows that the widows studied were all
over age thirty-five. Table VI shows the relation-
ship of atypical smears to the number of preg-
nancies is the surveyed group.
Table VII is a classification of the studied
cases by racial or ethnic origin. White women,
making up 94.8 per cent of the cases, had 90
per cent of the atypical smears while the negro
and Mexican women (5.2 per cent of the cases)
had 10 per cent of the reportable smears. Of
948 white women, 4.7 per cent had atypical
smears, while thirty-nine negro women had 10.2
per cent. Mexican women had 7.7 per cent
atypical smears. Wynder2 reports a high rate of
cervical cancer (not abnormal cervical smears as
reported here) in U. S. negroes, and implies an
association between the age at first coitus, cir-
cumcision and penile hygiene and the rate of
cervical cancer in U. S. negroes.
April, 1957
463
CARCINOMA OF THE CERVIX— HENDERSON ET AL
TABLE VI.
NUMBER OF SMEARS SUBMITTED IN RELATIONSHIP
TO THE NUMBER OF PREGNANCIES IN THE
SAGINAW COUNTY CERVICAL
CANCER SURVEY
February — July, 1955
Number of
Pregnancies*
Number of
Smears
Number of
Atypical Smears
0
138
5
1
135
9
2
267
7
3
186
12
4
123
8
5
63
4
0
40
2
7
18
8
10
1
9
11
1
10
3
11
1
12
3
1
13
1
14
0
15
1
Total
1,000
50
♦There are on the average two and one-half pregnancies reported from
married women in Michigan^).
Of the fifty women found to have abnormal
smears, only seven had menstrual irregularities.
No information concerning menstrual abnormali-
ties was submitted on one patient, while forty-two
had normal menstrual cycles reported.
Lesions of the cervix were observed in eighteen
patients while thirty women had no visualized
lesions of the cervix. This information was in-
complete on one woman. Only two of the fifty
women with abnormal smears had received hor-
mone therapy. Information was incomplete on
two cases.
Summary
The results of a survey for carcinoma of the
cervix, using the cytological smear technique, as
done in private physicians’ offices in Saginaw
County, Michigan, are reported. One new case
of cancer of the cervix was found as a result of
this survey. Four cases of carcinoma of the
cervix, each previously known to the physician
submitting the specimen, were detected by this
screening procedure. Some of the relationships
between age, race, ethnic groups, marital status,
TABLE VII. NUMBER OF ABNORMAL CASES FOUND
PER 1000 PATIENTS EXAMINED IN THE
SAGINAW COUNTY CERVICAL CANCER
SURVEY BY RACE OR
ETHNIC GROUP
Race
or
Ethnic
Group
Total
Number
of
Smears
Received
Number
of
Atypical
Smears
Per Cent of
Atypical
Smears by
Race or
Ethnic
Group
Per Cent of
Atypical Smears by
Race or Ethnic Group
and in Relation
to Total
Abnormal Findings
White
948
45
4.7
90.0
Negro
39
4
10.2
8.0
Mexican
13
1
7.7
2.0
Total
1,000
50
—
100.0
number of pregnancies and the atypical smear
are discussed.
It is our opinion that cytologic smear tech-
nique has a definite place in the practitioner’s
office and that the use of such facilities should
be expanded. The ready availability of slides and
fixative solution in the physician’s office and the
accessibility of a cytologist would serve to en-
courage such a practice.
The cytological method serves the valuable role
of pointing suspicion to malignancy, encouraging
close surveillance of the gynecologic patient with
atypical epithelium, and providing an indication
for repeated tissue evaluation.3
Acknowledgment
The writers would like to acknowledge their indebted-
ness to the physicians participating in the study and to
the members of the Cancer Research Committee of the
Saginaw County Medical Society; O. W. Lohr, M.D.;
H. C Matthews, M.D.; L. J. Morgette, M.D. ; R. F.
Powers, M.D.; P. E. Prather, M.D.; J. C. Smith, M.D.;
G A. Weidner, M.D. ; and to S. Wagner, M.D., for his
assistance in the compilation of the statistical material.
References
1. Michigan Department of Health, Division of Disease
Control, Records and Statistics. 1955.
2. Wynder, E. L.: Environmental factors in cervical
cancer. Brit. M. J., 1: (March 26) 1955.
3. Riley, G. M.; Dontas, E : and Gill. B. : Silver stain
cytology. Use of silver stain in the detection of
uterine cancer by the cytologic method: A survey
of over 6,000 cases. Obstet. & Gynec., 2:575, 1953.
MASS CASUALTY CONFERENCE
Monday and Tuesday, May 6-7, 1957, have been
established for a two-day Mass Casualty Conference at
Ann Arbor. The first day is to be devoted to activities
on a national level, the second day to regional and
local level planning.
There are now thirty-five medical schools affiliated
with the programs supported through the Department
of Defense with a goal to increase the teaching of
trauma in medical schools as related to national defense
and, where possible, items are being added to the
curriculum regarding trauma as related to national
disaster.
464
JMSMS
Cobalt60 Teletherapy in the Palliation of
Advanced Gastrointestinal Carcinoma
T^ORTY-FIVE patients with advanced gastro-
intestinal carcinoma have been treated by
means of Cobalt60 Teletherapy during the eighteen
months that the unit has been in use at Detroit
Memorial Hospital.
It has long been the. opinion of radiotherapists
that although adenocarcinomas of the gastro-
intestinal tract may present variable degrees of
radiosensitivity, they are, in general, not radio-
curable. However, the place of radiation in the
palliation of advanced disease of this nature is
well established. Unfortunately, irradiating the
abdomen with the usual x-ray apparatus (200 to
250 kilovolts) often causes symptoms of a more
severe nature than those for which the treatments
are given.
The Cobalt60 Teletherapy Unit provided a
source of high energy radiation similar to a con-
ventional x-ray machine operating at about 3
million volts. It was hoped that, using this unit,
a sufficient depth dose could be delivered to pro-
duce considerable palliation without causing the
patient undue distress due to the treatments. Two
factors pointed favorably to this possibility: (1)
The skin reactions with Cobalt60 radiation are
much less than with conventional x-rays. The
maximum dose rate is found not at the skin, but
at a level 4 mm. below the skin. The skin dose
rate is even lower than the dose rate in tissues
at a depth of 10 cm. (2) Since there is less
lateral scatter of the primary Cobalt60 beam, it
is possible to deliver a given tumor dose with
less irradiation of adjacent tissues. This permits
a smaller volume (integral) dose than with radia-
tion of lower energy Radiation sickness is, to
some extent, a function of volume dose.
Our earliest experience in the treatment of ad-
vanced gastrointestinal cancer encouraged the
acceptance of additional cases of a nature often
From the Department of Radiology, Wayne Univer-
sity College of Medicine and Detroit Memorial Hospital.
Dr. Williams is a Clinical Fellow, American Cancer
Society.
Aided by Grant from Atomic Energy Commission.
April, 1957
By J. E. Lofstrom, M.D., S. L. Balofsky, M.D.,
and C. R. Williams, M.D.
Detroit, Michigan
rejected for treatment with conventional radiation.
The first patient treated with the Detroit Memor-
ial Hospital Cobalt60 Unit was a man with an
inoperable, anaplastic carcinoma of the head of
LOCATION
NO.
AVERAGE
DOSE
NUMBER
PALLIATED
RADIATION
REACTIONS
Large Bowel
26
5000r/5 wks.
20
8
Stomach
9
5000r/6 wks.
5
4 '
Pancreas
6
5000r/6 wks.
2
1
Biliary
4
5000r/6 wks.
3
3
Total
45
30 :
16 :
67%
36%
Fig. 1. The entire group considered as to primary
site of disease, usual depth dose delivered, total number
palliated, and total number of radiation reactions.
the pancreas. He was accepted for treatment
with considerable hesitation and doubt. However,
following treatment, he improved subjectively as
well as objectively, and had six months of asymp-
tomatic, apparently normal life. Similar early
experiences with carcinoma of the large intestine
led us to be rather hesitant in rejecting patients
because of massive disease.
The forty-five patients now being considered
almost uniformly had massive local disease with
or without regional and/or distant mestases.
Many had lesions which were inoperable when
first diagnosed. An even larger group had dis-
ease representing postoperative recurrence. Figure
1 demonstrates the distribution of cases as to
location of the primary disease. It also indicates
the usual dose rate used in the treatment of the
various types. A fairly uniform dose schedule was
used ; in most instances a depth dose of 5000
gamma roentgens was delivered in a period of five
to six weeks. Alterations were made in this sched-
ule if necessary. These were determined by the
patients’ reactions to radiation and, occasionally,
by the response noted in tumor mass. Thirty
patients were, in our opinion, palliated to a great-
er or lesser extent. Sixteen patients experienced
465
GASTROINTESTINAL CARCINOMA— LOFSTROM ET AL
radiation reactions of some degree. No correla-
tion was observed between palliation and radia-
tion reactions. Figure 2 indicates the degree of
palliation achieved in the different groups of pa-
tients and in the group as a whole. The group of
Marked improvement in sense of well-being oc-
curred, and the patient survived six months, or
twice as long as the average for the group, in spite
of disease of the same type and extent as was pres-
ent in most of these patients.
DEGREE OF PALLIATION
Fig. 2. The degree of palliation achieved in each
group and in the group as a whole.
bowel cases is the only one large enough to be of
any real significance considered percentagewise.
It is seen that a total of 50 per cent of these pa-
tients received no or minimal palliation. In all,
38 per cent were palliated to a degree classified as
moderate or good. The remaining 12 per cent
were placed in an indeterminate group because of
our inability to say that we had brought about
any degree of palliation. This was due to the
fact that these patients had no definite symptoms
at the onset of therapy. They did, however, do
better for longer periods of time following treat-
ment than would be expected considering the
extent of their disease. For that reason we have
placed them in an indeterminate group — neither
classifying them as palliated nor unpalliated. The
symptom most commonly encountered in this and
the other groups was pain. Figure 3 shows that
77 per cent of the bowel cases had pain as a
presenting complaint. 75 per cent of these pa-
tients received some, frequently minimal, relief
of pain following Cobalt60 Teletherapy. Other
complaints frequently encountered were weakness,
anorexia, discharge, diarrhea, and general malaise.
Again examining Figure 2, it is noted that a
total of 88 per cent of patients with carcinoma of
the stomach received no or minimal relief follow-
ing irradiation. However, even though no defi-
nite symptomatic relief was obtained, we feel that
in this group obstruction was prevented in two
cases and bleeding halted in one case. One patient
has 'been classified as getting moderate palliation.
Fig. 3. Per cent of patients palliated when pain was a
primary complaint.
Fig. 4. Average survival time following irradiation.
We have treated only six patients with carci-
noma of the pancreas and four with carcinoma of
biliary tract origin. The value of roentgen ther-
apy for advanced carcinoma of the pancreas was
first demonstrated by Richards in 1922. Little
has been written on the subject in recent years.
We have had success in two of our six patients.
One was our first patient as previously de-
scribed, and the other our most recent case- — a
patient with very extensive local disease who
completed therapy four months ago and con-
tinues to feel well and gain weight.
Improvement following irradiation was noted in
three of the four patients with carcinoma of the
biliary tract. However, two of these were palliated
only minimally. The average duration of life in
these two groups (Fig. 4) was five months fol-
lowing therapy. For patients with cancer of the
bowel it was 5.5 months, stomach 3.1 months, and
the average for the entire group was 4.6 months.
466
JMSMS
GASTROINTESTINAL CARCINOMA— LOFSTROM ET AL
As was expected, the natural course of the disease
was not altered and patients well palliated did
not necessarily live longer than those getting no
relief at all.
Sixty-two per cent of the entire group were
Fig. 5. The degree of radiation reactions occurring
in each group and in the group as a whole. No severe
reactions occurred.
palliated not at all or only minimally. Consid-
ering this, and the fact that average life duration
following treatment was only 4.6 months, it be-
comes necessary to investigate the frequency and
severity of radiation reactions. It would indeed be
a sorry state if we were causing more distress
with the therapy than we were relieving. An ex-
amination of Figure 5 reveals that radiation re-
actions were remarkable only in their absence,
91 percent of patients experiencing no or minimal
symptoms due to therapy. In no case was it nec-
essary to discontinue treatments because of intol-
erance to irradiation. Only 9 per cent had reac-
tions of moderate severity. These were usually
well controlled by medication. In a few cases it
was necessary to decrease the daily rate, tempo-
rarily, while reactions were brought under control.
Considering the entire group, it would be diffi-
cult to say, with assurance, that more than 29 per
cent of these patients derived any definite benefit
from irradiation. This figure excludes all cases
classified as minimal palliation as well as those
called indeterminate. It is our feeling, however,
that many of these patients were not only signifi-
cantly benefited but that complications were fre-
quently prevented. Evaluation of minimal degrees
of palliation was most difficult because of the lack
of an adequate control group, and also, because
of the marked psychological reaction some patients
have to cobalt therapy. A more prolonged study
of a larger group of patients is needed for final
evaluation of Cobalt60 radiation as a means of
palliation of advanced gastrointestinal carcinoma.
Case Reports
The following two case histories are presented
as representative of the type of problems en-
countered.
A. W., a fifty-three-year-old white man was first
seen at another hospital on June 15, 1954, with a chief
complaint of abdominal pain and a history of dull pain
in the right upper quadrant for four years. There had
been a loss in weight of fifty-five pounds during the
past two years. On June 16, 1954 a complete gastro-
intestinal series, cholecystogram and chest x-rays re-
vealed normal findings. A second admission on June
29, 1954, resulted in cholecystectomy with a final diag-
nosis of cholecystitis and highly undifferentiated car-
cinoma of the pancreas which was deemed inoperable.
The patient was sent to us for cobalt teletherapy. Fol-
lowing discharge from the hospital the patient continued
to run a slight afternoon fever and complained of weak-
ness. He again lost approximately ten to fifteen pounds
in a three-week interval. An upper gastrointestinal se-
ries on July 20, 1954, revealed the entire descending
limb of the duodenum to be markedly irregular in
contour with complete destruction of mucosal pattern.
Cobalt therapy was started on July 21, 1954, and
was directed through two anterior and two posterior
12 x 15 cm. fields angled medially to crossfire the
pancreatic area. A tumor dose of 4400r was delivered
in six weeks. The final treatment was given on August
31, 1954, and an upper gastro-intestinal series on
September 28. 1954, revealed very marked improve-
ment in the appearance of the pancreatic area and
duodenum with decrease in size of mass and decrease
in duodenal infiltration. At a point midway in the
course of therapy, the patient became asymptomatic,
developed a sense of general well-being and began to
gain weight. He played nine holes of golf on his final
treatment day. A chest roentgenogram taken Decem-
ber 8, 1954, revealed metastatic carcinoma involving
the left lung. Pulmonary metastases advanced rapidly
and the patient died on February 23, 1955. He was
asymptomatic as far as his abdomen was concerned.
C. S., a thirty-eight-year-old white man was first
seen April 16, 1954. He had a history of bloody stools
for one week. Sigmoidoscopic examination revealed an
adenocarcinoma 15 cm. from anus. Abdominal perineal
resection of the rectosigmoid was done on April 22, 1954,
for adenocarcinoma of the rectum extending into serosa
with lymph node metastases. The postoperative course
was uneventful, except the patient complained of peri-
neal wound pain. A small mass appeared in this area
and was deeply excised on July 15, 1954, and showed
recurrent adenocarcinoma of rectum in the perineal
wound. It was felt that this was incompletely removed
(Continued on Page 473)
April, 1957
467
Results of Surgical Management of
Carcinoma of the Thyroid
T TOW EXTENSIVE should surgery be for
-L thyroid carcinoma? This controversial
question is especially applicable for the most com-
mon pathologic variety of thyroid carcinoma —
papillary adenocarcinoma, and the answer to this
question will come only from periodic, critical
evaluation of the results of treatment.
The objective of this study was to evaluate the
efficacy of the various surgical procedures done
at Henry Ford Hospital from 1924 through 1951,
and the data were correlated with the pathologic
type of lesion. An attempt was then made to
utilize this experience in arriving at a more ef-
fective and standardized plan of surgical treat-
ment.
Material
Thirty-seven patients with malignancy of the
thyroid were followed a minimum of three years
or until death. The distribution of cases with re-
gard to the pathology is shown in Table I.
Seventeen of these patients were followed from
five to twenty-seven years, seven from three to
five years and thirteen from operation to death, a
period which ranged from the immediate post-
operative period to twenty-one years.
The grouping of malignant thyroid lesions fol-
lowed in this report is based on the pathologic
classification used by Warren and Meissner.1 In
those instances where there were both papillary
and follicular elements, the predominating cellu-
lar arrangement determined the classification of
the neoplasm.
Group I. Papillary Adenocarcinoma. — Of the
nineteen patients with papillary adenocarcinoma
of the thyroid there were seven recurrences fol-
lowing the original surgery. Four of the patients
with recurrence expired of the disease (Table II).
In this group the primary surgery consisted of
From the Departments of Surgery and Pathology,
Henry Ford Hospital, Detroit, Michigan. Dr. Sawyer
is at present in the Department of Surgery, Middletown
Hospital, Middletown, Ohio. Dr. Bowman is at present
in the Department of Pathology, St. Mary’s Hospital,
Grand Rapids, Michigan.
By James L. Sawyer, M.D., Melvin A. Block, M.D.,
and Harold E. Bowman, M.D.
Detroit, Michigan
eight subtotal lobectomies in which there were
two recurrences; five total lobectomies with one
recurrence. The nodule only was excised in five,
with four recurrences. The fifth was deemed in-
operable after biopsy. There were seven radical
TABLE I. DISTRIBUTION OF VARIETIES OF THYROID
MALIGNANCY IN THIS STUDY
Type of Malignancy
No. of Patients
I. Papillary adenocarcinoma
19
Low grade
5
Papillary
14
II. Follicular adenocarcinoma
10
Low grade
1
Follicular
9
III. Undifferentiated carcinoma
(all small cell)
5
IV. Miscellaneous
3
Small cell carcinoma
1
Malignant Hurthle cell with metastases
1
Reticulum cell carcinoma
1
Total number of patients
37
TABLE II. PAPILLARY ADENOCARCINOMA
Operation
No.
Recurrences
Subtotal
8
2
Total
5
1
Nodule only
5
4
Biopsy only
1
0
Total
19
7
Radical Neck Dissection Papillary Adenocarcino'na
No.
Further Recurrence
Initial
3
0
After recurrence
4
1*
Total
7
1
^Distant metastases present at the time of neck dissection.
neck dissections in conjunction with either total or
subtotal lobectomy. Three were at the time of
the lobectomy with no recurrences; four were done
after recurrence with one re-recurrence. The re-
recurrence was not local and distant metastases
were present at the time of the neck dissection.
Thus, of the seven radical neck dissections done
either at the time of original surgery or after
recurrence, all are living without recurrence ex-
cept the one patient who had a metastasis at the
time of operation.
468
JMSMS
CARCINOMA OF THE THYROID— SAWYER ET AL
TABLE III. FOLLICULAR ADENOCARCINOMA
Operation
No.
Recurrences
Subtotal
4
2
Total
4
1
Nodule only
2
1
Total
10
4
Radical Neck Dissection
No.
Recurrence
Initial*
2
i
After recurrence
0
0
Total
2
1
*Both had a nodule excised within the previous month.
Group II. Follicular Adenocarcinoma. — None
of the ten patients with follicular adenocarcinoma
had apparent extensive lesions when first seen.
Four of these ten, however, developed recurrences
following the original surgery for their neoplasm.
One of the four patients experiencing recurrence
died of his disease and another has an inoperable
re-recurrence (Table III). Initial surgery con-
sisted of four subtotal lobectomies, with two re-
currences, four total lobectomies, with one recur-
rence; and two with excision of the nodule only,
with one recurrence. Both of the latter were fol-
lowed within one month with a limited and a
radical neck dissection respectively and cannot foe
considered as simple nodule excision for recur-
rence figures. Of the two neck dissections done
after nodule-only excision, one was a limited dis-
section followed in two years by a radical dissec-
tion for recurrence. The other was a bilateral
radical dissection. Both are living without evi-
dence of recurrence.
Group 111. Undifferentiated Carcinoma. —
Three of five patients in this group expired with-
in five years after surgery. Only one had definitive
surgery and this consisted only of subtotal lobec-
tomy. The two others had subtotal lobectomy
without recurrence.
Discussion
It is evident from this series that in certain
instances of thyroid carcinoma, especially the pap-
illary variety, limited removal of the neoplasm is
occasionally curative. However, such a plan of
therapy is followed by a significant number of
recurrences. In the group of papillary adenocarci-
nomas in this series, recurrences occured in eight
of nineteen patients, or 42 per cent. Further-
more, five, or 26 per cent, of this group died from
the disease. In the group of ten with follicular
carcinomas, four, or 40 per cent, developed recur-
rences and one patient succumbed from the neo-
plasm.
That papillary adenocarcinomas of the thyroid
grow and metastasize slowly is well recognized.
Thus, it is possible for limited excision to effect
a cure. These features of papillary adenocar-
cinoma of the thyroid have resulted in divergent
opinions as to how radical surgery should be for
this lesion. Crile2 had advocated conservative
surgical procedures for this malignancy. Others
have advised that radical neck dissections be
carried out concomitant with total lobectomy for
the primary thyroid lesion whether or not regional
node metastases are clinically evident.3"6 Several
investigators have emphasized that five and ten-
year follow-up evaluations are inadequate, since
fatal recurrences of thyroid carcinoma may occur
many years following the original surgery.7'9
Also, some papillary adenocarcinomas of the thy-
roid enlarge rapidly and metastasize widely to
regional nodes over a short period of time.10
It appears to us that a procedure consisting of
unilateral total lobectomy with excision of the
thyroid isthmus and ipsilateral radical neck dis-
section will be, in general, the operative pro-
cedure of choice for papillary and follicular
adenocarcinoma of the thyroid. Total thyroid-
ectomy is indicated where there are multiple foci
of malignancy in the gland.
It is not possible to predict which lesions will
respond to limited surgery. The risk of more
radical surgery is low. The malignancy has al-
ready spread to involve regional cervical lymph
nodes in approximately 50 per cent of the patients
with papillary adenocarcinoma even though the
metastases are not clinically evident.5 A significant
number of patients with papillary and follicular
adenocarcinoma of the thyroid will die of the
disease. Most of the patients with these types
of thyroid malignancy are young and have a long
life expectancy. Thus, more radical surgery ap-
pears reasonable and justified. The more radical
surgery for this disease need not be more muti-
lating than repeated, limited procedures.
In undifferentiated carcinoma of the thyroid,
radical procedures, if possible, are indicated.
However, the lesion is frequently so extensive that
definitive surgery is impossible.
There is no evidence available from this study
April, 1957
469
CARCINOMA OF THE THYROID— SAWYER ET AL
pertaining to the desirability or efficacy of media-
stinal dissection for thyroid carcinoma. The data
regarding postoperative radiation therapy is also
inconclusive, but our data do not indicate that
radiation has been curative in itself. Approxi-
mately an equal number of recurrences occurred
in those patients who received, and those who
did not receive, radiation therapy.
Summary and Conclusions
1. A follow-up study has been carried out on
the thirty-seven patients with carcinoma of the
thyroid treated surgically between 1924 and 1951.
All patients were followed a minimum of three
years or to death.
2. Most of the malignant lesions of the thyroid
are of the papillary or follocular variety or a
mixture of these two. Although these lesions
frequently enlarge and metastasize slowly, they
will cause death in a significant number of
patients.
3. Evidence from this study supports the view
that, even though limited excision of thyroid
carcinoma can be curative, recurrences which can
be fatal occur with sufficient frequency to warrant
total thyroid lobectomy with excision of the
isthmus and ipsilateral radical neck dissection as
the procedure of choice in treating papillary and
follicular varieties of thyroid carcinoma.
References
1. Warren, E., and Meissner, W. A.: Tumors of the
thyroid gland. Atlas of Tumor Pathology, Fasc.
14. Armed Forces Institute of Pathology, Washing-
ton, D. C., 1953.
2. Crile, G., Jr.; Suhrer, J. G., Jr.; and Hazard,
J. B. : Results of conservative operations for ma-
lignant tumors of the thyroid. J. Clin. Endocrinol.,
15: 1422-1431, 1955.
3. Martin, H. : The surgery of thyroid tumors. Can-
cer, 7:1063-1099, 1954.
4. Frazell, E. L., and Foote, F. W., Jr.: Papillary
thyroid carcinoma: Pathological findings in cases
with and without clinical evidence of cervical node
involvement. Cancer, 8:1104-1166, 1955.
5. Cattell, R. B., and Colcock, B. P. : The present-
day problem of cancer of the thyroid. J. Clin.
Endocrinol., 13:1408-1415, 1953.
6. Majarakis, J. D.; Slaughter, D. P.; and Cole,
W. H. : Carcinoma of the thyroid gland. J. Clin.
Endocrinol., 13:1530-1541, 1953.
7. Ward, R.: Malignant goiter; lessons to be learned
from twenty-year follow-up. West. J.. Surg., 55:
383-388, 1947.
8. Horn, R. C., Jr., and Dull, J. A.: Carcinoma of
the thyroid: a re-evaluation. Ann. Surg., 139:35-
43, 1954.
9. Sloan, L. W. : Of the origin, characteristics, and
behavior of thyroid cancer. J. Clin. Endocrinol.,
14:1309-1335, 1954.
10. Frazell, E. L., and Duffy, B. J., Jr.: Invasive pap-
illary cancer of the thyroid. J. Clin. Endocrinol.,
14:1362-1366, 1954.
CANCER REGISTRIES
(Continued from Page 450)
mittee are the American Cancer Society — South-
eastern Division, the American Cancer Society —
Michigan Division, Michigan Department of
Health, Michigan Health Officers Association,
Michigan State Dental Society, Michigan State
Medical Society.
The Michigan Tumor Registry has operated for
six years as a voluntary effort sponsored by the
Michigan Pathological Society and other organ-
izations interested in cancer control. It has been
felt that it should extend its operations and start
a central registry for cancer cases in the three
counties served by the Southeastern Michigan
Division of the American Cancer Society. The
Michigan Pathological Society has been requested
to seek the endorsement of the State Medical So-
ciety for this operation. The Board of Trustees of
the Southeastern Michigan Division has approved
of this action and is willing to support it.
Since most hospitals are now conducting regis-
tries within their institution, the first and most
important step in the success of a central registry
has already been accomplished. It depends upon
the cooperation of a group of well-established hos-
pital registries. The value and purpose of a hos-
pital registiy can be enhanced by the services of
a well-conceived and properly functioning central
registry.
470
JMSMS
Diagnostic Difficulties in
Carcinoma of the Colon
By Henry A. Chapnick, M.D.
Detroit, Michigan
HTHE THREE principal factors in the manage-
■*- ment of carcinoma of the colon are the nature
of the disease itself, the personality of the patient,
and the physician. The latter two are of particular
importance because if the nature of the disease
itself is fixed, the patient’s attitudes and the phy-
sician’s preparedness theoretically are not.
Carcinoma of the colon, as neoplasms else-
where, occur predominantly in the older age
groups. Its cause is not known, and the only
known predisposing factors are polyps, either pri-
mary or secondary to ulcerative colitis. The symp-
toms are due principally to the complications of
the disease and not to the mere presence of the
tumor. It is these complications of bleeding,
obstruction, perforation and distant metastases
that bring the patient sooner or later to the phy-
sician. For a disease that is readily diagnosable,
and that is surgically curable, a five-year survival
rate of less than 30 per cent1’2 is not a brilliant
yield.
The diagnosis of carcinoma of the large bowel
is easy enough in the patient who has rectal bleed-
ing, abdominal pains or changes in bowel habits
who promptly seeks medical advice, is sigmoido-
scoped and has a barium enema. It does not
detract from the importance of rectal or sigmoido-
scopic examinations to state that either one alone
or in combination without an x-ray of the lower
bowel does not constitute a satisfactory examina-
tion for carcinoma of the colon.
There is as yet no mass method of diagnosing
cancer of the colon. Each patient has to be stud-
ied individually and his co-operation is the first
prerequisite. Too frequently, however, there is
recourse to various cures for hemorrhoids and
constipation advertised on radio and television
before a diagnosis is made, and precious time is
lost. Even so, diagnosis can, for various reasons,
be very confusing. Some of these problems were
brought out from a review of the cases of carci-
noma of the colon seen at the Sinai Hospital of
Detroit.
From the Medical Service, Sinai Hospital of Detroit.
A common problem is that of the patient who
has been known to have diverticulitis for years,
and either because of a change of symptoms or
the radiographic appearance, the question of car-
cinoma arises. The problem may not be resolved
even at laparotomy. There is frequently delay by
the patient because he ascribes the new symptoms
to his antecedent disease and delay by the physi-
cian because of his reluctance to explore an el-
derly patient for an equivocally malignant lesion.
Similarly, patients with chronic ulcerative coli-
tis may develop carcinoma without any new
symptoms, and it may be impossible for the roent-
genologist to determine whether the mucosal
changes are due to pseudo-polyps or carcinoma.
Fever of unknown origin is a common enough
medical problem. All experienced physicians
consider neoplasms as a possible cause for fever,
but infections by various organisms and in various
anatomic regions and the lymphomata are usually
considered first. The correct diagnosis may be
impeded by misleading findings. A thirty-three-
year-old woman had been hospitalized elsewhere
for what was thought to be pneumonia. In spite
of the use of all the broad-spectrum antibiotics,
her spiking fever persisted over a period of
months. A hematologist thought she had abdomi-
nal Hodgkin’s disease; biopsy of a cervical node
was suggestive of histoplasmosis or torulosis. A
barium enema demonstrated carcinoma of the
transverse colon and at laparotomy there was
widespread metastasis. Another patient had low
grade fever for six months and rectal bleeding for
six weeks. A rectal polyp was found and fulgu-
rated 'but the fever persisted until a carcinoma of
the colon, that was subsequently demonstrated by
x-ray, was removed.
Not infrequently the patient’s presenting symp-
toms are extraintestinal and due to involvement
of another organ by metastasis or irritation. Oflfen3
recently reported six cases of what were consid-
ered to be primary ovarian tumors. In two cases
it was at the pathologist’s suggestion (Dr. S. D.
Kobernick), after studying the sections of the
April, 19 57
471
CARCINOMA OF THE COLON— CHAPNICK
ovarian tumor, that x-ray studies of the colon
were done and the primary lesion in the colon
was discovered; the ovarian tumor which gave
the patients their symptoms represented metasta-
ses. These surprises may be avoided if complete
gastrointestinal x-ray studies are done before such
patients are operated on.
A thirty-one-year-old patient was admitted
with a diagnosis of carcinoma of the bladder be-
cause of dysuria, a mass in the lower abdomen,
and anemia. X-ray of the lower bowel was done
because of bloody diarrhea on one occasion. Car-
cinoma of the sigmoid was demonstrated. The
presenting urinary symptoms were believed to be
due to attachment of the neoplasm to the dome
of the bladder.
Another patient was admitted for a cataract
operation but had no other symptoms. An ad-
mission photo-fluorogram, and a subsequent regu-
lar chest film, revealed pulmonary opacities.
Comparison with several previous chest films
revealed a gradual increase in the size of these
opacities. The roentgenologic interpretation was
metastatic carcinoma. Barium enema revealed
that the primary lesion was in the colon. The
patient was entirely asymptomatic.
One cannot depend invariably on the surgeon’s
ability to find an unsuspected carcinoma at a
laparotomy done for some other purpose. Some
parts of the colon, notably the flexures, are not
readily accessible to palpation and can be easily
missed even after a careful search. A sixty-five-
year-old man was admitted because of melena.
He had had a gastroenterostomy twenty-five years
previously for a duodenal ulcer. A barium meal
demonstrated an ulcer niche from which the
bleeding could have come. The gastroenterostomy
was undone and the patient had a subtotal gas-
tric resection. The surgeon noted no other ab-
normalities in the abdomen. The patient had a
slow convalescence from the surgery and within
a year was admitted with hepatic metastasis from
carcinoma of the hepatic flexure. The carcinoma
very likely was present at the time of the gastric
resection one year before but was not discovered
by palpation.
In carcinoma of the cecum, obstruction is a late
manifestation. The patient’s symptoms may be
entirely referred to the upper abdomen,4 and
carcinoma of the stomach rather than of the ce-
cum may be suspected. X-ray studies limited to
the upper gastrointestinal tract will of course fail
to reveal the cecal lesion, and the unsuspecting
physician may ascribe the patient’s symptoms to
functional disease.
Some of the more obvious errors are to assume
that a barium meal alone can exclude a lower
bowel carcinoma, or to blame a rectal polyp for
bleeding without searching for a carcinoma more
proximally. The frequently made statement that
70 per cent of all lower bowel carcinomas can
be detected either by the finger or the sigmoido-
scope5 is perhaps an oversimplification. Many
carcinomas will be missed if x-ray examinations
are not also done.
Some of our patients claimed to have had no
symptoms until the onset of obstruction. On
careful questioning, however, it was elicited, for
example, that several months before there had
been rectal bleeding lasting only one day. Both
physician and patient usually think that a symp-
tom of a serious disease will not occur for one or
two days and then disappear. Transitory symp-
toms, it should be emphasized, may be the fore-
runners of serious trouble and should not be
ignored.
Another problem tending to delay clinical diag-
nosis is the tendency for the patient to blame new
symptoms on previous chronic illness. One patient
had known for many years that she had chronic
gall bladder disease. Surgical treatment was de-
layed until symptoms became very severe. The
physician whom she consulted for the treatment
of her gall bladder disease found that the recent
aggravation of her supposed cholecystitis was due
to an inoperable carcinoma of the colon.
The patient’s attitude towards his illness is
usually an extension of the pattern in which he
has faced his other problems in life. He may deny
their existence, or minimize their importance, or
unconsciously choose a method that will lead to
his destruction. All the fears he may have had of
insecurity, dependency, humiliation, mutilation
and death seem to conspire at this time of illness
in his old age. The following are examples of
such attitudes. A man of sixty-seven, who had
never married, ignored his symptoms for two
years, partly because he couldn’t admit to himself
that he was ill, and also because he feared that
he might become an unwelcome burden to his
brothers with whom he was never close. He
sought help only when his life was almost at an
end. Just as he feared, there was no place for
472
JMSMS
CARCINOMA OF THE COLON— CHAPNICK
him at the homes of his kin; he died in a charity
institution.
Another patient was a chronic alcoholic with
severe heart disease who had rectal bleeding for
two years before he consulted a physician. By that
time he already had obvious liver metastasis from
cancer of the large intestine.
Another group that frequently dooms itself and
is helped along by its well-meaning children is the
elderly. The reasoning is that at sixty-eight the
patient will probably die of another disease be-
fore the existing cancer causes death. Why sub-
ject him to what is in all likelihood an unneces-
sary operation? These patients often become ob-
structed or perforate and have to undergo emer-
gency surgery when ill prepared for it and when
cure is no longer possible. One such patient had
a diagnosis of cancer made seven years before
and finally died of intestinal obstruction.
Any patient who has been treated for carcinoma
of the colon should be under medical observation
not only for the management of possible recur-
rence but also because of the greater suscepti-
bility to another carcinoma in the colon. One of
the patients had a carcinoma of the colon re-
moved. Eight months later she had a routine fol-
low-up barium enema which showed a polyp in
the more proximal colon. A frozen section was
suggestive of stalk invasion and a wedge resection
was done.
Summary and Conclusions
The diagnosis of carcinoma of the colon is
usually not difficult, but may be so. Antecedent
diseases, fever, and extra-intestinal symptoms may
divert the physician’s attention from the colon.
An important factor in the early diagnosis and
cure is the patient’s attitude and method of deal-
ing with life’s problems, including that of cancer.
References
1. Coller, Frederick, A.; Lillie, Richard A.; Bryant,
Milton F.; and Brown, William E.: Cancer of the
rectum. Ann. Surg., 135:841, 1952.
2. Buser, J. W.; Kirsner, J. B.; and Palmer, W. L. :
Carcinoma of the large bowel: Analysis of clini-
cal features in 478 cases, including 88 five-year
survivors. Cancer, 3:214, 1950.
3. Offen, J. A.: Diagnostic confusion of ovarian car-
cinoma with carcinoma of the colon. Bull. Sinai
Hosp., Detroit, 3:54, 1955.
4. Costello, Cyril: Cancer of the cecum. Cancer,
5:254, 1952.
5. Jackman, Raymond J.; Neibling, H. A.; and
Waugh, J. M.: Diagnostic errors in carcinoma of
the large intestine. J.A.M.A., 134:1287, 1947.
6. King, R. A., and Leach, J. E.: Factors contributing
to delay by patients in seeking medical care.
Cancer, 3:571, 1950.
GASTROINTESTINAL CARCINOMA
( Continued from Page 467)
and the patient developed increasing pain requiring
large doses of narcotics. For these reasons the patient
was referred to us for palliation with Cobalt60 radiation.
A series of Cobalt60 teletherapy treatments was start-
ed on August 19, 1954, and the fields included the low
lumbar and perineal regions. A depth dose (midline
pelvis) of 4000r was delivered in five weeks. Final
treatment was given September 23, 1954. The patient
experienced no difficulties from irradiation. Marked im-
provement was noted, the pain vanished, and the pa-
tient stopped taking narcotics.
On January 13, 1955, however, the patient noted on-
set of upper lumbar pain. Palliative irradiation to this
area (1700r in two weeks) resulted in decreased pain.
He remained asymptomatic for four months.
On May 25, 1955, the patient was seen and com-
plained of frequent vomiting and upper and abdominal
pain. X-ray examination at this time revealed mechani-
cal obstruction of small bowel. He experienced repeated
severe bouts of obstruction and was finally explored on
July 21, 1955, when metastatic adenocarcinoma was
found. The patient developed cardiac arrythmia, decom-
pensation, and expired on July 21, 1955.
The final autopsy diagnosis was peritoneal carcinoma-
tosis with adhesions and small bowel obstruction, exten-
sive metastases to liver, gall bladder, serosal surfaces,
mesentery and omentum. It was especially interesting
that the perineal area, which had received the largest
amount of irradiation, showed only minimal involvement.
Conclusion
Cobalt60 teletherapy provides a super-voltage
modality for the treatment of lesions of the gastro-
intestinal tract without disturbing side effects.
Palliation only should be expected, and this was
accomplished to a moderate or marked degree in
29 per cent of all cases. Relief of pain occurred
as a most subjective result in 75 per cent of pa-
tients having such complaints. In general, results
were best in carcinoma of the colon and rectum
(38 per cent).
Bibliography
1 . Richards, G. E. : Possibilities of roentgen ray in
cancer of the pancreas. Am. J. Roentgenol., 9: ISO-
152, 1922.
April, 1957
473
Cancer of the Stomach
By Cameron Morrison, M.D.,
and Gerald S. Wilson, M.D.
Detroit, Michigan
T'HERE have been 128 cases of carcinoma of
the stomach initially treated at the Dearborn
Veterans Administration Hospital from January,
1947, through December, 1954. During this
eight-year-period only those cases proven to be
gastric adenocarcinoma at operation or at autopsy
were included in the survey. Although this series
is relatively small, it has the value of being well
documented with excellent follow-up records. A
similar study at the Detroit Receiving Hospital
and a private institution is now in progress which
will supplement this group and add valuable
comparative data.
There were 128 men and no women, reflecting
the predominantly male population of the
Veterans Administration Hospital (Table I).
Although nearly 50 per cent of the patients were
in the sixth decade of life, there were an ap-
preciable number in the thirties, and one patient
was twenty-seven years of age. There were
ninety-six white and thirty-two negro patients.
TABLE I. 128 CASES OF CARCINOMA OF STOMACH
AT DEARBORN VETERANS HOSPITAL
January, 1947, through December, 1954 (8 years)
Sex
Color
Males
128
White
92
Females
0
Negro
32
Age
20-29
1
30-39
9
40-49
10
50-59
61
Youngest
27 years
60-69
32
Oldest
81 vears
70-79
14
80-89
1
Total
128
One of the most distressing problems in relation
to gastric carcinoma is the difficulty of detecting
the malignancy in an early stage while a curable
resection may still be feasible. Because the human
stomach is such an adaptable organ, early symp-
toms of the disease are likely to be vague and
disregarded for long periods of time by both the
patient and the physician. This delay in suspect-
ing a gastric lesion is borne out in our series in
From the Department of Surgery, Wayne University
College of Medicine and the Dearborn Veterans Ad-
ministration Hospital. Supported in part by the Ameri-
can Cancer Society, Southeastern Michigan Division.
474
that approximately one-half of the patients experi-
enced symptoms for three months or longer before
admission and one-third for six months or longer,
with the distribution as noted in Table II.
TABLE II. DURATION OF SYMPTOMS PRIOR TO
ADMISSION
0-1
21
1-3
37
3-6
23
6-9
19
9-12
6
Over 12
9
Unknown
13
128
3 months or longer
55 (50 per cent)
6 months or longer
34 (30 per cent)
The most common initial
symptom was upper
abdominal pain but in a number of instances the
patient first noticed epigastric distress or dis-
comfort short of actual pain (Table III). In
three instances the patient’s
first complaint was
his feeling of an abdominal
mass.
TABLE III. INITIAL
SYMPTOMS
Abdominal pain
62
Epigastric distress
27
Anorexia
10
Vomiting
8
Weight loss
6
Weakness
6
Constipation
3
Abdominal mass
3
Hematemesis
2
Tarry stools
i
Upper abdominal pain was the most frequent
presenting symptom, followed by vomiting,
anorexia and nausea, tarry stools, weakness,
dysphagia, and finally a palpable mass (Table
IV).
TABLE IV. PRESENTING SYMPTOMS
Epigastric pain
109
Vomiting
47
(a) Blood
16
Anorexia and nausea
43
Tarry bloody stools
22
Weakness
18
Dysphagia
6
Palpable mass
5
Although most of the patients were free of
symptoms referable to the stomach until the onset
of their present illness, it is of considerable interest
that approximately 20 per cent of the patients
volunteered a typical peptic ulcer history for
periods varying from five to twenty-five years
TMSMS
CANCER OF THE STOMACH— MORRISON AND WILSON
(Table V). In the latter cases there was a history
of an ulcer having been demonstrated by upper
gastrointestinal series in eight instances; previous
surgery had been performed for peptic ulcer in
TABLE V. PAST HISTORY RELATIVE TO ULCER
SYMPTOMS
No ulcer symptoms until onset of present illness 102
Ulcer symptoms for over five years 26
History of gastrointestinal series showing ulcer 8
Previous surgery for ulcer 3
Gastrointestinal tract bleeding 2
Gastrointestinal series showing duodenal ulcer at
Veterans Administration Hospital 7
Duodenal ulcer proven at surgery at Veterans
Administration Hospital 1
three cases; gastrointestinal tract bleeding had
occurred in two; and seven patients showed duo-
denal ulcers by x-ray at the Dearborn Veterans
Hospital during a previous admission. Only one
patient, however, was proven at surgery to have
a duodenal ulcer associated with the gastric
neoplasm. The actual demonstration of a duo-
denal ulcer at operation in only one instance in
this series agrees with other published reports1
that the association of a duodenal ulcer with a
gastric carcinoma is rare.
TABLE VI. PHYSICAL FINDINGS
Palpable mass
36
Abdominal tenderness
35
Enlarged liver
19
Palpable lymph nodes
8
Edema
5
Rectal shelf
4
Jaundice
3
Enlarged spleen
Blood on rectal exam
2
Ascites
2
No positive findings
49
The most commonly encountered positive
physical finding at the time of admission was the
presence of a palpable abdominal mass in thirty-
six instances, followed by abdominal tenderness in
thirty-five, an enlarged liver in nineteen, palpable
lymph nodes in eight, edema of the extremities in
five, rectal shelf in four, jaundice in three, enlarged
spleen in two, blood on rectal examination in two,
and ascites in two (Table VI). The palpable
lymph nodes were usually cervical and were ob-
viously involved by carcinoma. Approximately
one-third of the cases showed no positive physical
finding. As has been pointed out by other ob-
servers,2 a palpable mass does not indicate a non-
resectable or incurable lesion, in that nine patients
with abdominal masses in the present series under-
went gastric resection, three surviving five years.
Examination of the gastric aspirate by the
twelve-hour night secretion method was performed
in eighty-three instances (Table VII). Fifty-four
patients (65 per cent) showed complete anacidity,
seven showed values of free acid less than 20
units, eleven between 20 and 40 units, and in
eleven cases hyperacidity was demonstrated.
TABLE VII. LEVEL OF FREE HCL
Tests performed 83
Absent 54 (65 per cent)
Under 20 7
20-40 11
Over 40 11
The barium meal constitutes the most accurate
means of diagnosing gastric malignancy, although
lesions located in the fundic portion of the stomach
are likely to be missed and pyloric lesions may
give only indirect evidence of their presence by
producing obstructive phenomena. A barium
meal was administered in 121 instances in this
series, and the lesion was identified and correctly
designated as malignant in the vast majority of
cases (Table VIII), In ten cases, however, the
lesion was missed, the most common anatomical
location of error being the fundus.
TABLE VIII. GASTROINTESTINAL SERIES
Performed
121
Lesion missed
10
Gastroscopic Examination
Performed
47
Lesion missed
10
Gastroscopic examination was performed in
forty-seven of the 128 cases and the lesion
visualized in thirty-seven instances. More im-
portant, gastroscopy demonstrated the malignancy
in three instances where it had been missed by
x-ray studies. This agrees with the general con-
cept that x-ray and gastroscopy are both valuable
diagnostic procedures and should supplement one
another.
The gross pathologic anatomy of gastric carci-
noma is dependent upon the direction in which
the various forms of carcinoma spread from their
origin in the epithelium of the stomach.3 If the
speed of growth is greatest toward the lumen, a
cauliflower-like projection results and is termed a
fungating carcinoma. These eventually grow
laterally and also penetrate the wall of the stomach
but at a relatively slow rate. Forty-one of the
cases in this series were of the fungating type
(Table IX). In the more dangerous penetrating
variety, ulceration occurs initially, tending to
mimic benign gastric ulcer, growth is away from
the lumen and rapidly reaches the serosa. This
variety was present in forty-one of the patients
April, 1957
475
CANCER OF THE STOMACH— MORRISON AND WILSON
in our series. The superficial spreading variety
of carcinoma tends to remain locally confined to
the mucosa and occurred in one instance in this
series. The linitis plastica variety of carcinoma
to the inclusion in our series of only proven cases
(Fig. 2). Fourteen per cent were not suitable
for operation. Fifty-three per cent of the total
Fig. 1. Location of carcinoma at surgery (8 per cent
involved almost entire stomach).
originates from the deepest glands in the mucosa
and permeates the entire gastric wall stimulating
the production of abundant fibrous tissue. Two
of our cases were of this variety. In fifty-seven
instances, the lesion was not capable of gross
classification, either because of the advanced stage
of the disease or because the stomach was not
opened at surgery.
TABLE IX. GROSS PATHOLOGY
Penetrating (ulcer) 41
Fungating 27
Superficial spreading 1
Linitis plastica 2
No special type , 57
The anatomical location of the malignancy was
determined by reviewing the operative report, the
surgical pathology report, and in some instances
the autopsy protocol. Almost 50 per cent of the
lesions were situated in the distal third of the
stomach (Fig. 1). In 25 per cent the lesion was
in the body; in 9 per cent in the fundus; and in
10 per cent in the paracardial region. In 9 per
cent the involvement was so extensive that more
than one anatomical division of the stomach was
involved.
Our operability rate of 86 per cent is high com-
pared to other series2,4 and is in part due
OPERABILITY and RESECTABILITY
% 0 10 20 30 40 50 60
Fig. 2. Operability and resectability rates.
number of cases underwent gastric resection; 33
per cent for cure and 20 per cent for palliation.
In the latter group it was obvious to the operating
surgeon that all malignant tissue had not been
removed. Thirty-three per cent were not felt
to be suitable for resection.
Of the sixty-eight gastric resections, fifty-three
were of the so-called radical subtotal variety and
fifteen were total gastrectomies (Table X). In
the subtotal group there were five postoperative
deaths, giving an operative mortality of 9 per
cent. (An operative mortality has been arbitrarily
designated as a death occurring within thirty days
of the operation regardless of the cause, or within
any time interval if the death was attributable to
the operation.) One death resulted from a pul-
monary embolus on the twenty-first postoperative
day, one from a ruptured aortic aneurysm on the
thirteenth postoperative day, and one from bleed-
ing esophageal varices on the second postoperative
day. One patient died of an unrecognized
strangulating bowel obstruction secondary to an
adhesion at the site of a previously performed
appendectomy, and one patient succumbed to
pancreatitis on the forty-fifth postoperative day.
Five operative deaths followed total gastrectomy,
giving an operative mortality of 33 per cent. One
patient died during the third postoperative month
as the result of an esophageal fistula; another died
one month postoperatively as the result of an
evisceration and the development of a large bowel
fistula, and a third died on the nineteenth post-
operative day as the result of gangrene of the
476
TMSMS
CANCER OF THE STOMACH— MORRISON AND WILSON
transverse colon. The two remaining deaths
occurred as the result of a hemolytic transfusion
reaction and a pulmonary embolus. The total
number of deaths, therefore was ten, resulting in
5 YEAR SURVIVALS
°/o 0 5 10 15 20 25 30 35 40
ABSOLUTE
RESECTED
FOR CURE
Fig. 3. Five-year survival rate.
an over-all operative mortality of 14 per cent.
The over-all operative mortality in this series, and
especially the mortality in the subtotal gastrectomy
group, compares favorably with other reported
series.2,4"7
TABLE X. OPERATIVE MORTALITY
No.
No.
Cases
Deaths Mortality
Subtotal Gastrectomy
53
5
9.42 per cent
i.
Pulmonary embolus
— 21 days
2.
Rupture aortic aneurysm
— 13 days
3.
Small bowel obstruction
— 21 days
4.
Bleeding esophageal varices — 2 days
5.
Pancreatitis
— 45 days
Total
1.
Gastrectomy
Esophageal fistula
— 3 months
15
5
33 per cent
2.
Evisceration, large bowel
fistula
— 1 month
3.
Gangrene transverse colon
— 19 days
4.
Blood transfusion
— 3 days
5.
Coronary occlusion
— 3 days
All Resections
68
10
14.6 per cent
Through the efforts of the Tumor Board of the
Dearborn Veterans Hospital, all 128 patients in
this series have been successfully followed. Seventy-
seven of the 128 cases were operated on five or
more years prior to the final follow-up survey of
February, 1956, resulting in an absolute five-year
survivorship of 13 per cent (Fig. 3). This
absolute survival is high in comparison to other
reported series,2,4'7 partly because of the exclusion
of all cases from this series unless proven at
operation or autopsy. Twenty-five of the seventy-
seven cases were resected with the possibility of
cure, resulting in a five-year survivorship of 40
per cent for those resected for cure. Although the
number of cases involved is rather small, this
excellent outlook for those patients who are re-
sected in a stage where the surgeon believes he
has removed all grossly malignant tissue offers
considerable encouragement to those interested
in the treatment of gastric malignancy.
Summary
1 . One-hundred and twenty-eight cases of
gastric carcinoma initially treated at the Dearborn
Veterans Hospital during an eight-year period,
from January, 1947, through December, 1954, are
reviewed.
2. Fifty-three per cent of the entire series
underwent gastric resection, 33 per cent with the
hope of cure and 20 per cent as a palliative pro-
cedure.
3. The over-all operative mortality of 14 per
cent is discussed in relation to subtotal and total
gastrectomies.
4. A five-year survivorship of 40 per cent of
those resected for cure was found in this group of
patients.
References
1. Magovern, George J.; Friedman, M. N.; and
Freund, Robert H. : The coexistence of duodenal
ulcer and gastric carcinoma. Surgery, 33:421-424,
1953.
2. Moore, John R., and Morton, H. S.: Gastric car-
cinoma. Ann. Surg., 141:185-192, 1955.
3. Stout, A. P. : Tumors of the Stomach, AFIP
Fascicle 21, 1953.
4. Guiss, Lewis W.: End results for gastric cancer;
2,891 cases. Internat. Abstr. Surg., 93:313-331,
1951.
5. McNeer, Gordon, and Pack, George I. : Postopera-
tive mortality after total gastrectomy. Cancer,
7:1010-1015, 1954.
6. Ransom, Henry K.: Cancer of the stomach. Surg.,
Gynec. & Obst., 96:275-287, 1953.
7. Walters, Waltman, and Berkson, Joseph: An im-
provement of 180 per cent in the five-year sur-
vival rate of patients with carcinoma of the
stomach. Ann. Surg., 137:884-890, 1953.
“OPEN HOUSE” AT WMA SECRETARIAL OFFICE
During the entire week of the AMA meeting, June
1-6, 1957, there will be “open house” for U. S. Com-
mittee members at the World Medical Association office
on the 12th floor of the Coliseum Towers, immediately
adjoining New York’s famous Coliseum, where the
April, 1957
AMA’s Scientific and Technical Exhibits are to be
housed.
Members are urged to come up for a welcome respite
from the exhibit crowds, to enjoy a cup of coffee,
and see the home office of the “international voice of
medicine.”
477
Herniation of Abdominal Viscera into the
Thorax through the Foramen of Bochdalek
IAPHRAGMATIC hernias occur at weak
points in the diaphragm, usually at sites of
fusion of several components — at the foramen of
Morgagni (between the sternal and costal por-
tions), at the foramen of Bochdalek (between the
costal and lumbar portions), at the visceral for-
amina (the esophageal hiatus), and where failure
of development or congenital absence of a segment
of diaphragm occurs.9
The classification of diaphragmatic hernias can
be made on an etiologic basis. They may be
congenital or acquired, traumatic or nontraumatic,
true (hernial sac) or false.
The most common site of herniation is at one
of the visceral foramina, the most important of
which is the esophageal hiatus. The next most
common site of herniation is in the posterior por-
tion of the left dome of the diaphragm, because
it is the last part to fuse. Failure of fusion of the
pars costalis with the pars lumbalis results in a
persistent pleuroperitoneal hiatus, or foramen of
Bochdalek. This area is a common site of hernia-
tion in children.3
Less commonly, a hernia may present through
a defect at the site of fusion of the pars sternalis
and the pars costalis, forming the foramen of
Morgagni.
Congenital defects are usually present at birth
but actual herniation may not occur or be recog-
nized until later in life.
Embryology
Embryologically, the anterior and lateral costal
portions of the diaphragm arise from the ventrally
located septum transversum which eventually
forms most of the muscular elements of the dia-
phragm. The septum transversum originates in
the cervical region, accounting for the cervical
source of the phrenic nerve. The posterior and
lateral portions of the diaphragm are derived from
the pleuroperitoneal membrane and, posteromedi-
ally, from the dorsal mesentery.
From the Department of Radiology, Lakeside Medical
Center, Detroit, Michigan.
478
By Herbert L. Fishbein, M.D.,
and Samuel Fink, M.D.
Detroit, Michigan
Case Presentation
E. S.. a thirty-nine-year-old white woman, was well
until July, 1949, when she was involved in a severe
automobile accident, striking her abdomen against the
steering wheel and at the same time sustaining fractures
of the left hip, right ankle and the skull. She was
treated at a local hospital and during her stay experi-
enced vague upper abdominal discomfort accompanied
by occasional short episodes of nausea. Her abdominal
symptoms persisted to a mild degree after her discharge
from the hospital, but she never consulted a physician
about them.
In December, 1954, she was involved in a less serious
automobile accident, again striking her abdomen against
the steering wheel. The vague abdominal symptoms,
which had persisted since the previous accident, became
markedly increased, now accompanied by anorexia and
episodes of nausea and vomiting. She was then ad-
mitted to the Lakeside General Hospital.
Chest roentgenograms taken on admission revealed a
fluid level in the lower part of the left thoracic cavity.
The fluid apparently was contained in a sac, and the
additional finding of gas within this area suggested loops
of bowel, herniated through the left posterior diaphragm
(Figs. 1 and 2). In Figure 2, the bowel contour has
been outlined with crayon pencil. On the basis of
these findings, a complete study of the gastrointestinal
tract was done.
A barium enema (Figs. 3 and 4) revealed splenic
flexure, portions of transverse colon and descending colon
in the left posterior thoracic cavity, passing through a
defect in the posterior aspect of the left dome of the
diaphragm (note diaphragm outlined by crayon pencil
in the photographs).
A study of the upper gastrointestinal tract revealed
(Figs. 5 and 6) a complete inversion of the stomach
which appeared to be almost completely herniated into
the left thorax, through the same diaphragmatic defect.
She underwent surgery in January, 1955. There was
a large tear in the posterior portion of the left dome
of the diaphragm, corresponding to a foramen of Boch-
dalek. There was some scarring present as well, ap-
parently representing a traumatic lesion. The tear
extended from the posterolateral diaphragmatic attach-
ment, across the dome of the diaphragm, to within two
centimeters of the esophageal hiatus. A large segment
of transverse colon, splenic flexure, and descending colon
were herniated through the defect into the left thoracic
cavity, as well as omentum, the entire stomach, and
spleen. There was no evidence of a peritoneal sac.
JMSMS
HERNIATION— FISHBEIN AND FINK
Fig. 1. Fig. 2. Fig. 3.
The lower left pulmonary lobe was collapsed and dis-
placed toward the mediastinum.
Because of adhesions, the spleen was resected and
the other involved organs pushed back into the ab-
dominal cavity, followed by repair of the defect.
The patient made an uneventful recovery and was
discharged four and one-half weeks following surgery.
Discussion
The patient reported in this paper apparently
had a congenital malformation and either an
existent or potential foramen of Bochdalek. The
trauma resulting from two automobile accidents
completed the defect so that the involved viscera
herniated into the left thorax. The scarring found
at surgery and the markedly widened defect would
seem to indicate a long-standing or chronic process,
possibly begun following the first accident. The
absence of a peritoneal sac would seem to indicate
a basic congenital etiology, since the presence of a
sac usually indicates trauma as the basic etiologic
factor.
Acknowledgment
We wish to acknowledge, with sincere appreciation,
the clinical material furnished on this case by Dr.
Kenneth Campbell, and Dr. Joseph Arena, Jr.
987 E. Jefferson Avenue
Detroit 7, Michigan
References
1. Gotlieb, G. G. : Brit. J. Radiol., 19:429, 1946.
2. Hedblom, C. A.: Surg. Clin., North America, 4:543.
1924
3. Donovan, E. J.: Ann. Surg., 122:569-581 (Oct.)
1945.
(Continued on Page 503)
April, 1957
479
A Page from Medical History
IV. The Hebrews
“Argentina
“Unexpected Trends in the Art of Healing. — Some
unexpected developments have taken place in this
country in recent years. Official diplomas have been
granted, after previous examination, to practitioners
of two kinds. The members of one group claim that
through clairvoyance, they can see the body organs
and diagnose the patient’s illness. They give advice
as to whether operations recommended by surgeons are
necessary; in most cases they give their approval.
Members of the other group predict future events and
state that they can see persons not in the room. Neither
group is allowed to practice medicine, and both are
cautious not to interfere with the activities of competent
physicians.
“An American evangelist, Tommy Hicks, from Lan-
caster, California, has been speaking to groups of
10,000 to 40,000 persons assembled on football fields.
He claims that faith in God can completely cure most
diseases. Many people of Buenos Aires, having become
conditioned to the authority of radio addresses, are
readily impressed by anything broadcast over a loud
speaker. The number of persons announcing the cure
of cancer, hypertension, etc., without any demonstrable
evidence has greatly increased.” (J.A.M.A., 155:1179,
July 24. 1954.)
"P ALESTINE, the land bridge between Meso-
-*• potamia and Egypt, has recently been the
site of another attempt by the Jews to establish
a homeland. This has resulted in the ousting
of some 700,000 Arabs from their home.9 Palestine
and the Hebrews are of special interest to us be-
cause their literature forms the basis of our re-
ligious ideas.
The word Palestine is derived from Philistine.
Knowledge of the Jews is derived from internal
sources (The Old and New Testaments) and
external sources (archeologic investigations). The
Old Testament by no means includes the whole
of the ancient Jewish writings. The present text
of the Old Testament is thought to have become
fixed between the sixth and eighth centuries A.D.
A number of ancient Jewish writings not auth-
orized as being inspired are collectively known
as the Apocrypha. It is an interesting fact that
the oldest existing manuscript of the Hebrew
Dr. Summers at present is on active duty with the
U. S. Navy as Commander, MC, USNR, U. S. Naval
Hospital, St. Albans, Long Island, New York.
By John E. Summers, M.D.
Grand Rapids, Michigan
Old Testament, The Codex Babylonicus Petro-
politanus, goes back only to 916 A.D. The present
text of the New Testament was not fixed until
382 A.D. at a Council of the Church held in
Rome. At least 109 books of the New Testament
are not included in our present text.4
The Jews came rather late onto the stage of
civilization. Several Babylonian civilizations had
risen and fallen. Egypt had already reached her
Golden Age and was declining in political power.
The Hittite Empire had risen and fallen. The
Aegean civilization (a very high stage of civiliza-
tion had been attained on the island of Crete)
had been destroyed by the invading Greek bar-
barians and some of the Cretans had fled to
Canaan where they were known as Philistines.
The Hebrews played a minor role in the theater
of ancient history. Herodotus mentions them only
three times. One reference pertains to circumci-
sion. The second concerns the conquests of a
Pharaoh called Sesostris. This Pharaoh left vic-
tory monuments in the countries which he con-
quered. In those countries which submitted to
him without a struggle, “he inscribed on the pil-
lars, in addition to these particulars, female geni-
talia to mark that they were a nation of women,
that is, unwarlike and effeminate. . . in the part
of Syria called Palestine, I myself saw them still
standing, with the writing above mentioned, and
the genitals distinctly visible.”
The third reference is included in the list of
nations which accompanied Xerxes on his invasion
of Greece. “The Phoenicians, with the Syrians of
Palestine, furnished 300 vessels, the crews of which
were thus accoutred : upon their heads they wore
helmets made nearly in the Grecian manner; about
their bodies they had breast plates of linen; they
carried shields without rims; and were armed with
javelins. This nation, according to their own
account, dwelt anciently upon the Red Sea, but
crossing thence, they fixed themselves on the sea-
coast of Syria, where they still inhabit. This part
of Syria, and all the region extending from hence
to Egypt, is known by the name of Palestine.”
It must be admitted that insofar as it can be
480
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determined, the ancient Jews did not make any
headway in the field of medicine. In fact, they
developed very little in the way of culture besides
their literature.
The only surgical operation mentioned in the
Old Testament is that of circumcision. Circum-
cision had been practiced in Egypt for well over
one thousand years before the Jews began to drift
in from the Arabian desert and to take the prom-
ised land. This operation of circumcision must
have been a fairly rough one when one considers
the disability consequent upon it. This is il-
lustrated by the affair of Dinah and Shechem.
Dinah, the daughter of Jacob, was raped by
Shechem. Following this Shechem desired to
marry her. He proposed honorable marriage and
a large dowry but this did not satisfy Dinah’s
father and two brothers:
Genesis, 34:
13. And the sons of Jacob answered Shechem and
Hamor, his father, deceitfully, and said, because he had
defiled Dinah, their sister:
14. And they said unto them. We cannot do this
thing, to give our sister to one that is uncircumcised;
for that were a reproach unto us:
15. But in this we will consent unto you: If ye will
be as we be, that every male of you be circumcised:
16. Then we will give our daughters unto you, and
we will take your daughters to us, and we will dwell
with you, and we will become one people.
This proposal pleased Shechem and his father,
Hamor, so they went to their town and persuaded
all of the men to be circumcised. The men were
so prostrated by the circumcision that they were
unable to defend themselves, so that Dinah’s two
brothers were able to kill them all.
Genesis 34:25:
And it came to pass on the third day, when they were
sore, that two of the sons of Jacob, Simeon and Levi,
Dinah’s brethren, took each man his sword, and came
upon the city boldly, and slew all the males.
When did the Jews enter the theatre of history?
A group of clay tablets written in cuneiform were
found in the Pharaoh Akhnaton’s (Amenhotep
IV) capital city. These letters are known as the
Tell-El-Amarna Tablets and are from the gover-
nors of the provinces of Egypt to the Pharoah.
One such tablet written c. 1377 B.C. is in-
scribed2,3 :
Let the king care for his land. The land of the
king will be lost. All of it will be taken from me ; there
is hostility to me —
But now Habiru (Hebrews) are taking the cities of
the king —
If there are no archers this year, then let the king
send a deputy that he may take me to himself together
with my brothers and we die with the king, our Lord.
Fig. 1. Paradise Lost. Temptation of Eve by Wil-
liam Blake
The snake plays a large role in the superstitions of all
primitive peoples.
“Now the serpent was more subtile than any beast of
the field which the Lord God had made. And he said
unto the woman. Yea, hath God said. Ye shall not eat
of every tree of the garden? And the woman said
unto the serpent, We may eat of the fruit of the trees
of the garden: But of the fruit of the tree which is
in the midst of the garden, God hath said. Ye shall not
eat of it, neither shall ye touch it, lest ye die. And the
serpent said unto the woman. Ye shall not surely die:
For God doth know that in the day ye eat thereof,
then your eyes shall be opened, and ye shall be as gods,
knowing good and evil. And when the woman saw
that the tree was good for food, and that it was pleas-
ant to the eyes, and a tree to be desired to make one
wise, she took of the fruit thereof, and did eat, and
gave also unto her husband with her; and he did eat.
And the eyes of them both were opened, and they knew
that they were naked; and they sewed fig leaves together,
and made themselves aprons.” ( Genesis , 3:1-8). ( Cour-
tesy of Museum of Fine Arts, Boston, Massachusetts .)
In the victory stela of black granite erected by
King Merenptah of Egypt c. 1229 B.C., is the only
mention in any Egyptian inscription of the name
of Israel5:
The princes are prostate, while they say, “peace.”
There is no one who raises his head among the Nine
Bows.
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481
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Libya is ruined, Khatti is pacified: The Canaanite
land is despoiled with every evil.
Ascalon is carried captive, Gezer is conquered:
Yanoam is made as though it did not exist.
The people of Israel is desolate, it has no offspring:
Palestine (Khuru) has become a widow for Egypt.
All lands are united, they are pacified: Everyone that
is turbulent is bound by King Merenptah,
Given life like Re, every day.
From the available evidence the best guess is
that the Hebrews began to enter Palestine c.
1250 B.C. Further, the evidence indicates that
the Jews incorporated parts of the teachings of
the older Babylonian and Egyptian civilizations in
their own writings. The ancient flood story of the
Babylonians is found in the account of creation
in the Old Testament. Similarities between the
code of Hammurabi and the laws of Moses are
evident,5 the former being over 1000 years older
than the latter.
The Jews took over much of the Egyptian
civilization. About 1000 B.C., a wise Egyptian,
Amenemope, wrote down his advice to his son.
Compare a few sentences of Amenemope’s ad-
vice with the Proverbs of the Old Testament:
Amenemope . — Better is poverty in the hands of God,
than riches in the storehouse.
Proverbs, 15:16. — Better is little with the fear of the
Lord than great treasure and trouble therewith.
* * * *
Amenemope. — Better are the loaves when the heart
is joyous, than riches in unhappiness.
Proverbs, 15:16. — Better is a dinner of herbs where
love is, than a stalled ox and hatred therewith.
* * * *
Amenemope.—- Better is the praise as one whom men
love, than riches in the storehouse.
Proverbs, 17:1. — Better is a dry morsel, and quiet-
ness therewith, than a house full of sacrifices with strife.
* * ■* *
Amenemope. — Fraternize not with the hot-tempered
man, and press not upon him for conversation.
Proverbs, 22:24. — Make no friendship with an angry
man; and with a furious man thou shalt not go.
* * * *
Amenemope. — Remove not the land mark on the
boundary of the fields. Be not greedy for a cubit of
land, and trespass not on the boundry of the widow.
Proverbs, 23:10.- Remove not the old landmark;
enter not into the fields of the fatherless.
* * * *
The Pharoah Akhnaton (Amenhotep IV) of
Egypt attempted to establish the old sun god Re
(Aton) as the sole God. He had inscribed in
the tomb of Eye, his favorite nobleman, a hymn
of praise to Aton which was echoed centuries
later, in the 104th Psalm of the Old Testament:
Thou dawnest beautifully in the horizon of the sky,
O Living Aton, who wast the Beginning of life!
When thou didst rise in the eastern horizon. Thou
didst fill every land with thy beauty. Thou art beautiful,
great, glittering, high over every land.
Thy rays they encompass the lands, even to the end
of all that thou hast made.
Though thou art far away, thy rays are upon the
earth: Though thou art in the faces of men, thy
footsteps are unseen.
When thou settest in the western horizon of the sky,
The earth is in darkness like death.
They sleep in their chambers, Their heads are
wrapped up.
Every lion cometh forth from his den, All serpents
they sting. Darkness broods. The world is in silence,
He that made them resteth in his horizon;
When thou shinest as Aton by day Thou drivest away
the darkness.
Men waken and stand upon their feet, Then in all
the world they do their work.
How manifold are thy works! They are hidden before
men.
O sole God, beside whom there is no other. Thou
didst create the earth according to thy heart.
Thou settest every man into his place. Thou suppliest
their necessities, Every one has his food. And his days
are reckoned.
The tongues are divers in speech, Their forms like-
wise and their skins are distinguished.
How benevolent are thy designs, O lord of eternity!
Thou makest the seasons in order to make develop all
that thou hast made.
Winter to bring them coolness, And heat that they
may taste thee.
Thou makest millions of forms through thyself alone:
Cities, villages, and fields, highways and rivers.
All eyes see thee before them, For thou art Aton of
the day over the earth. When thou hast gone away,
yet art thou still in my heart.
The religion of a people is said to be an
idealized reflection of their own way of life. What
were the characteristics of the God of the ancient
Hebrews? A few illustrations from the Old Testa-
ment might be in order.
The Lord slays Onan because he did not marry his
brother’s wife. — •
Genesis, 38:
8. And Judah said unto Onan, Go in unto thy
brother's wife, and marry her, and raise up seed to thy
brother.
9. And Onan knew that the seed should not be his;
and it came to pass, when he went in unto his brother’s
wife, that he spilled it on the ground, lest that he
should give seed to his brother.
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10. And the thing which he did displeased the
Lord: wherefore he slew him also.
The Lord refuses to show Moses his face but permits
him to see his ‘‘back parts.” —
Exodus, 33:
18. And he said, I beseech thee, show me thy glory.
20. And he said. Thou canst not see my face: for
there shall no man see me, and live.
22. And it shall come to pass, while my glory
passeth by, that I will put thee in a clift of the rock,
and will cover thee with my hand while I pass by:
23. And I will take away mine hand, and thou shalt
see my back parts: But my face shall not be seen.
The Lord sends two she-bears to destroy forty-two
children because the children mocked Elisha. —
II Kings, 2:
23. And he went up from thence unto Bethel: and
as he was going up by the way, there came forth little
children out of the city, and mocked him, and said unto
him, Go up, thou bald head; go up, thou bald head.
24. And he turned back and looked on them, and
cursed them in the name of the Lord. And there came
forth two she-bears out of the wood, and tare forty
and two children of them.
The Lord forgives King David for adultery but re-
quires the child conceived in adultery to die. — King
David committed adultery with Bathsheba, the wife of
Uriah, the Hittite. After planning the death of Uriah,
David married Bathsheba: “But the thing David had
done displeased the Lord.” (II Samuel, 11:2, 3, 4, 15,
27). However, the Lord forgave David but ruled that
the child of David and Bathsheba must die, and so it
did (II Samuel, 12: 14, 15, 18).
The Lord instructs Moses to take the promised land
and to utterly destroy its inhabitants. —
Deuteronomy, 7:
2. And when the Lord thy God shall deliver them
before thee ; thou shalt smite them, and utterly destroy
them; thou shalt make no covenant with them, nor
shew mercy unto them:
3. Neither shalt thou make marriages with them;
thy daughter thou shalt not give unto his son, nor his
daughter shalt thou take unto thy son.
6. For thou art an holy people unto the Lord thy
God : The Lord thy God has chosen thee to be a
special people unto himself, above all people that are
upon the face of the earth.
It will be recalled how Joseph was carried to
Egypt and how he made good there. When
Joseph’s father died in Egypt “ — Joseph com-
manded his servants the physicians to embalm his
father: and the physicians embalmed Israel.”
( Genesis , 50:2).
The date of the Exodus of Moses and the
Hebrews from Egypt is not definite but it is
thought to have occurred during the reign of
King Merneptah (c. 1292-1198 B.C.) of Egypt.
According to the Old Testament, the Jews wan-
dered in the wilderness for forty years. While on
Fig. 2. Moses Breaking the Two Stone Tables of the
Law, by Rembrandt.
God called Moses up on Mt. Sinai, “And He gave
unto Moses when he had made an end of communing
with him upon Mount Sinai, two tables of testimony,
tables of stone, written with the finger of God” (Exodus,
31:18). But as Moses was on the mountain for forty
days and forty nights, the people thought that he was
not coming back. . . for as for this Moses, the
man that brought us up out of the land of Egypt, we
wot not what is become of him” ( Exodus , 32:1). Con-
sequently. they decided to return to their old gods.
They made a golden calf and worshipped it. When
Moses finally came down from Mt. Sinai; “And it came
to pass, as soon as he came nigh unto the camp, that
he saw the calf, and the dancing: and Moses’ anger
waxed hot, and he cast the tables out of his hands, and
brake them beneath the mount” (Exodus, 32:19).
Moses made short shrift of the backsliders; “. . . there
fell of the people that day about three thousand men”
(Exodus, 32:28). Later, the Lord replaced the tables
of the law: “And the Lord said unto Moses, Hew thee
two tables of stone like the first : and I will write upon
these tables the words that were in the first tables, which
thou breakest” ( Exodus , 34:1). ( Photograph of paint-
ing in Kaiser Friedrich Museum by Walter Steinkopf,
Berlin, Germany.)
this trip the Lord called Moses upon the moun-
tain Sinai and gave him the laws written upon two
stone tablets. A study of these laws is essential in
studying the culture of the ancient Hebrews.
Some of these laws are quoted:
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483
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Exodus, 20:
2. I am the Lord thy God, which have brought thee
out of the land of Egypt, out of the house of bondage.
3. Thou shalt have no other Gods before me.
4. Thou shalt not make unto thee any graven image,
Fig. 3. Relief from the Necropolis of Sakkara Vlth
Dynasty. The lower part shows circumcision operation
in progress. The upper part shows an operation on a
man’s foot and an operation on the back.
These operations were practiced by the Egyptians at
least 2,000 years B.C. Concerning circumcision, Herod-
otus wrote: “. . . but further and more especially, on
the circumstance that the Colchians, the Egyptians, and
the Ethiopians, are the only nations who have practiced
circumcision from the earliest times. The Phoenicians
and the Syrians of Palestine themselves confess that
they learned the custom of the Egyptians: and the Syrians
who dwell about the rivers Thermodon and Parthenius,
as well as their neighbors, the Macronians, say that
they have recently adopted it from the Colchians.”
(Photograph obtained from the Wellcome Historical
Medical Museum, London, England.)
or any likeness of anything that is in heaven above,
or that is in the earth beneath, or that is in the water
under the earth:
5. Thou shalt not bow down thyself to them, nor
serve them; for I the Lord thy God am a jealous God.
visiting the iniquity of the fathers upon the children
unto the third and fourth generation of them that
hate me ;
6. And shewing mercy unto thousands of them that
love me, and keep my commandments.
7. Thou shalt not take the name of the Lord thy
God in vain; for the Lord will not hold him guiltless
that taketh his name in vain.
8. Remember the sabbath day, to keep it holy.
9. Six days shalt thou labor, and do all thy work:
10. But the seventh day is the sabbath of the Lord
thy God : in it thou shalt not do any work, thou,
nor thy son, nor thy daughter, thy man servant, nor
thy maid servant, nor thy cattle, nor thy stranger that
is within thy gates:
11. For in six days the Lord made heaven and earth,
the sea, and all that in them is, and rested the seventh
day: wherefore the Lord blessed the Sabbath day, and
hallowed it.
12. Honour thy father and thy mother: that thy
days may be long upon the land which the Lord thy
God giveth thee.
13. Thou shalt not kill.
14. Thou shalt not commit adultery.
15. Thou shalt not steal.
16. Thou shalt not bear false witness against thy
neighbour.
17. Thou shalt not covet thy neighbour’s house, thou
shalt not covet thy neighbour’s wife, nor his man servant,
nor his maid servant, nor his ox, nor his ass, nor any-
thing that is thy neighbour’s.
Exodus, 2 1 :
2. If thou buy an Hebrew servant, six years he
shall serve: and in the seventh he shall go out free for
nothing.
3. If he came in by himself, he shall go out by
himself: if he were married, then, his wife shall go
out with him.
4. If his master have given him a wife, and she
have borne him sons or daughters; the wife and her
children shall be her master’s, and he shall go out by
himself.
5. And if the servant shall plainly say, I love my
master, my wife, and my children; I will not go free:
6. Then his master shall bring him unto the judges;
he shall also bring him to the door, or unto the door-
post; and his master shall bore his ear with an aul ;
and he shall serve forever.
12. He that smitheth a man, so that he die, shall
be surely put to death.
20. And if a man smite his servant, or his maid,
with a rod, and he die under his hand; he shall be
surely punished.
21. Notwithstanding, if he continue a day or two,
he shall not be punished: for he is his money.
22. If men strive, and hurt a woman with child,
so that her fruit depart from her, and yet no mischief
follow: he shall be surely punished, according as the
woman’s husband will lay upon him; and he shall pay
as the judges determine.
23. And if any mischief follow, then thou shalt give
life for life.
24. Eye for eye, tooth for tooth, hand for hand,
foot for foot,
25. Burning for burning, wound for wound, stripe
for stripe.
26. And if a man smite the eye of his servant, or
the eye of his maid, that it perish; he shall let him
go free for his eye’s sake.
28. If an ox gore a man or a woman, that they die:
then the ox shall be surely stoned, and his flesh shall
not be eaten; but the owner of the ox shall be quit.
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Exodus, 22:
1. If a man shall steal an ox, or a sheep, and kill
it, or sell it ; he shall restore five oxen for an ox, and
four sheep for a sheep.
16. And if a man entice a maid that is not betrothed,
and lie with her, he shall surely endow her to be his
wife.
17. If her father utterly refuse to give her unto him,
he shall pay money according to the dowry of virgins.
18. Thou shalt not suffer a witch to live.
19. Whatsoever lieth with a beast shall surely be put
to death.
21. Thou shalt neither vex a stranger, nor oppress
him: for ye were strangers in the land of Egypt.
The Lord also gave the Jews detailed in-
structions as what to eat and what not to eat
( Leviticus , 11), the purification of women after
childbirth ( Leviticus , 12), how to deal with lep-
rosy ( Leviticus , 13 and 14) and how men and
women with discharges were to be cleansed by the
priest ( Leviticus , 15).
Some years later, a young Hebrew, Jesus Christ,
attempted to soften the code of Moses. The Jews
did not take kindly to this break with tradition
and sacred teachings, so they killed him.
The penalty for adultery according to Moses. —
Leviticus, 20:10. And the man that committeth
adultery with another man’s wife, even he that com-
mitteth adultery with his neighbour’s wife, the adulterer
and the adulteress shall surely be put to death.
The penalty for adultery according to Jesus. —
St. John, 8:
3. And the scribes and Pharisees brought unto him
a woman taken in adultery; and when they had set her
in the midst,
4. They say unto him, Master, this woman was
taken in adultery, in the very act.
5. Moses in the law commanded us, that such should
be stoned: but what sayest thou?
6. This they said, tempting him, that they might
have to accuse him. But Jesus stooped down, and with
his finger wrote on the ground, as though He heard
them not.
7. So when they continued asking him, he lifted
up himself, and said unto them, He that is without
sin among you, let him first cast a stone at her.
8. And again he stooped down, and wrote on the
ground.
9. And they which heard it, being convicted by
their own conscience, went out one by one, beginning
at the eldest, even unto the last: and Jesus was left
alone, and the woman standing in the midst.
The Law of Moses called for an eye for an eye. —
Leviticus, 24:20.
Breach for breach, eye for eye, tooth for tooth : as he
hath caused a blemish in a man, so shall it be done to
him again.
But Jesus taught differently. —
St. Matthew, 5 :
38. Ye have heard that it hath been said, An eye
for an eye, and a tooth for a tooth:
39. But I say unto you, That ye resist not evil:
but whosoever shall smite thee on thy right cheek,
turn to him the other also.
Jesus also taught that necessary work should
be done on the Sabbath Day (St. Matthew, 12:1-
14), and that divorces shall not be allowed (St.
Matthew, 19:3-10). These teachings also were
opposed to the code of Moses.
Disease as a penalty for sin. — In the Old Testa-
ment, disease is considered to be a penalty for
disobeying the Lord. When Moses pled with the
Pharoah to let the Hebrews leave Egypt, the
Lord did certain things to show his power and
to show whose side he was on. He first turned
Moses’ rod into a serpent (Exodus, 7:11), then
he turned the river to blood, killing all of the
fish (Exodus, 7:20, 21). Then the Lord did the
following against the Egyptians: He sent a plague
of frogs (Exodus, 8:6) ; the dust was turned into
lice (Exodus, 8:17); He sent a swarm of flies
(Exodus 8:24) ; He killed all of the cattle of the
Egyptians ( Exodus , 9:6); He caused boils to
break out upon all of the Egyptians and their
beasts (Exodus, 9:11); He sent a severe hail-
storm which destroyed all the crops of the Egyp-
tians (Exodus, 9:25) ; He sent a plague of locusts
which ate every green thing (Exodus, 10:15); and
finally killed the first born of every Egyptian,
even the first born of the Pharoah (Exodus,
12:29).
The Lord instructs Moses how to avoid disease. —
Exodus, 15:26:
And said, If thou wilt diligently hearken to the voice
of the Lord thy God, and wilt do that which is right
in his sight, and wilt give ear to his commandments, and
keep all his statutes, I will put none of these diseases
upon thee, which I have brought upon the Egyptians;
for I am the Lord that healeth thee.
When Miriam and Aaron spoke against Moses
because he had married an Ethiopian woman,
the Lord turned them (Miriam and Aaron) into
lepers so that their skin became “white as snow”
(Numbers, 12:1). Later the Lord killed “fourteen
thousand and seven hundred” of those who spoke
April, 1957
485
A PAGE FROM MEDICAL HISTORY— SUMMERS
against Moses and Aaron ( Numbers , 16:49). On
one occasion, the Lord sent a pestilence upon
Israel and laid low seventy thousand men (II
Samuel , 24:15). When Sennacherib, King of As-
Fig. 4. Hebrews Paying Tribute to the King of Assyria.
This is a scene carved on a black stone shaft set up by
the Assyrian King Shalmaneser, III in his palace on the
Tigris River. In the upper panel, the Assyrian King,
Shalmaneser, III, stands at the left with two attendants
behind him. Before him is the winged sun-disk. The
Hebrew’s envoy is shown bowing to the King, while
behind the envoy are two Assyrian officers leading a line
of thirteen Hebrews (not shown here), bearing tribute
for the King. (Photograph obtained from the British
Museum.)
syria, attacked Jerusalem, the Lord destroyed his
army and thus lifted the seige (II Kings, 19:35).
The taking of the promised land. — The Lord
promised the Jews the Land of Canaan, but, un-
fortunately, this area had already been occupied
by other peoples for a long period of time. The
Jews probably felt about those people much the
same as we felt about the Indians when we took
their land away from them. One difference was
that the people occupying the area of Palestine
were much more civilized than the invading Jews
while the Indians were in the stone age when
Columbus came over.
The manner in which the Jews took the promised
land and disposed of the inhabitants. —
Numbers, 31:
7. And they warred against the Midianites, as the
Lord commanded Moses; and they slew all the males.
9. And the children of Israel took all the women of
Midian captives, and their little ones, and took the
spoil of all their cattle, and all their flocks, and all their
goods.
10. And they burnt all their cities wherein they
dwelt, and all their goodly castles, with fire.
15. And Moses said unto them, Have ye saved all
the women alive?
17. Now therefore kill every male among the little
ones, and kill every woman that hath known many by
lying with him.
18. But all the women children, that have not known
a man by lying with him, keep alive for yourselves.
The seizure of Palestine by the Jews required
several years and they were never able to drive
out all of the native peoples. They continued to
war with these and especially the Philistines, their
constant enemies. One recalls how Samson
wished to marry the daughter of a Philistine. His
parents took a rather dim view of this:
Judges , 14:3:
Then his father and his mother said unto him, Is
there never a woman among the daughters of thy
brethren, or among all my people, that thou goest to
take a wife of the uncircumcised Philistines? and Sam-
son said unto his father, Get her for me; for she pleas-
eth me well.
Samson would probably have done much better
had he followed his parents’ advice, as the court-
ship of the Philistine girl turned into a rather
large affair with Samson slaying one thousand
Philistines with “a new jawbone of an ass”
( Judges , 15:15). The Philistines bribed Delilah
to get him, and she did ( Judges , 16:20). Then
David made quite a name for himself by slaying
the Philistine giant, Goliath (I Samuel, 17:49);
he also secured a hundred foreskins of the Phil-
istines as a dowry for the daughter of King Saul
(I Samuel, 18:25).
Palestine, like so many countries, was divided
into a north and a south. Northern Palestine was
called Israel and was productive and rich, where-
as southern Palestine, called Judah, was unpro-
ductive and poor. Saul, the first King of the
Jews, (c. 1000 B.C.) was from the south (I
Samuel, 10:24). After being defeated in battle
by the Philistines, Saul committed suicide (II
Samuel, 31:4), and David became king of Judah.
After a number of battles between the north and
south, David became king of Israel also (II Sam-
uel, 5:3). David secured from Hiram, king of
486
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A PAGE FROM MEDICAL HISTORY— SUMMERS
Tyre in Phoenicia, cedars from Lebanon and skilled
workmen to build himself a house (I Chronicles,
14:1). Evidently, at this time, there were no
skilled craftsmen among the Jews.
After David, Solomon became king. He ac-
One of the very rare references to a physician
in the Old Testament is the following:
II Chronicles, 16:12.
And Asa (king of Judah) in the thirty and ninth
year of his reign was diseased in his feet, until his dis-
Fig. 5. Christ Driving the Money-Changers from the Temple, by El Greco.
“And Jesus went into the Temple of God, and cast out all of them that sold
and bought in the temple, and overthrew the tables of the money-changers, and the
seats of them that sold doves.
“And said unto them, It is written, My house shall be called the house of prayer;
but ye have made it a den of thieves.” (St. Matthew, 21:12, 13). (Photograph
obtained from the Minneapolis Institute of Arts.)
cumulated great wealth and married the daughter
of the Pharoah of Egypt (I Kings, 3:1). He had
forty thousand stables of horses for his chariots
and twelve thousand horsemen (I Kings, 11:3).
Solomon, like David, obtained cedar and skilled
workmen from King Hiram and built a great
church and house for himself and one for his
wife, Pharoah’s daughter.
Solomon’s extravagances (one can imagine the
expense of feeding one thousand women) required
increased taxation (I Kings, 9:15). This caused
discontent among the Jews so when Solomon died,
Jeroboam, who had been in exile in Egypt where
King Shishak (Sheshonk) was ruling, returned to
Palestine, and led a revolt of the north (Israel).
Thus Palestine was again divided with Jeroboam
being king of the north (Israel) and Rehoboam,
king of the south (Judah).
ease was exceeding great: yet in his disease he sought
not the Lord, but to the physicians. (He died anyway.)
Palestine, strategically located on the trade
routes of the Near East, was controlled by first
one great power and then another.
II Kings, 15 : 29.
In the days of Pekah, king of Israel came Tiglath-
pileser, king of Assyria, and took Ijon, and Abelbeth-
machah, and Janoah, and Kedesh, and Hazor, and
Gilead, and Galilee, all the land of Naphtali, and car-
ried them captive to Assyria.
In 722 B.C. Shalmaneser, King of Assyria, cap-
tured northern Palestine (Israel) and transported
the Hebrews to the cities of the Medes (II Kings,
17). While around 700 B.C. Sennacherib, King
of Assyria, raided southern Palestine (Judah) and
carried off over 200,000 captives, it remained for
Nebuchadnezzar, King of Babylon, in 586 B.C.,
April, 1957
487
A PAGE FROM MEDICAL HISTORY— SUMMERS
to destroy Jerusalem and carry most of its inhab-
itants into captivity to Babylon. This completed
the destruction of the Jewish state. In 538 B.C.,
King Cyrus of Persia captured Babylon and al-
lowed those Jews who wanted to to return to
Palestine.
In the New Testament, healing is accomplished by
faith. —
St. Matthew, 4:23:
And Jesus went about all Galilee, teaching in their
synagogues, and preaching the gospel of the kingdom,
and healing all manner of sickness and all manner of
disease among the people.
Jesus was the great healer who healed all man-
ner of sick people (St. Matthew, 4:24), who
cleanseth the leper (St. Matthew, 8:3), who
cured a soldier’s servant of palsy without seeing
him (St. Matthew, 8:5-13), and drove out dev-
ils (St. Matthew, 8:16, 28-33), who cureth the
bloody issue (St. Matthew, 9:20-22), who raised
Jairus’ daughter from the dead (St. Matthew,
9:24-26), who restored sight to the blind (St.
Matthew, 9:28-31).
Jesus cured where the physicians failed:
St. Mark, 5:
25. And a certain woman which had an issue of
blood twelve years,
26. And had suffered many things of many physi-
cians, and had spent all that she had, and nothing
bettered, but rather grew worse.
27. When she had heard of Jesus, came in the press
behind, and touched his garment.
28. For she said. If I may touch but his clothes, I
shall be whole.
29. And straightway the fountain of her blood was
dried up; and she felt in her body that she was healed
of that plague.
It would appear that physicians did not play
an important role in the community of the ancient
Jews. They at least, however, did not receive
the lambasting which Jesus gave the rich (St.
Matthew, 6:19. 19:16-25. 21:12-13), the scribes
and Pharisees (St. Matthew, 23:1-29), and the
lawyers (St. Luke, 11:46, 52). In fact, one gets
the impression that the physician was held in
some respect. Apparently, Jesus not only taught
the doctors but also learned something from them :
St. Luke, 2:
42. And when he was twelve years old, they went
up to Jerusalem after the custom of the feast.
43. And when they had fulfilled the days, as they
returned, the child Jesus tarried behind in Jerusalem;
and Joseph and his mother knew not of it.
44. But they, supposing him to have been in the
company, went a day’s journey; and they sought him
among their kinsfolk and acquaintance.
45. And when they found him not, they turned back
again to Jerusalem, seeking him.
46. And it came to pass, that after three days they
found him in the temple, sitting in the midst of the
doctors, both hearing them, and asking them questions.
Are not the teachings of Jesus summed up in
the following story?
St. Matthew, 19:
16. And, behold, one came and said unto him, Good
Master, what good thing shall I do, that I may have
eternal life?
17. And he said unto him, Why callest thou me
good? there is none good but one, that is, God: but
if thou wilt enter into life, keep the commandments.
18. He saith unto him, Which? Jesus said, Thou
shah do no murder, Thou shalt not commit adultery,
Thou shalt not steal, Thou shalt not bear false wit-
ness,
19. Honour thy father and thy mother: and, Thou
shalt love thy neighbour as thyself.
20. The young man saith unto him. All these things
have I kept from my youth up: what lack I yet?
21. Jesus said unto him, If thou wilt be perfect, go
and sell that thou hast, and give to the poor, and thou
shalt have treasure in heaven : and come and follow me.
22. But when the young man heard that saying, he
went away sorrowful: for he had great possessions.
23. Then said Jesus unto his disciples, Verily, I
say unto you, That a rich man shall hardly enter into
the kingdom of heaven.
24. And again I say unto you, It is easier for a
camel to go through the eye of a needle, than for a
rich man to enter into the kingdom of God.
Conclusion
The literature of the ancient Jews gives us an
extremely fascinating account of how they lived
and what they thought about in those days. With
this in mind, a more extensive study of the Bible
is recommended. Along with other primitive peo-
ples, the ancient Jews regarded disease and other
misfortunes as punishment by their God for sin.
Certain illnesses were attributed to the possession
of devils. Healing was accomplished through
faith. It has been shown that the Hebrews bor-
rowed many ideas from the older and more cul-
tured civilizations, the Babylonian and the Egyp-
tian.
References
1. Bailey, A. E. : Daily Life in Bible Times. New
York: Charles Scribner’s Sons, 1943.
2. Breasted, J. H.: A History of Egypt. New York:
Charles Scribner’s Sons, 1916.
3. Breasted, J. H.: Ancient Times. A History of
the Early World. Boston: Ginn and Company,
1944.
(Continued on Page 534)
488
JMSMS
Acute Pancreatitis
By J. Edward Berk, M.D., Sc.D.
Detroit, Michigan
HPHE WIDESPREAD use of serum pancreatic
enzyme determinations and greater awareness
on the part of physicians have led to increased fre-
quency of recognition of acute pancreatitis. With
this has come heightened interest in the disease.
It is now appreciated that the disorder occurs in
two principal forms : ( 1 ) an acute edematous or
interstitial variety; and (2) a more serious and
severe acute hemorrhagic or necrotic variety.
Sharp clinical distinction between these two types
is difficult and often impossible, particularly in
the early stages. The principles of treatment,
however, are the same in both types. Basic man-
agement is also the same whether the process is
an isolated acute primary episode, an acute recur-
rence, or an acute exacerbation of chronic relap-
sing pancreatitis.
The discussion to be presented has been con-
structed with the foregoing considerations in
mind. It is not intended as an exhaustive review
of the subject, but rather as a digest of some of
the salient features of the diagnosis and manage-
ment of acute pancreatitis.
Predisposing Factors
Two things have emerged as important precurs-
ors, concomitants, or associates of acute pancrea-
titis. One is biliary tract disease and the other
is excessive indulgence in alcohol.1 It is common
to obtain a history of excessive ingestion of alco-
hol, accompanied often by a heavy meal, shortly
before the onset of acute pancreatitis. One other
factor whose etiologic importance has come to be
appreciated more in recent years is surgically in-
duced trauma to the gland, its blood supply, or its
ducts.2 The development of pain, fever, or signs
of peritoneal irritation or inflammation in the
period immediately following a surgical procedure
in the upper abdomen should arouse suspicion of
complicating postoperative acute pancreatitis.
Presented before the 12th Annual Clinical Conference
of the Chicago Medical Society, Chicago, Illinois, March
2, 1956.
From the Departments of Medicine, Sinai Hospital of
Detroit and Wayne State University College of Medi-
cine.
Diagnosis
Symptoms and Signs. — The outstanding symp-
tom of acute pancreatitis is pain. This ordinarily
is severe and steady in character. In some cases,
however, it is described as somewhat intermittent.
It is usually prolonged and tends to be resistant to
opiates. It is situated most often in the epigas-
trium but may be located in other areas, depend-
ing on the portion of the pancreas that is primarily
affected and on whether or not parietal struc-
tures have been involved. Radiation of pain to
the back is common. Characteristic of pain of
pancreatic origin is assumption by the patient of
certain postures to obtain relief. These typically
involve bending over or leaning forward, often
with the hand pressed against the abdomen.
Jaundice is an important sign. Compression
of the common duct by an inflamed and swollen
pancreas may be responsible, but it has been the
experience of several observers that overt jaun-
dice is seen most often in patients who have con-
comitant or associated biliary tract disease.1 The
occurrence of jaundice, therefore, should alert one
to the possibility of coexisting biliary tract disease.
Still another mechanism that may be operative
in some cases is pronounced intrahepatic peri-
cholangitis. This has been observed in some jaun-
diced dogs with experimentally induced acute pan-
creatitis.3 It remains to be determined, however,
whether a similar change occurs in human cases
of acute pancreatitis and, if it does, whether the
severity is ever such as to account for jaundice.
Shock, with cold, clammy skin, rapid pulse and
marked lowering of the blood pressure, is pop-
ularly considered to be a feature of acute pancre-
atitis. Bluish, greenish or ecchymotic discoloration
of the skin in the flank (Grey Turner’s Sign) or
about the umbilicus (Cullen’s Sign) is also pop-
ularly associated with acute pancreatitis. While
shock and skin changes of the variety described are
classical findings, they are seen relatively infre-
quently in patients with acute pancreatitis.1’4
When they occur they may be taken as evidence
pointing to pancreatic necrosis and hemorrhage.
Abdominal signs in acute pancreatitis are
April, 1957
489
ACUTE PANCREATITIS— BERK
worthy of note because they have many similari-
ties and also differences from other inflammatory
conditions in the upper abdomen. Abdominal dis-
tention is fairly common. The abdominal wall
may be soft or show variable degrees of muscle
guarding. True muscle rigidity, however, is un-
common. Tenderness is commonplace and ordi-
narily is most pronounced over the area of maxi-
mal pain. Peristaltic sounds may be unaltered,
reduced or completely absent, depending on the
degree and extent of ileus.
Pulmonary signs may be noted on one or the
other or even on both sides of the chest. These
include rales, impaired transmission of breath
sounds, friction rub and occasionally signs of pleu-
ral effusion. The fact that such changes are en-
countered not infrequently in cases of acute pan-
creatitis deserves particular mention because their
detection may divert attention to the supradia-
phragmatic area and cause confusion in diagnosis.
Laboratory Findings. — The outstanding labora-
tory test used to diagnose acute pancreatitis is de-
termination of serum amylase. To this determina-
tion should be added that of serum lipase. These
enzymes do not always behave in a predictable
fashion and the values for each may be discrep-
ant. It is always wise, therefore, to determine the
concentrations of both enzymes and to repeat the
determinations serially if at all possible. The
height of the rise in pancreatic enzymes in the
serum is not a reliable estimate of the degree of
inflammation or of the presence or absence of
necrosis of the pancreas. Nor is there a close cor-
relation between the height of the serum amylase,
for example, and the clinical signs of toxicity. On
the other hand, the degree of elevation may have
diagnostic importance. Bockus and his associates
have pointed out that levels of serum amylase or
lipase exceeding five times the top normal level
provide fairly reliable evidence of primary acute
pancreatitis.0 Determinations of serum pancreatic
enzyme concentrations are subject, however, to
certain limitations in interpretation which deserve
to be emphasized.
The concentration of amylase and lipase in the
serum will vary depending on the time the deter-
minations are made after the onset of the disease.
Serum amylase generally tends to rise and attain
its maximal level within twelve to twenty-four
hours after the onset of the disease. Ordinarily,
the values return to normal within three or four
days. Serum lipase, on the other hand, shows its
maximal rise a little later than serum amylase
and tends to remain elevated a bit longer. Should
the patient first be seen beyond the period of
maximal rise, or should the determinations not be
made until several days after the onset of disease,
normal values may be obtained. Contrariwise, if
the inflammatory process is so severe as to result
in extensive destruction of the pancreas, the rem-
nant acinar cells may not be able to produce
enough amylase or lipase to elevate the concentra-
tion of these enzymes in the peripheral blood.
In such circumstances, one may be confronted with
serious, severe and extensive pancreatic necrosis
in a patient with entirely normal, perhaps even
less than normal, concentrations of serum amylase
and lipase.
Prior injection of opiates may influence the level
of serum pancreatic enzymes, and this too must
be borne in mind. It has been demonstrated by
several investigators that the administration of
opiates, even of codeine, may result in some in-
stances in significant elevation of serum amylase
and lipase.6 Indeed, these elevations may persist
for as long as twenty-four hours. Since most pa-
tients with acute pancreatitis are seen at home,
and since pain is the outstanding symptom, an
opiate or analgesic is usually given. When the
patient is subsequently admitted to the hospital, it
must be considered that elevation noted in serum
amylase or lipase may not be truly representa-
tive of the process within the pancreas per se but
may be a reflection in part of a previously admin-
istered opiate.
Interference with excretion due to impaired
renal function may be responsible for heightened
or sustained elevation in the level of serum amyl-
ase. This factor acquires importance in acute pan-
creatitis because renal impairment is common-
place in this condition.7
Elevation in serum amylase and lipase may also
occur in disorders from which acute pancreatitis
must be differentiated. These include such con-
ditions as free anterior perforation of duodenal
ulcer, intestinal obstruction and peritonitis due to
various causes.
Urinary diastase has largely been abandoned
because of the considerable variation in results.
Examination of peritoneal fluid for amylase is val-
uable because the concentration of amylase in this
material may not only be hypernormal but may
persist above normal for periods of from two to
490
JMSMS
ACUTE PANCREATITIS— BERK
four days longer than in the blood.8 The same
situation obtains with pleural fluid developing in
association with acute pancreatitis.
Hyperglycemia and glycosuria are commonly
noted in patients with acute pancreatitis.9 The
disturbance in carbohydrate metabolism reflected
in these findings is usually transient but in some
cases may persist with diabetes mellitus ensuing as
an aftermath of acute pancreatitis.
The concentration of serum calcium is frequent-
ly lowered in the acute phase of pancreatitis.10
This occurs as a rule between the second and fifth
days and may persist for as long as two weeks.
The lowering results primarily from withdrawal
of calcium from the blood into areas of fat ne-
crosis where the calcium combines with liber-
ated fatty acids to form soaps. Since the amount
of calcium withdrawn from the blood depends
largely on the degree and extent of fat hydrolysis,
the degree of lowering of serum calcium concen-
tration is a measure of the severity of the process
and the degree of fat necrosis. The lowest levels
of serum calcium occur in cases of pancreatic ne-
crosis with levels of 7.5 mg. per cent or less point-
ing to the possibility of fatal outcome.11
Alterations in some of the factors responsible
for coagulation of blood may be utilized as a means
of detecting acute pancreatitis. One measure that
has received much attention is the antithrombin
titer}2 This has been shown to be elevated in
acute pancreatitis. It is said to have the additional
advantage of remaining elevated throughout the
acute phase of the disease. However, many inves-
tigators, including my associates and myself, have
not been successful with the use of this test.
I would like to call attention to serum alkaline
phosphatase as another laboratory test of possible
value in the diagnosis of acute pancreatitis. Ele-
vations in serum alkaline phosphatase without con-
comitant hyperbilirubinemia have been observed
to occur in dogs with experimentally induced acute
pancreatitis.3 Whether or not acute pancreatitis
as seen in man is regularly or frequently accom-
panied by elevation in serum alkaline phosphatase
without coincident hyperbilirubinemia remains to
be determined. There would seem to be good
reason, nevertheless, to include serum alkaline
phosphatase among the chemical determinations to
be made in patients suspected of having acute pan-
creatitis.
Roentgen Findings. — Roentgen examination of
the chest may demonstrate pneumonitis, pleuritis,
effusion, atelectasis or elevation of the diaphragm.
A scout film of the abdomen may show any one
of several patterns of gas distribution in the in-
testine.13 These are most apt to be seen in roent-
genograms taken between twelve and forty-eight
hours after the onset of pain. The patterns vary
from localized ileus with a so-called sentinel loop
of distended and gas-filled small bowel in the
upper abdomen, to generalized ileus. Concomit-
ant disease in the biliary tract may be disclosed by
the presence of radiopaque biliary calculi. This
examination may also serve to confirm the exist-
ence of pancreatic disease by demonstrating cal-
cification within the pancreas.
After subsidence of the acute phase, or in the
early convalescent phase, barium may be given
by mouth and the upper gastrointestinal tract stud-
ied. This may disclose the presence of a space-
taking lesion within the pancreas manifested by
displacement of neighboring segments of the upper
gastrointestinal tract and/or alterations in the
mucosa of the stomach or duodenum.
Cholecystography merits special mention since
this examination is commonly elected as a means
of study of a patient with upper abdominal pain.
The point to be emphasized is that cholecystograms
done by the oral method, and even by the intra-
venous method, in the presence of acute pancrea-
titis may fail to visualize the gall bladder.14 In
the absence of intrinsic gall-bladder disease this is
only a temporary and transient alteration; the gall
bladder in such cases usually can be satisfactorily
demonstrated by cholecystography within a month
after subsidence of the symptoms of acute pan-
creatitis. Hence, one must be alert to the possi-
bility of misinterpreting the unvisualized gall blad-
der in cholecystographic studies conducted in the
presence of acute pancreatitis.
Intravenous cholangiography, performed when
there is no jaundice and when liver function is un-
impaired, may successfully visualize the ducts.
Calculi may be disclosed in the common duct.
Theoretically, at least, this examination may also
show narrowing and obstruction of the distal end
of the common duct and perhaps, on occasion,
reflux of contrast material into the pancreatic duct.
Electrocardiography. — This examination de-
serves mention because it is often used to help dis-
tinguish between acute pancreatitis and myocardial
infarction, disorders which frequently resemble
each other in their clinical manifestations. Alter-
April, 1957
491
ACUTE PANCREATITIS— BERK
ations are not uncommonly seen in the electrocar-
diograms of patients with acute pancreatitis.43
Such changes as may occur are ordinarily transient
and nonspecific and may be related to electrolyte
alterations. One may be hard pressed sometimes,
however, to distinguish clearly and precisely from
the electrocardiographic tracing alone between
myocardial infarction and acute pancreatitis.1
Treatment
Majority opinion today favors conservative non-
operative management of acute pancreatitis.16’17
Surgical intervention is reserved for those cases in
which diagnosis is uncertain and those with seri-
ous complications developing while being managed
conservatively.
A major objective of conservative management
is to relieve pain. This may be accomplished
through the use of drugs, such as the nitrites, which
relax smooth muscle. Counterbalancing this ac-
tion on the part of the nitrites are the transient
nature of the relaxing effect and the threat of
hypotension. Opiates and related synthetic anal-
gesics are much more effective pain relievers. A
word of warning should be sounded about the use
of morphine. While this drug may effectively
relieve pain it may contribute to worsening of the
local condition because of its spasmogenic action.
The latter induces spasm of the choledochal
sphincter, the pancreatic ducts and the duodenal
musculature. Demerol is perhaps the analgesic
of choice, not because it is without spasmogenic
effect, but because ductal and duodenal spasm re-
sulting from its use is less pronounced and less
persistent than that following morphine. Drugs
which interfere with neural transmission through
their action principally as autonomic ganglionic
blockaders (such as tetraethylammonium (Eta-
mon) chloride and hexamethonium (Bistrium)
bromide), or as parasympatholytic agents as well
as ganglionic blockaders (such as methantheline
(Banthine) bromide and allied compounds), or
as parasympathetic depressants (such as atropine)
may also relieve pain in acute pancreatitis.
Pain relief following the use of these drugs
probably results from reduction of motility and
tone in the musculature of the upper gastro-
intestinal tract and the ducts, together with di-
minution in gastric and pancreatic secretion. The
decrease in gastric secretion reduces stimulation
of pancreatic secretion by secretin, a hormone re-
leased when hydrochloric acid comes in contact
492
with the mucosa of the small intestine. Intraven-
ously administered procaine has also been used to
relieve pain, but since this is attended by some
dangers its use has not gained popular acceptance.
In the event that the use of the various drugs
mentioned is ineffective in relieving pain, one may
resort to nerve blocking procedures. These in-
clude splanchnic block, paravertebral sympathetic
block and fractional epidural block. My asso-
ciates and I have found the latter procedure es-
pecially effective.18
The technique we employ consists of introducing
a fine catheter into the epidural space between
vertebra L-l and L-2. The catheter is then passed
upward until its tip comes to lie between vertebra
T-5 and T-6. This corresponds with neural seg-
ment T-8, which is about the center of the nerve
supply to the pancreas. A solution of procaine
or a similar local anesthetic is then introduced.
The anesthetic solution by diffusing up and down
from T-8 affects the important neural segments in-
nervating the pancreas. The indwelling catheter
in the epidural space may be maintained for as
long as a week with instillations of anesthetic so-
lution being made as often as necessary. While
pain control is excellent, it has been our impres-
sion that the procedure does not significantly in-
fluence the disease process itself.
The second major objective of conservative man-
agement is to combat shock and restore fluid and
electrolyte balance. This involves the use of fluids
such as saiine, glucose, lacrated Ringer’s and Dar-
row’s solutions, plasma, blood and albumin. Hu-
man serum albumin appears to be strikingly ef-
fective in the management of patients of acute
pancreatitis.19 Its effectiveness seems attributable
more to its ability to restore plasma loss than to any
possible antitryptic action it may possess. Glucose
solutions should be used with care because of the
disturbance in carbohydrate metabolism that oc-
curs so commonly in acute pancreatitis. The latter
may require the use of insulin. Insulin should be
used cautiously, however, to avoid hypoglycemia
which is vagotonic. Calcium is often required
because of the tendency for serum calcium to be
lowered. Disturbances in sodium, potassium and
chloride must be corrected as indicated and require
close attention. Care should be exercised partic-
ularly in the administration of potassium, because
of the possibility of accompanying renal impair-
ment.
The third major objective of conservative treat-
JMSMS
ACUTE PANCREATITIS— BERK
ment is to reduce pancreatic secretory activity.
This is done chiefly by withholding all food and
drink and by inserting a nasogastric tube to which
constant suction is applied. The purpose of the
latter is to remove all gastric contents and thereby
prevent hydrochloric acid from entering the duo-
denum and provoking hormonal stimulation of
pancreatic secretion. Nervous influences are com-
batted by the use of sedatives, vagal depressants
and ganglionic blockaders as mentioned earlier.
External roentgen radiation has also been used in
animals20 and in man21 to diminish pancreatic
secretion, but since the effects are still not alto-
gether known this form of management is not
widely used.
The fourth major objective is to combat infec-
tion and peritonitis. Broad spectrum antibiotics
that are well concentrated in the bile and are
effective against the bacterial flora of the intestine,
are the drugs of choice. They are preferably given
by mouth but may have to be given intravenously
or intramuscularly because of nausea and vomiting
or because of the constant gastric suction that is
applied.
Additional therapeutic measures may be men-
tioned even though some of them are still largely
in the experimental stage. Soy bean extract con-
taining a trypsin inhibitor has been employed in
dogs22’23 on the basis of the theory that much of
the ill effects of acute pancreatitis stems from the
diffusion of trypsin from the pancreas into the
systemic circulation. The results in dogs thus far
have been varied. Carbonic anhydrase inhibitor
(Diamox) has been used in dogs and more re-
cently in man.24 It has been demonstrated that
the drug is capable of diminishing volume and bi-
carbonate content of pancreatic secretion. This
material gives promise as a useful agent to reduce
pancreatic secretion. Lipase inhibitors, more espe-
cially quinine25 and sodium formaldehyde sulfoxa-
late,26 have been shown in dogs to counteract fat
necrosis induced by experimental methods.
Whether these will come to have clinical value
remains to be determined. Finally, cortisone and
hydrocortisone have been reported to have been
used in some instances of acute pancreatitis with
beneficial effect.17’27,29
The conservative regimen should be continued
until all signs of inflammation have subsided. The
diet is then increased cautiously until the patient
is able to eat and tolerate a low fat, high protein,
high carbohydrate diet. At this time studies are
undertaken designed to disclose associated biliary
tract disease, residual pancreatic cysts, and other
complications. Elective surgery designed to correct
such abnormalities as may be found may be done
at this time. Lastly, the patient is cautioned that
the chance of recurrence is good and that to help
avoid recurrence or future distress, overeating and
the use of alcohol should be avoided.
References
1. Bockus, H. L.; Kaiser, M. H.; Roth, J. L. A.; Bog-
och, A. L.; and Stein, G.: Clinical features of acute
inflammation of the pancreas; Analysis of ninety-
four attacks in seventy-eight patients. Arch. Int.
Med., 96:308, 1955.
2. Frieden, J. H. : Postoperative acute pancreatitis.
Sur., Gynec., & Obst., 102:139, 1956.
3. Shay, H.; Komarov, S.; Siplet, H.; and Lorber, S.:
Effect of pancreatic duct ligation and induced acute
pancreatitis on serum alkaline phosphatase in dogs.
Gastroenterology, 23:460, 1953.
4. Fallis, L. S.: Acute pancreatitis. Proc. Roy. Soc.
Med., 46:113, 1953.
5. Bockus, H. L. ; Bogoch, A.; and Roth, J. L. A.:
Acute pancreatitis: Diagnosis and treatment. South.
M. J., 46:388, 1953.
6. Bogoch, A.; Roth, J. L. A.; and Bockus, H. L.:
The effects of morphine on serum amylase and lip-
ase. Gastroenterology, 26:697, 1954.
7. Dankner, A., and Heifetz, C. J. : The interrelation-
ship of blood and urine hiastase during treatment
of acute pancreatitis. Gastroenterology, 18:207,
1951.
8. Keith, L. M., Jr.; Zollinger, R. M.; and McCleery,
R. S.: Peritoneal fluid amylase determinations as
an aid in the diagnosis of acute pancreatitis. Arch.
Surg., 61:930 (Nov.) 1950.
9. Warren, K. W.; Fallis, L. S.; and Barron, J. :
Acute pancreatitis and diabetes. Ann. Surg., 132:
1103, 1950.
10. Lipp, W. F., and Hubbard, R. S.: The serum cal-
cium in acute pancreatitis. Gastroenterology, 16:
726, 1950.
11. Edmondson, H. A., and Berne, C. J.: Calcium
changes in acute pancreatic necrosis. Surg., Gynec.,
& Obst., 79:240, 1944.
12. Innerfield, I.; Angrist, A.; and Benjamin, J. W.:
Plasma antithrombin patterns in disturbances of the
pancreas. Gastroenterology, 19:843, 1951.
13. Barry, W. F., Jr.: Roentgen examination of the
abdomen in acute pancreatitis. Am. J. Roentgenol.,
74:220, 1955.
14. Kaden, V. G.; Howard, J. M. ; and Doubleday, L.
C.: Cholecystographic studies during and imme-
diately following acute pancreatitis. Surgery, 38:
1082, 1955.
15. Gottesman, J. ; Casten, D.; and Bellar, A. J. :
Changes in the electrocardiogram induced by acute
pancreatitis; a clinical and experimental study, J.-
A.M.A., 123:892, 1943.
16. Berk, J. E.: Management of acute pancreatitis.
J.A.M.A., 152:1, 1953.
17. Jones, C. A.: Medical management of pancreatitis.
Arch. Int. Med., 96:332, 1955.
18. Berk, J. E., and Krumperman, L. W.: The use
of fractional epidural block in management of acute
pancreatitis. Am. J. M. Sc., 224:507,1952.
19. Elliott, D. W., Zollinger, R. M.; Moore, R.; and
Ellison, E. H.: The use of human serum albumin
in the management of acute pancreatitis; experi-
mental and clinical observations. Gastroenterology,
28:563, 1955.
(Continued on Page 497)
April, 1957
493
Development in Prepayment Plans
By Jay C. Ketchum
Detroit, Michigan
SECURITY is an important word to Americans.
To most of us) its achievement is the main goal
in our lives. But it has become more meaningful
and has assumed a greater significance since the
early thirties when the depression struck our coun-
try a cruel and hard blow. Shortly after that finan-
cial nightmare, we picked up the threads of our
economic system and rewove them to create a
more prosperous future. We sought security. It
was our main worry and concern. Without it,
we faced a turmoil, similar to the one through
which we had just passed, with all its poverty,
misery and unemployment.
Security, to the individual and to the Nation,
as we all know, is based to a very large degree
on health. During the depression, hospitals and
doctors, while receiving little or no reward for
their work, had to bear the burden of providing
medical care. The depression, proposals for Fed-
eral compulsory health insurance, the scarcity of
money to pay medical bills during those years,
all had their effect as had the action of your
Michigan State Medical Society, in fostering the
organization of Blue Cross and Blue Shield and
other prepayment methods.
We saw our weaknesses in those dark days and
we prepared to remedy them. The result has been
that the trend in financing health care has been
more and more toward prepayment through vol-
untary methods, the Blue Cross and Blue Shield
Plans and the insurance companies. The trend
has been away from compulsory health insurance.
Indeed, there has also been a trend to greater
participation by the Government in the financing
of health care for certain categories of its wards
and indigents. Statistics and opinions expressed
by informed, responsible persons support these
statements.
In Seattle, last November, Dr. Elmer Hess, at
the American Medical Association clinical meeting,
said: “Today’s professional freedom to be a pri-
vate practitioner of medicine instead of a slave of
Presented at the Mt. Carmel Mercy Hospital, Annual
Clinic Day, January 30, 1957.
Government is due solely to Blue Shield — the
physician’s answer to socialized medicine.”
Even some of the most rabid proponents of
Federal compulsory health insurance have recently
admitted that voluntary methods have been an
effective alternative and obstacle to enactment of
their proposals. The trend can be demonstrated
statistically by the growth in Michigan of Blue
Shield which, since its beginning, as one of the
first such plans, has grown to provide coverage
for nearly half the population of the State, and in
1956 paid physicians approximately 41 millions
of dollars for 1,212,873 individual services for
subscribers.
The trend toward the participation by Govern-
ment in costs of health care is most apparent in
the recently established “Medicare” program for
care of dependents of members of our armed
forces and in the Welfare Act of 1956 which will
put the Federal Government into business with
the States in financing of care of four categories
of indigents. Anyone who is sufficiently interested
can review the trends by studying available litera-
ture and statistical material. It is not impossible
to ascertain, to a reasonable extent, what we
might refer to as the current, or today’s trend.
There is another trend, in spite of all that has
been accomplished (and perhaps, to a great ex-
tent, because of what has been done) and this
appears to be an increasing discontent with the
present quality and quantity of prepayment meth-
ods. These signs of dissatisfaction are readily
apparent if you have, and will take, the time to
observe them. They may require considerable
evaluation and appraisal, but the evaluation will
reveal that the trend is toward broader, more
comprehensive coverage as to types of services
covered.
There is certainly a trend toward efforts to con-
trol costs of care; to eliminate charges beyond
the provisions of prepayment, to control abusive
utilization of benefits by such as unnecessary hos-
pitalization, unnecessary diagnostic and surgical
procedures. An interesting and indicative state-
494
JMSMS
PREPAYMENT PLANS— KETCHUM
ment was given in the AFL-CIO News, December
22, 1956, by Morris Brand, M.D.
Dr. Brand stated that since Congress has not
enacted legislation to set up a national insurance
program — which most labor unions favor — unions
have had to find other sources of health insurance
coverage for their members, mainly Blue Cross-
Blue Shield and commercial carriers.
However, Dr. Brand continues, since home and
office care is rarely offered in these plans, some
“labor groups have established direct service medi-
cal centers where services are actually provided
rather than cash indemnities to cover part of the
costs. The latter type of plan has proven more
popular with members because there are no bar-
riers to the service, preventive services are usu-
ally included in the benefits and there are no
hidden bills cropping up after the services are
rendered.”
In general, Dr. Brand believes that:
“The extent to which commonly available insurance
programs meet a family’s health needs is not too im-
pressive to Labor. . . . Indemnity patients are not a
satisfactory method of paying for services and are a
base upon which some physicians too frequently add
substantial charges. Also the emphasis on hospital and
surgical coverage as in the case of most plans without
substantial out-patient benefits is frequently a cause
for unnecessary hospitalization. Also, as a result of
inadequate concern for operating efficiency in hospitals
and an unwillingness to enforce legitimate controls,
there are unjustified premium increases.”
According to Dr. Brand, these are Labor’s goals
for better health plans:
1. Complete prepayment for medical care without
co-insurance and deductible features and hidden added
costs.
2. Comprehensive benefits — only if the range of
health services is complete will the individual’s health
needs be effectively and economically met.
3. Rational organization of medical services — on the
basis of group practice, and
4. Control of the quality of medical services which
must be built into medical care plans.”
A representative of organized medicine, Ralph
T. Ogden, M.D., President of the Connecticut
State Medical Society in the Journal of that
Society says:
“The voluntary health insurance plans, which pro-
vide benefits only when they are received in a hospital,”
are largely responsible for the present acute shortage
of hospital beds. On the Presidents Page of the
Connecticut State Medical Journal, he stated that many
people “are hospitalized today for diagnostic and thera-
peutic purposes only because they possess prepaid health
insurance which will pay for benefits under no other
circumstances. These ambulatory people are occupying
beds that should be available only for the sick. . . .”
Dr. Ogden does not feel that the answer to this
dilemma lies in building new hospitals or expand-
ing present facilities.
“A more effective answer would be a change in policy
of the voluntary health insurance plans which would
provide payments for medical services regardless of
where carried out, providing that safeguards against
abuse and exploitation could be assured. The medical
profession, the Hospital Association, Blue Cross, Blue
Shield, and all other health insurance agencies should
get together and develop a program that would pay
for medical services when rendered in private offices
or as patients of private physicians in the out-patient
departments of hospitals.”
Dr. Ogden further urges physicians to support
and recommend “ways and means whereby the
comparatively well patient may get the diagnostic
and therapeutic benefits of his health plan with-
out occupying a bed in a hospital. Every effort
should be made ... to eliminate the hospital
waiting list as quickly as possible.”
Having sponsored and encouraged voluntary
plans as its answer to problems of financing health
care, there is an understandable trend toward
holding the medical profession responsible for the
conduct and results of voluntary prepayment.
I will repeat, Dr. Brand, in his statement said it
in this manner: “Also, as a result of inadequate
concern for operating efficiency in hospitals and
an unwillingness to enforce legitimate controls,
there are unjustified premium increases.”
The Wisconsin Physicians Service, a part of the
Wisconsin State Medical Society, recently in its
State Journal said this:
“For while most people will have implicit confidence
in a health insurance program approved by the medical
profession, there is always the possibility that some
may think ‘the Doctors’ Plan’ is designed primarily to
benefit the doctor, rather than the patient.”
I doubt that it is necessary to remind this audi-
ence of the attitude of representatives of large
groups of subscribers to Michigan’s Blue Cross
and Blue Shield. The daily press, not so long
ago, was full of it. The hospitals and doctors
were charged with taking advantage of the exist-
April, 1957
495
PREPAYMENT PLANS— KETCHUM
ence of the Plans and of refusing or neglecting
to accept responsibility for controlling abuses.
A Commission was appointed by the Governor,
as a result of these charges, to make an investiga-
tion which is still being carried out. Since then,
the UAW-CIO has announced its intention of
organizing a prepayment plan which presumably
will employ groups of physicians on a salary or
capitation basis in order to control improper uti-
lization, costs and provide a wider scope of serv-
ices. It has been clearly demonstrated that, at
least in part, it is hoped that this plan will result
in assumption and exercise of responsibility and
control of abuses of Blue Cross, Blue Shield and
insurance on the part of the sponsoring hospitals
and doctors.
The demands for expanded and extended bene-
fits under Blue Shield have not only been voiced
by organized labor. Similar attitudes are ex-
pressed by employers, many of whom pay all or a
large part of the cost of protection; by many doc-
tors who have no hospital affiliation or would
prefer to render in their offices some services such
as minor surgery, diagnostic procedures, etc.; and
by those hospitals equipped to provide many of
these services on an out-patient basis.
Admittedly, your Michigan Blue Shield Plan
has provided, until now, little other than care for
hospitalized subscribers. The Board of Directors
and the management of Michigan Medical Serv-
ice are anxious to provide all the benefits which
can safely be offered on a sound actuarial basis,
without detriment to quality of care.
Our subscribers are asked to pay a fair and
reasonable rate for the benefits which they are
offered. But if members ask MMS to defray the
cost of unnecessary procedures and the abuse of
their contract, it is evident that the rate cannot
be reasonable. Our subscribers will consider our
rate unreasonable if, when entitled by the terms
of our contracts to service benefits, they are
charged fees over and above our payments to
physicians which have been established by the
physicians themselves. It is also difficult to justify
our program when, in a particular community,
our subscribers have difficulty finding physicians
who participate in Blue Shield.
If voluntary plans are medicine’s answer to
problems in financing medical care costs, then the
Profession must make the plans work.
Dr. Hess, at Seattle, also said:
“Since we have accepted the insurance principle,
many patients who previously would be non-paying pa-
tients have had their bills at least partially paid, and I
am rather intolerant of the physician who is not a
participating member of Blue Shield and who com-
plains when Blue Shield pays the patient and not him
directly. I also am intolerant of the physician who in
defense of his attitude in not being a participating
member, says with a loud voice: ‘Nobody is going to
tell me what to charge’.”
Michigan State Medical Society membership
now totals around 6,000 doctors of whom about
4,800 are engaged in the active practice of medi-
cine. Approximately half of the latter group
started their practice after the depression years,
without the experience of practicing in an atmos-
phere devoid of a voluntary prepayment medical
care plan. This lack of personal experience with
the kind of economic problems that gnawed at
medical practice in the depression years may, in
part, account for the negative attitude towards
prepaid medical care demonstrated by some of
these men.
These are the men who take for granted the
benefits of Blue Shield, who regard it as merely
a collection agency, who do nothing positive to
further its cause, who quarrel about its limitations
or even question the need for its existence.
No one can deny Blue Shield’s role in improv-
ing the over-all economic situation of physicians
in Michigan. Contrast the average physician’s in-
come in the 1930’s, when he rarely grossed $5,000
per year, with his situation today. In 1955, MMS
paid out to 6,237 physicians a total of $31,883,-
215.00. On the average, that would be a little
over $5,100 each. In 1956, almost $42,000,000.00
was paid out. Obviously on an individual basis,
many received far more than that average, many
far less. Nevertheless, it is an imposing picture.
And this, remember, is income from Blue Shield
alone and just a portion of the physician’s total
income.
Trends, in financing health care, as in every
other field, don’t just happen. Trends are the re-
sult of action and reaction by someone or some-
thing. The trends we’ve experienced in prepay-
ment are, in part, the result of actions long be-
fore Michigan Medical Service was conceived,
and since.
Natural competition, too, between the non-
profit plans and the insurance companies has
tremendously affected the trends. The develop-
496
JMSMS
PREPAYMENT PLANS— KETCHUM
ment of dosed panel and group practice plans has
had an effect and will have more. And what
Blue Shield and Blue Cross do now and in the
future will have much to do with establishing
the trend.
What influence your Blue Shield Plan will
exert in the future will depend on what you, col-
lectively, want of it; direct it to do; and the de-
gree to which you support its efforts. Blue Shield
itself, as a separate entity, can do nothing. Blue
Shield was created by your Michigan State Med-
ical Society, is responsible to, and is the respon-
sibility of organized medicine. Blue Shield must
have direction; it must know the attitude and the
policy of a united medical profession.
The medical profession must speak as one,
direct as one, and act as one. It is not sufficient
that the profession express itself critically and with
many voices. We are unable to completely satisfy
fifty-four County Medical Societies and eighteen
or nineteen different specialty groups with some-
times opposing views. The Profession must com-
municate with all segments, all the many specialty
groups, all the components, all the individual phy-
sicians. It must consider all the varied interests,
evaluate all the special problems. It must agree,
compromise, and reach decision. It must then
direct and support united action in behalf of all
the profession. Medicine needs intelligence, com-
munication, organization and authority in this
field.
Dr. Dwight Murray, at Seattle two months ago,
in his presidential address, warned:
“No nation can merely reap the benefits of freedom;
it must also sow the seeds of freedom. In medicine the
situation is the same. If an apathetic profession takes
its freedom for granted, it will be the beginning of the
end. . .
“The day has come, gentlemen,” Dr. Murray con-
tinued, “when we can no longer look upon medical
economics and social changes merely as issues to be
considered during our limited leisure hours. . . . We
must now pay daily attention to these matters. . . . They
must be a vital part of our life.”
Perhaps you’ve assumed that the past success
of your Blue Shield-Blue Cros and other volun-
tary prepayment plans in forestalling enactment
of compulsory health insurance should have been
enough. Perhaps you feel that you should be left
alone to enjoy the “status quo” or even return to
the old days. However, trends have a way of
continually advancing, changing direction and of
being influenced by action and reaction.
Trends are set by public opinion and favor, and
their courses can be altered as rapidly as they are
made. As a result, we must not be indifferent to
them. Instead, we must always concern ourselves
with the inevitable changes that will occur as we
advance into the future.
Our philosophy must be to make honest effort
toward improvement by recognizing those changes
and exploiting them to our advantage. And our
purpose should find its aim and its effect in the
betterment of mankind.
ACUTE PANCREATITIS
( Continued from Page 493)
20. Rauch, R. F., and Stenstrom, K. W.: Effects of
x-ray radiation on pancreatic function in dogs. Gas-
troenterology, 20:595, 1952.
21. Heacock, C. H., and Cara, D. J.: Radiation ther-
apy of pancreatitis. Radiology, 62:654, 1954.
22. Rush, B., Jr., and Cliffton, E. E.: The role of
trypsin in the pathogenesis of acute hemorrhagic
pancreatitis and the effect of an antitryptic agent
in treatment. Surgery, 31:349, 1952.
23. Hoffman, H. L. ; Jacob, J. ; and Freedlander, S. D.:
Use of crystalline soybean trypsin in acute hemor-
rhagic pancreatitis in dogs. Arch. Surg., 66:617,
1953.
24. Dreiling, D. A.; Janowitz, H. D.; and Halpem, M.:
The effect of a carbonic anhydrase inhibitor, Dia-
mox, on human pancreatic secretion; implications
on the mechanism of pancreatic secretion. Gastro-
enterology, 29:262, 1955.
25. Popper, H. L., and Necheles, H.: Prevention of
pancreatic fat necrosis by enzyme inhibitors. III.
Quinine. Surgery, 3,3:896, 1953.
26. Popper, H. L., and Necheles, H. : Prevention of
pancreatic fat necrosis; an experimental study. Surg.,
Gynec., & Obst., 96:299, 1953.
27. Stephenson, H. E., Jr; Pfeffer, R. B.; and Seypol,
G. H.: Acute hemorrhagic pancreatitis; report of a
case with cortisone treatment. Arch. Surg., 65:307,
1952.
28. Eskwith, I. S. ; Cagage, V. A.; and Sollosy, A.:
Acute hemorrhagic pancreatitis: Treatment with
cortisone. New England J. Med., 252:494, 1955.
29. Bloodworth, A. F., and Cohen, S. L.: Cortisone
in treatment of acute pancreatitis associated with
mumps epidemic parotitis. U. S. Armed Forces
M. J., 7:285, 1956.
April, 1957
497
St. Luke’s Hospital Clinico-Pathologic Conference
Edited by Chandler Smith, M.D.
Saginaw, Michigan
^HE PATIENT was a white man, forty-three
-L years old, who experienced an illness of
twelve years’ duration. The onset was heralded by
a fall from which he sustained several fractured
ribs on the left side. At that time he first noticed
a firm mass -below the left costal margin. Over
the ensuing years this mass receded and reappeared
so that its presence was intermittent. The patient
consulted a physician nine years after the onset
of this illness and the mass was again noted.
Radiographic examination of the upper gastro-
intestinal tract was said to be normal. The patient
experienced discomfort over the left upper ab-
dominal quadrant but continued to work. One
year before admission to the hospital he was
thought to have had a heart attack and sub-
sequently remained at home for several months.
During that time, he experienced some pain and
a sensation of pressure over the left upper ab-
dominal quadrant that radiated to the left
shoulder. Pain did not extend down the left
arm. The patient resumed work two weeks be-
fore entering the hospital and shortly thereafter
first noticed swelling of the abdomen and blue
discoloration of the peri-umbilical skin. During
the past six months there had been increasing
shortness of breath. The patient denied decreased
appetite or loss of weight but volunteered that
his face had become thin. There had been no
hemoptysis, hematemesis, melena, or black viscid
stools. Bowel movements had been normal. The
patient denied the use of alcoholic beverages.
The past history was not contributory.
Physical examination revealed a markedly
emaciated white man in no acute distress. The
temperature was 99.0 degrees (F.), pulse 80,
respirations 14 and blood pressure 135/90 mm.
Hg. The skin was clear without discoloration or
“spider angiomas.” The eyes were sunken and
the pupils were round and equal, reacting
promptly to light and accommodation. The
sclerae were white and the conjuctivae were pallid.
The neck was supple and cervical lymph nodes
were not enlarged. Auscultation of the chest re-
vealed normal breath sounds and elevation of the
diaphragm on both sides. The heart was not
enlarged, the rhythm was regular, and the valve
sounds were normal. The abdomen was soft and
markedly distended. Subcutaneous hemorrhage
discolored the skin about the umbilicus, over an
area that measured approximately 12 cm. in
diameter. A distinct fluid wave was elicited.
Tenderness was limited to the left upper quad-
rant where palpation revealed the splenic edge
6 cm. below the costal margin. The surface felt
smooth, the texture was firm, and the margin
was -blunt. The liver was not palpable. Ausculta-
tion revealed faint bowel sounds that were other-
wise not remarkable. The external genitalia were
normal. Rectal examination disclosed slight soft
symmetrical enlargement of the prostate. There
was no induration of the rectal shelf. The ex-
tremities were normal except for slight pitting
edema of the right lower leg. There was no
palmar erythema. The modalities of neurologic
function were normal.
Urinalysis was not remarkable. Hematologic
examination revealed 10.1 grams of hemoglobin
per 100 cc. There were 3,300,000 erythrocytes
and 8,500 leukocytes per cu. mm. Differential
count of 100 cells revealed sixty-seven segmented
granulocytes, three band cells, twenty-nine lympho-
cytes, and one eosinophil. The nonprotein nitrogen
was 47 mg. per 100 cc. The fasting blood sugar
was 114 mg. per 100 cc. The icterus index was
4.8 units. The total serum protein was 5.05
grams with 3.25 grams albumin and 2.8 grams
globulin. Bromsulphalein excretion was normal.
There was three plus flocculation of cephalin after
twenty-four and forty-eight hours. The serum
prothrombin content was 90 per cent. The Kahn
serologic test for syphilis was negative. Stool ex-
amination revealed only a trace of gross blood.
Radiographic examination of the chest revealed
elevated diaphragmatic domes that were smooth
and regular. The lung fields and costophrenic
angles were clear and the cardiac contour was not
remarkable.
After eighteen days in the hospital the abdomen
was explored. The operative report states that,
498
JMSMS
CLINICO-PATHOLOGIC CONFERENCE— SMITH
“many, many quarts of blood tinged, ascitic fluid
were aspirated.” Laboratory examination of that
fluid revealed a specific gravity of 1.021. No
tumor cells were identified. The peritoneum was
smooth and glistening. The liver appeared normal
with smooth surface and sharp margin. The
spleen was markedly enlarged and extended
medially to the midline and inferiorally to a point
midway between the xiphoid process and the left
anterior superior iliac spine. The anterior surface
was smooth and dark bluish red. The posterior
surface was firm, nodular, and discolored pale
yellowish gray. The nodularity was attributed to
enlargement of retroperitoneal lymph nodes.
Biopsy of a lymph node was attempted, but so
much bleeding was encountered that the pro-
cedure was discontinued and the abdomen was
closed. Chills and fever, accompanied by a pulse
of 120 and a respiratory rate of 40 developed on
the second postoperative day. Death occurred on
the next day.
Clinical Discussion
Dr. Bert M. Bullington: The clinical record reveals
that a forty-three-year-old white man incurred an illness
of twelve years’ duration that was characterized by an
intermittent mass in the upper quadrant of the abdomen.
There was an episode of pain in the left side of the
chest radiating to the left shoulder that was thought to
represent a “heart attack.” The distribution of the
pain, without extension into the left arm, and the sub-
sequent course were not characteristic of myocardial
infarction and suggest, instead, disease of the spleen
or left lung with involvement of the diaphragm. As-
cites developed toward the last portion of this illness
and probably accounts for the maintenance of body
weight in the presence of emaciation as indicated . by
wasting of the facial tissues. An interesting clinical
feature was the blue discoloration of the peri-umbilical
skin. This appears to have been hemorrhage into the
skin rather than a true Cullen’s sign which indicates
intraperitoneal hemorrhage. Some important negative
information includes the absence of “spider angiomas,”
palmar erythema, jaundice, alcoholism, hepatomegaly,
lymph node enlargement, or melena. The laboratory
data reveal a slight anemia, probably of normochromic
normocytic type, with normal leukocyte and differential
counts. There was a slight decrease in the serum albu-
min an^ a positive serum cephalin flocculation. Radio-
graphs of the chest revealed clear lung fields and ele-
vation of both domes of the diaphragm. We may
pause here to consider the pre-operative diagnosis.
An intermittent mass in the left upper abdominal
quadrant of long duration associated with laboratory
evidence of diffuse liver disease and subsequently with
emaciation and the formation of ascites is most sug-
gestive of the decompensation phase of portal cirrhosis.
The absence of dermal angiomas and palmar erythema
does not preclude this diagnosis. Failure to palpate the
liver is also consistent with portal cirrhosis as contrac-
tion of fibrous connective tissue reduces the organ to a
size smaller than normal. The subsequent course is also
acceptable under this diagnosis as clinical events may
be rapidly progressive after the onset of portal decom-
pensation. Cirrhosis may occur, of course, in the ab-
April, 1957
sence of chronic alcoholism, and abdominal exploration
may have been undertaken with this diagnosis in mind.
Operation, however, revealed a normal liver. The
peritoneal sac contained a large amount of red fluid
and examination disclosed pronounced enlargement of
the spleen. The splenic capsule was for the most part
smooth, although pale gray discoloration and nodularity
were identified over the posterior surface as well as
beneath the adjacent parietal peritoneum. The latter
was attributed to enlargement of retroperitoneal lymph
nodes. The abdomen was closed and the patient died
three days later.
The differential diagnosis regards those conditions
that are characterized by prolonged and pronounced
enlargement of the spleen. Both the duration and the
degree of this enlargement eliminate the possibility of
those acute infections that are often attended by spleno-
megaly. Only a small number of conditions are sug-
gested by this splenic lesion. Gaucher’s disease is one
of these. This condition usually is manifest earlier in
life but may be first detected at the age of forty-three
years. A main clinical feature is marked splenic en-
largement with or without hypersplenism. In addition,
ascites may follow thrombosis of the splenic or portal
veins. However, a familial occurrence is often detected,
involvement of the skeletal system is usually observed,
and enlargement of both liver and lymph nodes is char-
acteristic. Without these findings, the diagnosis of
Gaucher’s disease appears unlikely. Pronounced en-
largement of the spleen of long duration is often a
feature of chronic myelogenous leukemia. However, this
condition, even in the aleukemic phase, is usually accom-
panied by the presence of abnormal cells in the differen-
tial count, by a progressive and often pronounced ane-
mia, and occasionally by widespread enlargement of
lymph nodes. Furthermore, purpuric bleeding into skin
and mucous membranes, particularly the gums, is a
common feature of the terminal phase that derives from
thrombocytopenia. This record does not describe these
observations and the diagnosis of myelogenous leukemia
is passed over. Boeck’s sarcoid may be the cause of
splenomegaly. However, manifestations in other tissues,
notably lungs and lymph nodes, would be expected
with an illness of twelve years’ duration. Furthermore,
hyperglobulinemia, characteristic of sarcoidosis, was not
present. This diagnosis does not seem tenable. Myelo-
sclerosis is also characterized by pronounced enlargement
of the spleen that may be chronic. Lymph node en-
largement in the region of the spleen is not a feature of
this condition, however, and evidence of fibrous replace-
ment of bone marrow is usually apparent in the form
of anemia with immature cells of the granulocytic
series in the differential count of circulating leukocytes.
The diagnosis does not appear likely in the absence
of these findings. There is no evidence to indicate the
diagnosis of syphilis or chronic malaria which may also
be the couse of splenic enlargement.
Particular attention may be paid to Banff’s syndrome.
This condition is characterized by splenomegaly, anemia,
usually leukopenia, and frequently thrombocytopenia.
The hematologic disturbances are known as hypersplen-
ism. Banti’s syndrome results from intrahepatic or
extrahepatic obstruction of the portal system, and thus
many conditions may be causative. In this case, throm-
bosis of the splenic vein warrants consideration. Ex-
tension of the thrombus into the portal vein may have
been the event that preceded the rapid formation of
ascites, and rupture of a small vein into the peritoneum
may have been the cause of the hemorrhagic nature of
the ascitic fluid. Furthermore, the bleeding into the skin
of the abdomen could be due to thrombocytopenia. The
diagnosis of Banti’s syndrome is thus suggested. How-
ever, in Banti’s syndrome, cirrhosis is common, gastro-
intestinal hemorrhage is frequent, and leukopenia is a
constant feature. None of these was noted in this
patient. Furthermore, it is most important to emphasize
that enlargement of retroperitoneal lymph nodes and
499
CLINICO-PATHOLOGIC CONFERENCE— SMITH
focal nodularity of the spleen are apart from the mor-
phologic changes of Banti’s syndrome. Because of this,
and in the apparent absence of hypersplenism, the diag-
nosis of Banti’s syndrome is discarded. We now come to
malignant tumors of the spleen. Two possibilities are
Fig. 1. Primary Hodgkin’s disease of spleen.
reticulum cell sarcoma and Hodgkin’s disease. Both
may occasion splenic enlargement of long duration with
ascites, slight anemia, and regional lymph nodes in-
volvement without cirrhosis or abnormality of the cir-
culating leukocytes. It is extremely likely that reticulum
cell sarcoma would be demonstrable in tissues over a
wider region than the spleen and adjacent nodes after
twelve years’ duration. Hodgkin’s disease, however, may
affect the spleen primarily, and may be localized in that
organ for a long period, extending slowly to adjacent
lymph nodes. The liver may be normal, the leukocytes
are often within usual range, and a slight anemia is
consistent. Peritoneal involvement may occasion hemor-
rhagic ascites, and emaciation is typical of this malig-
nant disease. It is my opinion, therefore, that the infor-
mation provided in this clinical record is most consist-
ent with the splenomegalic type of Hodgkin’s disease.
Diagnosis of Doctor Bullington
Hodgkin’s disease of splenomegalic type
Diagnosis of Interns
Banti’s syndrome secondary to splenic vein thrombosis
Anatomic Diagnosis (SLH-A-163)
Primary Hodgkin’s disease of spleen with extension to
diaphragm and involvement of pancreatic, gastric, and
para-aortic lymph nodes
Acute diffuse fibrino-purulent peritonitis
Dr. J. C. Smith: Autopsy examination revealed a
spleen weighing 2,200 grams that was massively replaced
with tumor (Fig. 1). A large central portion was ne-
crotic. The tumor extended into the diaphragm and
was found in retroperitoneal and intra-abdominal lymph
nodes. Tumor was not identified in tissues other than
the spleen, diaphragm, and lymph nodes. Histologic
examination revealed the polymorphous cell structure of
Hodgkin’s disease with characteristic Sternberg-Reed
cells. The pronounced splenic enlargement with massive
tumor replacement and the relatively slight involvement
of lymph nodes and contiguous structures establishes on
the basis of distribution, the primary nature of the
splenic lesion. The massive fluid accumulation in the
peritoneum was probably related to extension of tumor
to that serosal surface. The intestinal tract was intact
and the acute inflammation of the peritoneal serosa was
a complication of the laparotomy. Death was attrib-
uted to acute fibrinous peritonitis associated with pri-
mary splenic Hodgkin’s disease.
REPOSITORY FOR MEDICAL CERTIFICATES
Because of the tragic losses of educational records and
official credentials of physicians resulting from wars and
natural disasters in the past, the tenth General Assembly
of World Medical Association adopted a recommendation
of its Council, approving establishment of a Central
Repository for Medical Records.
This action followed an extended study and con-
sultation with other international organizations, none of
which proposed to develop such a project themselves. All
agreed it was urgently desirable and pledged their sup-
port and co-operation to the World Medical Association
in developing the plan.
The national medical association in each country is
to act as the “receiving agent” for the records of the
doctors in that country, to verify such records, and to
forward them to the World Medical Association
Secretariat for deposit. The types of credentials to be
legally recognized and eligible for deposit have been
established, as well as a system of identification. A
repository has been selected. Identification forms and
detailed information will be furnished individual
physicians through their national medical societies and
their component units in the near future.
The Central Repository Project has been developed
in accordance with one of the World Medical Associa-
tion’s chief objectives: “to protect the interests of the
medical profession.” The success of the enterprise will
depend on the co-operation of the national medical
associations, and ultimately on the participation of the
individual doctor whose vital interests this undertaking
is intended to protect.
500
JMSMS
The Detroit Physiological Society
Meeting of December 20, 1956
ENZYMATIC ACTIVITY IN CELLS DURING
CARCINOGENESIS
BJARNE PEARSON
The field of enzymatic histochemistry is approxi-
mately 15 years old. During this time many of
the earlier uncertainties have been resolved and
methods have been improved. It attempts to dem-
onstrate and interpret activity and energetics on a
molecular level and to correlate this on a cellular
level.
The work to be reported here is limited mainly
to the demonstration of enzyme activity in cells
and tissues during carcinogenesis, normal growth
and regression. The enzymes which will be dealt
with are B-glucuronidase, nonspecific cholinester-
ase, alkaline phosphatase, succinic dehydrogenase,
and nonspecific esterase.
Tissues to be studied are frozen to — 70°C and
cut in a Linderstrom Lang cryostat at — 20°C
at 5u. They are transferred to slides and kept in
the cryostat until ready to go into their specific
substrate. This procedure prevents loss of enzyme.
Serial incubation times are used as well as stand-
ard pH conditions and substrate concentration.
The substrates used are (a) multiple reaction
types, where the final product is inorganic, (b) azo
compounds as naphthol esters coupled with stabel
diazotates forming an insoluble organic compound
and (c) single type reactions in which the enzyme
changes the substrate to an insoluble chromogenic
compound. The latter two have been modified
and developed in this laboratory. They offer the
best possibility for histoehemical study of enzyme
activity in normal and pathological tissue. Repre-
sentatives of these are the iodo and nitro substi-
tuted tetrazolium chlorides for the study of suc-
cinic dehydrogenase activity and the bromo sub-
stituted indoxyl esters for the study of nonspecific
esterases and other hydrolytic enzymes.
To study enzymatic histochemistry in tissue one
has to be aware of the possibility of strain and
genetic differences in animals with tumors and
other pathological lesions. Two examples will be
given. The first example is a survey of a series
of animals with transplanted adenocarcinomas of
the breast but of four tumors originating in their
specific strains, one was high in B-glucuronidase
activity and one was low. The enzyme activity of
the liver and the kidney parallel the tumors. The
next example is nonspecific cholinesterase assayed
in ten strains of animals. The livers were high in
three, intermediate in two and low in five strains.
April, 1957
During carcinogenesis of the liver produced by
azo dyes there is a marked increase in activity of
the enzyme alkaline phosphatase. Our study of
several hundred tumors so produced showed that
the increase in the enzyme was due to an increase
in the bile ducts and vascular sprouts preceding
tumor formation and that in the fully developed
tumor only the vascularity accompanying the tu-
mor showed enzyme activity. The tumor cells
were negative for enzyme. In a series of induced
carcinomas of the breast the alkaline phosphatase
activity was present only in the luminal margins
of the adenocarcinoma, scattered myoepithelial
cells and vascular stroma. The solid areas of the
tumor were negative. It was felt from this work
that the role played by alkaline phosphatase during
the formation of a carcinoma was that of trans-
ference of materials across membranes for synthe-
sis and secretion. The total enzyme activity of
the tumor depended upon the magnitude of such
surfaces.
Several hundred tumors of the liver were stud-
ied for succinic dehydrogenase activity. These
were induced by azo dyes and sacrificed every
month until the eighth month when all the ani-
mals had developed tumors. Succinic dehydro-
genase is present in normal liver cells, absent in
normal and proliferating bile ducts, present in
areas of cholangiofibrosis, present in the adeno-
carcinomatosis portion and absent in the solid por-
tion of the tumor. Methods were worked out by
us to estimate the succinic dehydrogenase activity
on a single 5u microscopic section. The lowering
or absence of succinic dehydrogenase activity pre-
viously reported by Schneider and Potter was due
to the proportion of solid to adenomatous areas
of the tumor and not necessarily due to the defect
in the enzyme system as postulated by Warburg.
Our conclusion was that you can have an equally
malignant tumor with presence or absence of
succinic dehydrogenase.
Nonspecific esterase was demonstrated by means
of a new 5-bromoindoxyl acetate synthesized in
our laboratory. After hydrolysis by tissue esterase
immediate oxidation to a highly chromogenic in-
soluble 5,5 dibromoindigo takes place which is
precipitated at the locus of enzymatic activity.
Tumors which we have examined so far are devoid
of nonspecific esterase activity. Nonspecific cho-
linesterase activity was studied in a variety of tu-
mors and anabolic and catabolic processes. Dur-
ing rapid growth phase of the endometrial glands
no enzyme activity was present but during secre-
tory (or catabolic) phase the glands show marked
501
DETROIT PHYSIOLOGICAL SOCIETY
activity. In tumor growth the same phenomena
occurs. During active growth in a carcinoma no
enzyme activity is apparent but during regression
of the tumor marked activity occurs. We have ex-
pressed a hypothesis that this may be due to the
adsorption of the enzyme to the areas of necro-
biosis from the blood stream.
SPECTROPHOTOMETRIC TITRATION OF
SERUM AND SPINAL FLUID CALCIUM
AND MAGNESIUM
BENNIE ZAK
A discussion of the several phases of the titration
of calcium and magnesium in serum and spinal
fluid has been investigated and these phases in-
clude dye variance, constitution of the titrant,
spectral studies and accuracy and precision of the
determination. Both separate determinations of
the individual cations of the same sample as well
as the use of the difference between total divalent
cation and either constituent are involved in the
analyses.
GLYCOPROTEIN PATTERNS OBTAINED
BY THE ELECTROPHORETIC SEPARATION
OF HUMAN SERUM ON STARCH
OTTO W. NEUHAUS and MARCIA LETZRING
A modification of the Elson and Morgan pro-
cedure for hexosamines has been devised that is
readily used in conjunction with zone electropho-
resis on starch. Aliquots of the eluates from the
starch segments were hydrolyzed, dried over KOH,
and neutralized. The compound (s) formed by
the hexosamines in the hydrolysate and acetylace-
tone was extracted with isoamyl alcohol and an
aliquot of this extract was then treated with Ehr-
lich’s reagent. This procedure minimizes interfer-
ences from hydrolysate color and non-glucosamine
substances that frequently react with Ehrlich’s
reagent. Each step involved in this procedure has
been studied to establish optimal conditions.
Protein and glycoprotein patterns were prepared
with five normal individual sera and two pooled
sera. Albumin, alpha- 1, alpha-2, beta, and gamma
fractions were evaluated planimetrically. Average
values were obtained for hexosamine of 26.8 per
cent in alpha- 1, 33.0 per cent in alpha-2, 20.3 per
cent in beta, and 19.8 per cent of the total in the
gamma fractions. No significant hexosamine could
be found in the albumin region. The average total
hexosamine concentration for the sera used was
88.0 mg/100 ml.
THE SPECTROFLUOROPHOTOMETER AS
A TOOL IN THE DEVELOPMENT OF NEW
METHODS OF FLUOROMETRIC ANALYSIS
JOHN F. R. KUCK, JR.
With the spectrofluorometer, it is possible to
examine with a high degree of resolution both the
excitation spectrum and the fluorescent spectrum
of any fluorescing solution. We have studied our
standard method for the determination of total
bile acid to show its deficiencies, and to attempt
modifications which might improve it. Such at-
tempts failing, we have developed a new procedure
in which 0.1 millimole to 0.5 millimole of mixed
bile acid (Cholic, deoxycholic, and chenodeoxy-
cholic) is heated at 65° for 80 minutes with 10
ml of 65 per cent sulfuric acid containing formal-
dehyde in the ratio of 2 moles of HCHO to 1
mole of bile acid. When such a mixture is excited
at 365 m^u and the fluorescence measured through
a yellow filter, each bile acid gives about the
same molar yield of phosphor. This determination
is of clinical value as a simple and rapid method
for evaluating the efficacy of a portacaval shunt
and for studies of biliary disease. It is valuable in
research for the presurvey of experimental samples
and for checking specific methods for the individ-
ual bile acids.
Meeting of January 17, 1957
CHEMICAL AND IRRADIATION BONE
MARROW DAMAGE AND ITS
AMELIORATION IN RATS
J. K. WESTON, R. E. MAXWELL, J. FINZEL,
M. LEE and R. A. FISKEN
Myleran administration to Holtzman rats in
single, intravenous doses of 20 mg./Kg. uniformly
produces severe bone marrow hypoplasia by the
second week with over 90 per cent mortality be-
fore fourteen days have elapsed. No evidence of
marrow recovery is demonstrable during this pe-
502
riod by either chemical (DNA, RNA) or histologi-
cal (total nucleated count, smear count, histologi-
cal section) techniques.
Single (or multiple) marrow injections of 125
x 106 rat nucleated marrow cells on any day from
the first through the fifth after Myleran marrow
insult reduces the fourteen-day mortality to near
zero and causes about a 70 per cent return to-
ward a normal marrow as evaluated by the same
chemical and histological criteria. Rats have sur-
vived as long as 8 months in apparent good health
following Myleran insult and single marrow trans-
fusion as above.
TMSMS
DETROIT PHYSIOLOGICAL SOCIETY
Comparable marrow damage and mortality have
been found to result following CO60 gamma irra-
diation at 800 r and the hypoplastic picture at
14 days post-irradiation marrow insult can be ame-
liorated to the same degree by similar rat marrow
transfusion therapy. Comparable marrow and mor-
tality results have been obtained at lower doses of
irradiation where, of course, the mortality rate
is much lower without treatment.
Although the total nucleated cell counts are
comparable between the 800 r irradiation and My-
leran insults, the distribution of cell types is dif-
ferent, particularly with regard to the lympho-
cyte (?) population.
ELECTRICAL ACTIVITY OF THE VISUAL
SYSTEMS OF ANIMALS WITH PURE
CONE RETINAE
ERNEST GARDNER, M.D. Department of Anatomy
Wayne State University College of Medicine
Among mammals, pure cone retinae are appar-
ently restricted to the Sciuridae, and in this fam-
ily, ground squirrels are the most strongly diurnal.
The present report, ia preliminary one, is the
beginning of a study of the visual system of the
antelope ground squirrel, Citellus leucurus, from
California deserts, carried out in collaboration with
Dr. Frederick Crescitelli.
C. leucurus is diurnal, has a pure cone retina,
and relatively large optic nerves. The guinea pig
by contrast has a pure rod retina, or nearly so.
In these two species, studies were made of elec-
troretinograms and visual cortex responses as
evoked by flashes of light, in light and dark
adapted states.
The ERG of C. leucurus is characterized by a
sharp a-wave, prominent b-wave of varying com-
plexity, and positive “off” response. The ERG of
the guinea pig also has a definite a-wave, a prom-
inent b of varying complexity, a longer lasting
c-wave, and, depending on state of adaptation,
sometimes an “off” response.
The cortical response in the guinea pig is mainly
surface positive, sometimes diphasic. That in
C. leucurus is mainly surface negative, sometimes
with an initial, much smaller positivity.
Although C. leucurus has a pure cone retina,
there were changes after light adaptation. These
were especially striking in the cortex.
The following conclusions are offered, some
very tentative, some more certain.
1. The eye of Citellus leucurus has a pure cone
retina.
2. The ERG of C. leucurus is similar to that
reported by Arden and Tansley for the grey squir-
rel and souslik. That of a rod retina (guinea pig)
does not differ greatly.
3. The ERG of C. leucurus has a high thresh-
old and shows definite changes during light and
dark adaptation.
4. The evoked response in contralateral cortex
is mainly surface negative, complex in shape, and
changes during adaptation are more marked than
in ERG.
5. There appears to be a marked neurological
component in adaptation, probably mainly in
retina.
THE RELATION OF PRENATAL AND
POSTNATAL AGE TO RADIOPHOS-
PHORUS DISTRIBUTION IN THE RAT
The relative uptake of maternally administered
radioactive phosphorus, P32, at various times of
gestation, will be presented and discussed in terms
of the growth and specific growth curves of the
intrauterine animal. The relative uptake of radio-
phosphorus by specific organs and systems at vari-
ous times in the fetal and postnatal rat will also
be presented. An attempt will be made to corre-
late these distribution patterns with the develop-
mental processes at these various times of life.
HERNIATION OF ABDOMINAL VISCERA
(Continued from Page 479)
4. Harrington, S. W.: Ann. Surg., 122:546-568 (Oct.)
1945.
5. Harrington, S. W., and Kirklin, B. R. : Radiology,
30: 147-156 (Feb.) 1938.
6. Kirklin, B. R., and Hodgson, J. R. : Am. J.
Roentgenol., 58 : 77-101 (July) 1947.
7. Ohler, W. R., and Ritvo, Max: New England J.
Med., 229:191-196 (July) 1943.
8. Feldman, M.: Clinical Roentgenology of the Diges-
tive Tract. 3rd Edition. Baltimore: The Williams
and Wilkins Company, 1948.
9. De Lorimer, A. A.: Moehring, H. G. ; and Hannan,
J. R.: Clinical Roentgenology. Vol. 3. Springfield,
Illinois: Charles C Thomas, 1955.
10. Patten, Bradley M.: Human Embryology. New
York: Blakiston Co., 1946.
April, 1957
503
Editorial
THE SPECIAL SESSION
For a year and a half, the medical profession has
been the butt of a tremendous amount of mis-
representation and criticism about the increases
asked for Blue Cross, the Hospital Service plan.
The doctors were quite freely blamed by certain
pressure groups for what they called “abuses,” not
recognizing that four interests were involved — the
hospitals, the patients, and pressure groups in
addition to the doctors. Delay of granting the
rates requested prompted the Governor to appoint
a Study Commission to hold open hearings and
try to solve the problem, but no report has yet
appeared. Newspaper publicity was very strong-
ly tainted against the doctors.
The CIO threatened to take measures to cor-
rect the “Blue Shield insufficiencies,” and or-
ganized in Detroit the Community Health Asso-
ciation, with the announced plan to offer to all
who wished a medical service plan to cover
“comprehensive” services — at a set subscription
rate, with the guarantee there would never be any
extra charges. Various meetings with invited per-
sons, including physicians, established the evident
threat to Medicine’s cherished voluntary, non-
profit program.
Recognizing the seriousness of the situation,
the Council of the Michigan State Medical So-
ciety authorized the calling of a special session
of the House of Delegates, the policy-making body:
1. To alert the medical profession to the com-
petition facing Blue Shield (CHA; Government;
Commercial Insurance) .
2. To retailor Michigan Medical Service con-
tracts to meet said competition more adequately.
3. To develop collective thinking among mem-
bers of the profession as their only survival device
— a united front must be presented.
4. To develop plans that satisfy the public
(the ultimate judge), that are realistic and ac-
tuarily sound.
THE HAND WRITING
The Blue Cross-Blue Shield prepayment pro-
gram of assuring the best of medical care to the
lower income population saved the private prac-
tice of medicine from the double threat of an
unprecedented depression with no money to pay
for medical services, and the very apparent wil-
lingness of government to take over and run the
health services by civilian rules and regulations —
W agner-Murray-Dingall.
Many of our older practitioners fail to see the
conditions as they are today, an entirely new
medico-socio-economy, and refuse to conceive that
government medicine can come. — All they need
to do is look around. A large number of our
younger physicians, graduated since 1939, have
never experienced “hard times,” and do not be-
lieve they can ever return — “government will
never allow another depression.” That attitude is
not new and has never protected us.
Medical genius and willingness to sacrifice,
faced with an intolerable problem, found the
answer in the late 1 930’s and gave us almost a
score of years of contented, satisfying, unhamp-
ered practice. The last three or so years have
seen a complete change in socio-medical economy.
The rewards for services have been good, the
hours favorable, and an “established” practice al-
most for the asking.
But times were too good, obstacles too few, and
our medical men discovered that because of “pre-
paid insurance” their patients could have the
abundant and available best medical attention.
All facilities for diagnosis and methods for con-
venient care were used — “insurance will pay, so
why not order everything we might need?” Not
a thought as to who pays — the patient always for
his premium costs must be boosted to pay the bills.
Too many physicians forget that Blue Shield
is their own creature, their own pocket-book. Blue
Shield is not insurance (by the enabling act) ;
it is our own medical services which we are selling
for a prepaid fee to our patients. Blue Shield is
the Michigan State Medical Society.
Our patients, up to the $5,000 income level,
are now in the same relative condition as were
those in the $2,500 level when Blue Shield was
born. There are some flaws which have been
pointed out to us by various interests which, if
not corrected, threaten to bankrupt Blue Shield
and Blue Cross. For three or four years, the
(Turn to Page 506)
504
JMSMS
Professionalism: Our Greatest
Value to Patients
All doctors of medicine are different, and no single com-
posite face will fit them all . . . but it can be said that they are
all products of their profession. And the key to understanding
them and their work and the value that they are to their
patients lies in that word “profession.” The “professionalism”
of the doctor is the one factor that makes his service of
greatest value to the patient.
It is because the doctor is a professional man that the pa-
tient can confidently and confidentially reveal his secrets to
him.
It is because the doctor is a professional man that the
patient can accept his decisions as being directed solely to-
ward the best interests of the patient and dictated by no
ulterior motives.
It is because the doctor is a professional man that the pa-
tient can be assured that his doctor has access to all the
knowledges of every other doctor because there can be no
secret remedies practiced by any doctor of medicine. It is be-
cause the doctor is a professional man that every patient can
be assured that when the real need arises, he will receive the
best treatment the doctor can offer regardless of payment.
It is because he is a professional man that no doctor will
decrease his quality of treatment, regardless of payments in-
volved. It is because of these professional attributes and
standards, plus the pride of the doctors in their profession,
that the Michigan patient can have the best medical care in
the world.
President, Michigan State Medical Society
president
e66acj
April, 1957
505
EDITORIAL
medical leaders, officers of Michigan State Medical
Society and of Michigan Medical Service, have
pointed out practices which are reprehensible
(with apparently little heed from medical men).
Hospitals, in their fight for survival, patients who
demand extra or increased service and pressure
groups of various kinds must also accept respon-
sibility for some of the abuse.
Is there any excuse for the physician who for
a submucous operation, submits his hospitalized
patient to a complete periodic health examination
including gastro-intestinal, x-ray series, BMR,
EKG, and blood studies amounting to about $150
worth of extra laboratory expenses? How about
the girl with hives who spends three days in the
hospital with complete gastro-intestinal examina-
tion, x-ray survey, EKG, gastric and feces study,
besides a complete physical and blood study? How
about any diagnostic or acute case in which the
patient has been given the whole gorment of ex-
aminations? Isolated cases? If they only were!
Our record committees say the same men con-
tinue the same offenses day after day. Some
method must be found to obviate these gross
abuses among our doctors. Studies show that
over 90 per cent of doctors never commit these
errors.
Continuation of absolute heedlessness in our use
of Blue Shield could abolish the whole voluntary,
medically controlled, prepayment of medical ser-
vices. Only two outcomes are then possible. The
job of insuring will be done privately and commer-
cially, but will not be medically controlled, or
publicly by government-socialized medicine —
which is now on the rocks in England.
Medical officers are again visiting every section
of the state trying to carry the message to each
and every member, hoping that each one of our
members will attend and be convinced.
Several years ago the late Senator Vandenberg
told us, “If Blue Cross and Blue Sheid fail — -
socialized medicine will take charge.”
MEDICAL EDUCATION WEEK
The week of April 21-27, 1957, has been desig-
nated as Medical Education Week by six organiza-
tions keenly interested in free, unhampered use
of our medical teaching facilities: (1) Associa-
tion of American Medical Colleges, (2) Ameri-
can Medical Association, (3) American Medical
Education Foundation, (4) National Fund for
Medical Education, (5) Students American Medi-
cal Association, and (6) Women’s Auxiliary of
the American Medical Association.
Several years ago, authoritative studies deter-
mined that our medical schools at that time
desperately needed an additional $10,000,000 a
year to cover their needs and to maintain inde-
pendent instruction. It was feared government
grants which were being offered could lead to
domination. Graduates were urged to make
private gifts to the cause or to their own Alma
Mater.
Too little was obtained, but the unemcumbered
sums have allowed most of our medical school
Deans to retain desirable teachers, and to set up
research problems of great value. Drs. Fursten-
berg and Scott at our “Dean’s Conference” sev-
eral years ago were glowing in their praise of this
facility.
Medical Education Week offers us another op-
portunity to each to pay his tribute to his Alma
Mater or to medical education in general. The
month of April is a good one to remind ourselves
of a duty and a privilege of making tax-free
donations to what is probably the most important
feature of education.
Michigan also has its own Foundation for
Health and Medical Education, doing a worth-
while job of helping medical students to stay
medical students. This, too, is a worthy objec-
tive. Earl I. Carr, M.D., Lansing, is President
of this organization. Wm. M. LaFevre, M.D.,
Muskegon, Councillor for the Eleventh District,
suggested that we all make a habit of a birthday
or anniversary gift to any one or both of our
special programs: Medical Education, The Michi-
gan Foundation. The World Medical Association,
organized to further independent medicine
throughout the world and to combat communistic
threats, is another worthy group to which we
should send our $10 memberships.
All this reminds us that Michigan is not pro-
ducing enough doctors of medicine to supply all
needed service to the people of this state. Our
State Legislature is in session, and Wayne State
University Medical School is asking for money
to hire teachers and thus add another fifty doctors
to our capacity and ability to serve our needy
people.
506
JMSMS
EDITORIAL
MEDICARE TODAY
The Medicare program has now been in opera-
tion four months. Numerous problems have arisen
and are being negotiated as they occur. Some
of the rules do not work, and some services which
most of the doctors and patients thought were
covered must be paid by the patient, if at all.
Office and home calls, except maternity, are not
included.
General Paul R. Robinson, representing the
Army, gives some interesting facts. Army depend-
ents make up 25.5 per cent of medical claims;
the Navy, 30.1 per cent; the Air Force, 42.7 per
cent, and Public Health Service, 2.7 per cent.
All State Medical Societies are participating,
except Rhode Island, where the Army is paying
the doctors directly, and Ohio, where no agree-
ment could be arranged and where an insurance
company is handling the physicians’ statements.
All the States will be asked to extend their
programs beyond July 1, 1957, until they may be
renegotiated at the rate of five per month.
CANCER CONTROL INVENTORY
American business takes time out each year to
make an inventory of the past twelve months of
operation. We, in medicine, and more particu-
larly in the field of cancer, can profit by a critical
self-analysis of our past years of work.
Through the program of lay and professional
education, more lives are being saved. Cancer
is seen and diagnosed earlier. There is more
effective utilization of our treatment methods.
Business and industry have a greater awareness
of the toll cancer takes not alone in human lives
but in lost time, lost production. Educators have
found that the Junior High School level is not
too young to begin the story of cancer.
The American Cancer Society, appreciative of
the great need for a more active fight against
cancer, has seen fit to re-appraise its research
program. More funds must be channeled into
research if we are to win the battle of cancer.
True, the program has grown tremendously the
past ten years, from about a million dollars to
more than fifty million this year. This seems
like quite a sum, yet there are departments of
government spending many times more on re-
search. This represents only a drop in the bucket
to what industry allocates to research for im-
provement of its products. We must furnish the
tools, the space, and the climate for the researcher.
April, 1957
As physicians, we are keenly aware of the attack
on cancer through the use of chemicals. This
vast field is being systematically explored through
research. On the other hand, Dr. Wendell M.
Stanley, Director of the Virus Laboratory of the
University of California, stated at the Third Na-
tional Cancer Conference, “The experimental
evidence now available is consistent with the idea
that viruses are the etiological agents of most, if
not all, cancer, including cancer in man.” Here,
too, we see a great field for research. There
have been pilot studies on the early diagnosis of
uterine cancer through the use of cervical smears.
These studies have shown conclusively the need
for a broad acceptance of the cytological tech-
nique in the early diagnosis of cancer. Through
the many avenues of research, we, as physicians,
can be proud of the contribution science is making
in the crusade against cancer.
The newly established Scientific Advisory Coun-
cil of the American Cancer Society passes on all
research programs. T hey point the way.
The immediate future has many facets from
the test tube of the chemist, the microscope of the
pathologist, the scalpel of the surgeon on to mul-
tiple million volt radiation therapy. Our inven-
tory of the past shows progress; our predictions
for the future are most hopeful.
Cancer Coordinating Committee
OUR CHALLENGE
The past ten years have seen a tremendous in-
crease in activity to control and eradicate the
various forms of cancer. As the result of the
organized educational campaigns of the medical
profession and the American Cancer Society and
even in this brief span of time, many physicians
are seeing substantial improvement in mortality
and morbidity from many malignant tumors. In
spite of this ray of hope, however, much remains
to be done if cancer is to be completely conquered.
Furthermore, much more can be done if the
medical profession will more adequately and ef-
ficiently use the knowledge now in its hands.
Delay in the diagnosis of cancer has always
loomed large in the unsuccessful treatment of
many forms of this disease. The forty-year cam-
paign of the American Cancer Society has been
largely responsible for the considerable improve-
ment in public knowledge about cancer, thus re-
ducing delay which is the fault of the patient.
Cases where the physician is at faidt are appar-
507
EDITORIAL
ently or actually increasing, according to the re-
port by Leach and Robbins from Memorial Hos-
pital in New York City. With optimum applica-
tion of the readily available techniques of diag-
nosis and treatment, it is estimated that at the
present time, five-year survivals could be im-
proved by 10 per cent for skin cancer to more
than 60 per cent for rectal cancer. Reliable
estimates indicate that the number of cured cases
of cancer could theoretically be more than doubled
— this with our present knowledge of the disease.
Furthermore, we must emphasize that it is pos-
sible to identify the presence of a number of im-
portant cancers in advance of their usual signs
and symptoms through the application of a few
simple procedures adapted to office practice — an
enterprise known as cancer detection. Here, we
must stress the importance of thorough examina-
tion of female breasts, the routine use of the
Papanicolaou smear test and the digital and proc-
tosigmoidoscopic examination of the rectum. The
examination of well persons does disclose unsus-
pected “silent” cancer in eight of every 1,000
persons unselected as to age, the rate rising with
age to thirty- five per 1,000 among those over sixty.
One may well ask, “Is this yield worth the
time, effort and expense?” Admittedly, this kind
of scrutiny of presumably well people might be
tedious for those who prefer to open boils and
give injections as most of us do. There are many
examples of why the concept of cancer detection
in its preinvasive stages must be practiced by all
physicians if we are to make progress against
this common enemy.
Cancer of the cervix, the chief cause of death
from cancer among women, is 100 per cent cur-
able when adecjuately treated in the noninvasive
stage, which is now identifiable by the simple
Papanicolaou smear. Cancer of the lung is found
to be localized — nearly equivalent of curable —
seven times more often in patients whose tumors
are discovered in a “routine” chest x-ray examin-
ation than in patients who need a chest examina-
tion because they are coughing or having chest
pains and other symptoms. Cancer of the rec-
tum can be felt in most cases and can be seen
through the proctoscope in all when it is no
bigger than a pencil’s eraser, before bleeding,
diarrhea and tenesmus occur — when seven or
eight in ten may look forward to cure. This
challenge is clear. To withhold prophylactic ex-
amination is to jeopardize life.
508
Recent clinical research has demonstrated
growth-restraining properties of a number of hor-
monal and chemotherapeutic compounds, natural
and synthetic, in advanced cancer of the prostate,
breast cancer, Hodgkin’s disease and other malig-
nant lymphomas, acute leukemia and multiple
myeloma. The list of these agents is not long,
their range is limited, and their effects transitory.
Yet, in selected cases, they do accomplish what
was not possible five and eight years ago.
They, together with hematinic agents, vitamins
of every known kind and in nearly every con-
ceivable combination, nutritional adjuvants, seda-
tives, narcotics and hypnotics offering variety in
dynamics and duration, make the management
of terminal illness more effective for the patient
and more satisfying to the doctor than it has
even been before. Furthermore, it is our duty
under the Oath of Hippocrates to use any or all
of these agents to alleviate pain and suffering and
thus forestall patients and relatives from seeking
out the charlatan and quack who only raise false
hopes and extract uncountable quantities of money
solely for their own gain.
The challenge, then, to every physician and
especially to the general practitioner is to accept
his pivotal place in the contemporary effort to
reduce deaths from cancer, to accommodate in
his services any and every practice for achieving
the earliest possible recognition of cancer, and
finally, backed by the numerous fruits of modern
pharmaceutical and clinical research to enable
his patient to approach death from cancer in
dignity and in comfort.
C. Allen Payne, M.D.
POLIO DISCUSSION
It had been our intention to publish an article
in the March, 1957, issue of The Journal by
M. V. Veldee, M.D., of the Stanford Research
Institute, Menlo Park, California, entitled “Polio-
myelitis Vaccine: Problems in Processing and An-
tigenic Value,” which he presented to our Michi-
gan Clinical Institute in March, 1956.
In the face of a rapidly changing problem and
constant research, Dr. Veldee has requested that
his paper not be published at this time, but that
instead, we call your attention to Dr. Rutstein’s
discussion of the problem in the February, 1957
issue of Atlantic Monthly, which accurately and
clearly presents the polio vaccine problem as it
now exists.
JMSMS
Code of Procedures and Ethics Relating to Autopsies
Purpose
The performance of autopsies is essential to the wel-
fare and protection of the public and to the advancement
of medical science. All who are concerned with the
performance of the autopsy must serve the interest of
the relatives or friends of the deceased with respect to
the care of the body. In connection with the autopsy,
therefore, the hospital, the pathologist, and the funeral
director agree to discharge their responsibilities on the
highest professional standards, and to promote mutual
trust, confidence, and good will.
Toward this end, the present Code has been arranged
by agreement between the Michigan Funeral Directors
Association, the Michigan Hospital Association, the
Michigan Pathological Society and the Michigan State
Medical Society.
This code shall not supersede any agreement made
between local groups of funeral directors, hospitals
or pathologists.
Responsibilities of the Hospital
Preparation of the Body. — In the preparation of the
body, the head and shoulders should be elevated to
prevent postmortem lividity in these exposed parts. The
arms should be crossed over the trunk and held by
cotton-padded strips of gauze above the elbows but
not at the wrists. The eyes should be closed but
nothing should be placed under the eyelids. The
mouth should not be closed. (Strips of gauze used for
this purpose leave objectionable marks.) Surgical
dressing should be left in place. The body should be
covered but not wrapped, and when possible kept
refrigerated at 38 to 40° F.
Interest of Hospital in Autopsies. — The autopsy is
performed as a public service and in the interest of
science. It represents a considerable cost to the
hospital.
Permission for Autopsy. — Permission should be secured
Note: The provisions and wording of this tentative
draft were agreed upon by the following representatives
of the designated organizations at a meeting held on
November 29, 1956, at the Wayne County Medical
Society, 4421 Woodward Avenue, Detroit.
Mr. Harold Dumancia and Mr. H. C. Burrell, Michi-
gan Funeral Directors Association
Dr. James T. Howell and Dr. F. W. Hyde, Michigan
Hospital Association
Dr. Lawrence W. Gardner, Michigan Pathological
Society
Dr. John W. Robuck, Committee on Pathology, Wayne
County Medical Society
Dr. S. E. Gould, Michigan Pathological Society and
Michigan State Medical Society
Adopted by Michigan Funeral Directors Association,
Inc., Michigan Hospital Association, Michigan Patho-
logical Society, and Michigan State Medical Society,
March 15, 1957.
April, 1957
with the least practicable delay. A suitable legal form
should be used and properly witnessed, a copy of
which shall be made available to the person granting
permission. In general, a complete autopsy includes
examination of the brain and organs of the neck, as
well as the contents of the thoracic, abdominal and
pelvic cavities. In requesting permission for autopsy,
the nature and the extent of the autopsy should not
be misrepresented; the hospital staff shall not use
coercion or threaten to designate the death as a
“coroner’s or medical examiner’s case,” or refuse to
sign the death certificate, if the cause of death is
known.
Notification. — The hospital administration should
notify the pathologist as soon as the autopsy permit
is signed. As soon as the hospital learns the name
of the funeral director, the hospital shall notify him
that an autopsy is to be performed and that the body
will be ready for delivery at a specified time. In order
to obviate any inconvenience to the family of the
deceased and in order to facilitate the funeral arrange-
ments, it is essential that every effort be made to ex-
pedite the autopsy and permit the body to be delivered
to the funeral director with a minimum of delay. Ver-
bal and written notification shall also be given of any
unusual hazard in handling of body, such as from gas
gangrene or radio-activity.
Every effort should be made for the prompt com-
pletion of the death certificate or transit-permit.
When a promise has been made to relatives that they
will be informed of the autopsy findings, the person
making the promise should notify the pathologist of the
name and address of the family physician or attending
physician to whom the findings should be mailed. This
physician will then be in a proper position to interpret
the clinical manifestation of disease in the light of
the autopsy findings.
Responsibilities of the Funeral Director
The funeral director (and embalmer) recognizes that
his work is usually simplified in a body.
The funeral director (or embalmer) shall co-operate
in every way with the hospital in requesting permission
for autopsy; he shall assist the hospital in locating
relatives in order to obtain permission for autopsy. It
shall be deemed improper for a funeral director (or
embalmer), by any manner or by implication, to dis-
suade the family from granting permission for an
autopsy or to influence the family to change its mind
after permission has been given.
It shall be considered unethical for a funeral director
or embalmer to make a specific charge to the family
because of preparation of a body following autopsy.
509
AUTOPSIES
In order to correct misunderstanding or prevent
possible criticism from any source, it is understood that
the funeral director and the pathologist will com-
municate with each other at once if any question is
raised in connection with the performance of an autopsy.
The funeral director should telephone the hospital
to inquire when the autopsy will be completed, rather
than call or have his attendant call at the hospital,
without notice, to remove the body.
As a convenience to the family and as a courtesy
to the pathologist, the funeral director, upon receipt
of legal form granting consent for autopsy, will permit
autopsies to be performed in the funeral home.
Responsibilities of the Pathologist
The autopsy shall be performed and the body made
ready for delivery to the funeral director with the least
practicable delay.
In some instances arterial embalming may be per-
mitted (in the autopsy room, morgue, funeral parlor),
before autopsy. However, such embalming interferes
with the proper performance of the autopsy, as in sep-
ticemia, bacterial endocarditis, or suspected poisoning
since there may be no way of knowing in advance if
any of these conditions are present.
If delay is anticipated by the pathologist in per-
formance of the autopsy, the funeral director should
be notified so that the time of delivery of the body
to the funeral director will be mutually satisfactory.
If permission for autopsy is obtained after 4:30 p.m.,
the body should be ready for delivery by 11:00 a.m.
of the next day; if permission for autopsy is obtained
by 10:00 a.m., the body should be ready for delivery
by 4:00 p.m. of the same day; if consent is obtained
between 10:00 a.m. and 4:30 p.m. the body should
be ready for delivery within 6 hours. It is obvious
that the permission for autopsy must be delivered to the
pathologist immediately after it has been obtained.
If any unusual procedure is found necessary for the
proper performance of the autopsy, which may interfere
with the work of the embalmer, the pathologist shall
attach a note to the body or telephone the funeral
director to explain the need for the procedure. Notifi-
cation shall also be given of any unusual hazard in
handling of body, such as from gas gangrene or radio-
activity.
The pathologist should transmit his findings of the
cause of death to the attending physician or responsible
hospital medical officer as soon as possible to facilitate
prompt competion of the death certificate or transit-
permit.
Mutual Responsibilities
All hospitals, pathologists, and funeral directors (and
embalmers) shall periodically instruct all members of
their staffs, employes, or agents who are concerned with
these recommendations to enable them to carry out
these provisions intelligently and efficiently. (In hos-
pitals, this personnel will include administrative and
office employes, nursing and medical staff, telephone
operators, orderlies, and morgue attendants.) A copy
of these provisions shall be posted in a conspicuous
location or made available to the personnel concerned.
It is recommended that this Code be incorporated in
the curriculum of all schools of embalming, mortuary
science, medicine and nursing in the State of Michigan.
Recommended Procedures in Autopsy
A “Y” incision is recommended for routine use, both
in males and females. In females, the incision should
be made below the breasts along the normal folds, and
should not extend laterally beyond the anterior axillary
lines.
Should it be necessary to turn the body over in
examining the spinal column, the forehead should be
placed on a support sufficiently high to prevent the face
from touching any surface. The entire face, and par-
ticularly that portion of the forehead resting against
the support, should be protected with a heavy cotton
pack.
Cranial Examination. — Special care should be taken
to preserve the normal facial features. A transverse
incision in the scalp should be made from behind one
ear, across the vertex (but not anterior to it), and to
a point behind the other ear. In the removal of the
calvarium, the temporal muscles should not be excised ;
instead, a single horizontal cut should be made through
the thickest portion of each muscle and the incised
portions bluntly reflected toward the cephalic and
caudal attachments. The lines of sawing of the
calvarium should be arranged to avoid over-riding by
the replaced bone. One recommended procedure is to
saw the occipital bone as far posteriorly as possible,
leaving an inverted V-shaped or square projection on
the remaining portion of the bone. Laterally the ex-
cised calvarium in the region of the mastoid process
of each temporal bone should form an obtuse angle.
If autopsy is performed prior to arterial embalming, the
ends of the internal carotid and vertebral arteries should
be left as long as possible and ligated prior to removal
of the brain. Unless other arrangements are agreed
upon locally for restoration of the cranial cavity, the
latter should be left open. A few sutures in the scalp
will hold the skull cap in place temporarily.
The nature of the autopsy will determine the extent
of the examination. In general, certain precautions
should be followed :
1. Incision in the posterior or lateral abdominal or
thoracic wall should be avoided.
2. Surgical incision near the midline should be
utilized as far as possible.
3. The breast plate should not be removed partially
or retracted against the face. It should be disarticulated
at its clavicular junction and be removed completely.
At the end of the autopsy it should be replaced.
4. Long stumps and long ligatures should be left
on the main arteries arising from the arch of the aorta.
If tissue is to be removed from the neck regions for
examination, the carotid and subclavian arteries should
remain intact and major branches should be tied. If
the trachea and larynx are to be removed, the superior
510
JMSMS
AUTOPSIES
thyroid arteries should be ligated close to the external
carotid arteries.
5. The external iliac arteries should not be ligated
but long stumps should be left so that they may be
used for injection in embalming the inferior portions
of the body. The internal iliac arteries should not be
removed unless necessary.
6. If it is desired to remove a section of an artery
of an extremity, the artery should be ligated beyond
the cut ends prior to removing the section, unless the
body has been previously embalmed.
7. The testes should be removed through the inguinal
canals.
8. In removing the rectum, the anal stump should
be ligated and care should be taken not to cut the
rectum too close to the anus. The pelvic floor should
not be cut.
9. If the entire uterus is removed, the vaginal canal
should be closed by properly placed “purse-string”
sutures, best applied externally.
10. As far as possible, all fluid shall be removed
from the body cavities.
11. Depending upon local preference and agreement,
after examination the organs may be inserted within
plastic bags and placed within the body cavity, and the
main incision then approximated with a running suture.
12. Tissues such as corneas, eyes, skin, bones, and
blood vessels which are to be used for special purposes,
other than for pathologic examination, shall be retained
by the pathologist or the hospital, providing special
CIVIL DEFENSE ME
At a recent meeting of the Committee on National
Defense, C. A. Anderson, M.D., reported on the Detroit
Area Evacuation Plan which concerns itself with the
care of evacuees and the care of casualties. It is felt
that current planning and training programs are
adequate. There are now fourteen training cadres
meeting in the Detroit metropolitan area, six advance
courses, approximately forty-two persons in each class.
Recently, seven counties met regarding co-ordination
of medical civil defense activities in the down-state area.
Max L. Lichter, M.D., speaking on evacuation, stressed
the need to plan for evacuation until some other better
plan is introduced. The current planning is that with
a warning or an alert time, an attempt will be made
to get as many people out of the area as possible. There
is a need to rendezvous personnel and some periphery
area — doctors, nurses, dentists, and others trained to
aid in case of a disaster. There is a need to plan how
to utilize other professional personnel in areas to which
the population has moved, and how to care for the
evacuees, and development of plans for a hospital system.
The Committee was informed of some basic premises
of its September, 1956, report, stating that an attack
is possible; the aiming point could involve an error of
possibly 20 miles and the mission of an enemy still be
accomplished through radio-active fallout within the
area of the point of impact based in some degree upon
wind direction, speed, et cetera. Trained cadres for
portable emergency hospitals, and casualty care stations
are necessary and infirmary type units for continuing
care of casualties. It is planned to publish a road map
of Detroit and the area indicating assembly points and
a proposed buffer zone between 15 and 25 miles from
the central point of the City of Detroit. After discus-
sion, a resolution was presented by J. S. Lambie, M.D.,
as developed by representatives of the medical societies
April, 1957
permission has been obtained. The embalmer should
appreciate that the removal of some tissues, such as
skin, may pose an additional problem for him.
Adjustment of Complaints
If any violation of this Code occurs, the matter should
not be discussed with the family of the deceased but
instead an effort to adjust the differences should be
made promptly by the funeral director, the pathologist
and the hospital concerned without any discussion with
the family of the deceased, or by a local co-ordinating
committee appointed for this specific purpose.
If agreement is not reached through such efforts, the
violation may be referred to the State Committee on
Autopsies. This committee should be selected annually
and should be composed of one member selected by
each of the following organizations: Michigan Funeral
Directors Association, Michigan Hospital Association,
Michigan Pathological Society, and Michigan State
Medical Society. All complaints should be submitted to
this committee in writing. Decisions and recommenda-
tions made by the committee with respect to complaints
considered by the committee should be transmitted to
the organization concerned for appropriate action.
Should a member of the committee be involved in a
dispute and such dispute be referred to the committee
for investigation, an alternate member should be selected
from the organization which he represents to take his
place temporarily on the committee.
\L ORGANIZATION
and civil defense medical services of seven southeastern
counties of Michigan.
Whereas, today’s weapons of war are of such magni-
tude that they transcend political boundaries, that the
effects of such weapons will greatly concern geographical
areas and populations far beyond the limits of physical
damage, and
Whereas, the capabilities, efficiency and uniformness
of civil defense forces and plans would be tremendously
strengthened to prepare to meet the demands on the
medical profession of perhaps hundreds of thousands of
casualties caused by a military attack on the above
mentioned area, and
Whereas, this target area has great problems of
common concern which require intensive co-ordination
and planning; and, eventually, operational control,
therefore be it
Resolved, That we the representatives of the medical
societies and civil defense medical services of the counties
of Livingston, Macomb, Monroe, Oakland, St. Clair,
Washtenaw and Wayne do hereby appoint a committee
composed of Max Lichter, M.D., William Henry Gordon,
M.D., John E. Griffin, or designee, Major General Clyde
E. Dougherty, or designee; with Paul J. Shafer as Secre-
tary, whose function shall be to establish a committee
composed of a representative of the Public Health Office
and the civil defense medical services of the respective
counties, whose duties, in turn, will be to solicit the
sanction, endorsement and support of the Inter County
Board of Supervisors Committee, the Michigan State
Medical Society; and to promote the establishment of a
seven-county civil defense medical organization and
operational plan, which shall be in conformity with the
general civil defense planning of the State of Michigan.
Representatives of additional counties may be added at
a later date, if regarded desirable.
511
Michigan’s Department of Health
Albert E. Heustis, M.D., Commissioner
POLIO CASES AND DEATHS IN 1956
Analysis of polio cases and deaths in Michigan in
1956 shows that both dropped sharply, compared with
totals for 1955. There were 656 cases and twenty-three
deaths in contrast to the 1,177 cases and thirty-one
deaths in 1955.
Both cases and deaths shifted away from the age
group that has received maximum protection through
vaccination, children of fourteen and under.
Of the twenty-three Michigan persons who died from
polio in 1956, none had received vaccine. Stated in
another way, no person in Michigan who had received
any portion of the three-shot polio immunization series
died from this disease during 1956.
Of the 656 polio cases reported to the state health
department in 1956, a total of 308 (47 per cent) were
paralytic cases. This follows the average division be-
tween paralytic and non-paralytic cases in previous
years.
Of the 308 paralytic cases in 1956, a total of 194
(63 per cent) were in the best protected age group,
children from birth through fourteen. In previous
years, 70 per cent or more of the paralytic cases oc-
curred in the fourteen and under group. Three per cent
of the 1956 paralytic cases occurred in persons over
thirty-five years old. The oldest person to die from polio
in Michigan last year was fifty-four.
Of the twenty-three deaths from polio in 1956, a total
of eight (35 per cent) were in the fourteen and under
age group. Prior to 1956, about 45 per cent of the
polio deaths were in this age group.
The 1956 polio record was the best in Michigan since
1947, when 646 cases and twenty-nine deaths were
reported. The state’s worst polio year was' 1952 when
there were 3,912 cases and 213 deaths.
VENEREAL DISEASES NOT DECREASING
The continued high incidence of syphilis and gonor-
rhea in Michigan and their prevalence among teen-
agers are highlighted in figures compiled recently in
the state health department.
The venereal diseases are not going down. New cases
of syphilis totalled 4,865 in 1955, a slight increase over
the 1954 total. Gonorrhea cases in 1955 numbered more
than 10,000, highest since the post-war record of 1947.
Of equal signifiance is the age group in which cases
of both syphilis and gonorrhea occurred. Twelve per
cent of the early, infectious syphilis was in persons
fifteen to nineteen years of age. About one out of six
new cases of gonorrhea were reported in this age
group, a total of 1,627 cases.
A survey in one of the large school systems has dis-
closed that venereal disease among school pupils, begin-
ning at eleven years of age, has increased by about 100
per cent in the past fourteen years. And most of this
increase is in active, infectious disease.
Practicing physicians are reporting six of every ten
new cases of syphilis but less than three of every ten
new cases of gonorrhea.
Both physicians and VD clinics are finding that peni-
cillin reactions are much more frequent than in the
past. When a reaction occurs, other, less effective,
drugs must be used. There has been, for the first time
so far as we know, definite proof that some strains of
gonococci are penicillin-resistant.
TRAINING FOR TEACHERS OF
EXPECTANT PARENT CLASSES
The department is continuing to assist communities
interested in offering expectant parent classes by helping
in the training of teachers.
An Institute for Teachers of Expectant Parent Classes,
sponsored by the department and the Clara Elizabeth
Fund of Flint were held at Gull Lake on April 10 to
12. In addition to Michigan specialists in expectant
parent education, the faculty will include Kate Hyder,
well known for her teaching in maternity nursing at
Yale University and at Teachers College, Columbia.
TRAILER PARK SURVEY IN PROGRESS
A survey of trailer parks in Michigan has been in
progress for several months, carried on by the division
of engineering of the state health department. The
survey has already covered thirty-three counties and
work is being done in the southeastern counties.
The purpose of the survey is to obtain information
which should be of help to park operators and those
responsible for the administration of laws and ordinances
pertaining to the installation and operation of such
parks.
RADIOACTIVE FALLOUT IN LANSING AREA
Since April, 1956, the Michigan Department of
Health has been measuring the radioactive fallout in the
Lansing area. Because of public interest in the subject,
reports have been made routinely to the press. These
reports have been discontinued in view of the lack of
variation in the figures.
Records show that the radioactive fallout in the
Lansing area has been slightly less this winter than it
was last summer. The winter fallout is averaging
1.68x1 O'6 microcuries per cubic meter of air. Last
summer’s average was 1.8 xlO-6 microcuries. Readings
during the two weeks preceding January 7 averaged
1.75 xlO'6 microcuries, about l/200th of a dangerous
dose for humans.
Over 75 per cent of all tumors of the large bowel
are within the reach of the palpating finger, and nearly
85 per cent can be seen by the sigmoidoscope.
512
JMSMS
COMPREHENSIVE VAGINITIS REGIMEN
Powder Insufflation
Tablet Insertion
Floraquin Rebuilds the Defense
Mechanism in Vaginitis
Combined office and home treatment with Floraquin
provides a comprehensive regimen which encourages restoration
of the normal “acid barrier” to pathogenic infection.
Vaginal secretions normally show a high
degree of protective acidity (pH 3.8 to 4.4).
When this “acid barrier” is disturbed, growth
of benign Doderlein bacilli is inhibited and
that of pathogens encouraged. Floraquin not
only provides an effective protozoacide and
fungicide (Diodoquin®) destructive to path-
ogenic trichomonads and yeast, but also
furnishes sugar and boric acid for reestab-
lishment of the normal vaginal acidity and
regrowth of the normal protective flora.
Suggested Office Floraquin Insufflation
. . the vagina is treated daily by swab-
bing with green soap and water, drying and
insufflation of Floraquin powder.”*
Suggested Home Floraquin Treatment
“The patient is also issued a prescription
for Floraquin vaginal suppositories which
she is instructed to insert high into the vagina
each evening. On the morning following each
application of these suppositories, the patient
should take a vinegar water douche. . . .”*
A Floraquin applicator is supplied with
each box of 50 Floraquin tablets. G. D. Searle
& Co., Chicago 80, Illinois, Research in the
Service of Medicine.
*Williamson, P.: Trichomonad Infestation, M. Times 84:9 29
(Sept.) 1956.
April, 1957
Say you saw it in the Journal of the Michigan State Medical Society
513
CARBASED
ACETYLCARBROMAL TABLETS
• Proved safe and effective by 6 years’
clinical use.
• Soothes the central nervous system,
produces calmness without hypnosis.
• Non-toxic, non-cumulative, non-addict-
ing, no known contraindications.
• Does not impair mental or physical
function.
• Orally effective within 30 minutes for
sustained action up to 6 hours.
• Economical.
Indications: Tension, nervousness,
anxiety and muscular spasm.
Supplied: White round tablets
Aeetylcarbromal 5 g r. in bottles
of 100, 1000.
Write for samples and literature
There's Always A Leader
MALLARD, inc
3021 WABASH, DETROIT 16, MICHIGAN
In Memoriam
Charles E. Anderson, M.D., sixty-three, of Modesto,
California, practitioner in Anvil for twenty-nine years.
Born in Ironwood in 1893, he received his M.D. degree
from the University of Michigan. Doctor Anderson was
a member of the Michigan State Medical Society until
1955 when he moved to California following his retire-
ment because of ill health. He died October 28, 1956.
* * *
Lewis E. Bracey, M.D., eighty-four, Sheridan physi-
cian for fifty-one years. Born in Greenville in 1872,
he graduated from the Detroit Medical College in 1905.
Dr. Bracey was a member of the Ionia-Montcalm County
Medical Society, and a Life Member of the Michigan
State Medical Society. He died January 20, 1957.
* * *
Harvey F. Brown, M.D., fifty-six, of Detroit, former
Notre Dame football star, had practiced in Detroit
since 1928. Born in 1900. he received his M.D. degree
from St. Louis University. Dr. Brown was active in
Wayne County Medical Society affairs. He died Janu-
ary 13, 1957.
* * *
Constantine A. Cetlinski, M.D., sixty-two, former
Hamtramck councilman and health director. Born in
1895, he was a member of the Wayne County Medical
Society and the Michigan State Medical Society. He
died January 2, 1957.
* * *
Robert P. Coseglia, M.D., forty-seven, of Grosse
Pointe Park. A staff member of Holy Cross, Doctor’s,
Detroit Memorial, St. John and Saratoga General Hos-
pitals, he was also a member of the Wayne County
Medical Society and the Michigan State Medical Society.
He died February 25, 1957.
* * *
Joshua Hanser, M.D., eighty-two, general practitioner
in Detroit for more than fifty years. Born in 1874, he
received his M.D. degree from the Detroit Homeopathic
College in 1906. He was a member of Wayne County
Medical Society, a Life Member of the Michigan State
Medical Society, and a member of the MSMS Fifty-
Year Club. He died January 9, 1957.
* ■* *
Thomas F. Horrigan, Jr., M.D., thirty-six, Highland
Park practitioner. A native of Detroit, he received his
M.D. degree from Wayne State University College of
Medicine in 1945. He was a member of the Wayne
County Medical Society. He died August 13, 1956.
* * *
John B. Horwitz, M.D., fifty-five, family doctor in
Detroit for three decades. Born in Russia, Dr. Horwitz
came to Detroit fifty-one years ago. He was graduated
from the Detroit College of Medicine, and was a
member of the Wayne County Medical Society. He
died January 13, 1957.
(Continued on Page 538)
514
Say you saw it in the Journal of the Michigan State Medical Society
JMSMS
can you read "is thermometer,
/ ^ "™ s
p'Vt i « ftTm ? iiiiii > * * 1 1 * * until#
^^"Too
.. - .. , ... . . „
doctor?
Naturally not. Missing calibration makes it worthless.
Equally useless and dangerous is a “quantitative” urine-sugar test that does not
quantitate dependably, or omits readings in the critical range.
Enzyme urine-sugar tests are sensitive and specific for glucose- excellent “yes”
or “no” tests but undependable for quantitation. King and Hainline,1 after testing
1,000 urines, found an enzymatic urine-sugar test unable to distinguish in the
important range between Vz per cent and 2 per cent or more of urinary glucose.
Leonards,2 in a report on 4,020 tests, revealed that “...in 502 out of 804 tests
the wrong interpretation was made.” He concluded that enzymatic urine-sugar
testing “ ...as a quantitative procedure is unsatisfactory and can lead to serious
error in the interpretation of a patient’s clinical condition.”2
Failure to recognize this limitation of enzyme tests may result in incorrect
insulin dosage,2 and may lead to diabetic complications.
(1) King, J. W., and Hainline, A., Jr.: Commercial Glucose Oxidase Preparations for the Detection of
Glucose in Urine, Cleveland Clin. Quart. 23:212, 1956. (2) Leonards, J. R.: Evaluation of Enzyme Tests
for Urinary Glucose, J.A.M.A. 163:260 (Jan. 26) 1957.
reliable readings throughout the critical range-
does not omit %.% and 1% (+- bH-)
BRAND
a 15 year “standard” in urine-sugar testing
AMES COMPANY, INC . ELKHART, INDIANA . Ames Company of Canada, Ltd., Toronto
April, 1957
Say you saw it in the Journal of the Michigan State Medical Society
38157 ?
i
515
CORRESPONDENCE
FOR “SIGNIFICANT”
THERAPEUTIC HEAT
The Burdick MICROWAVE
DIATHERMY UNIT
Studies by Martin and Herrick* indicate that
microwave diathermy creates "significant” rapid
deep heating of localized tissues for effective
relief of pain and muscular rigidity in such
conditions as:
bursitis fibrositis myositis
strains and sprains pelvic inflammatory disease
neuritis (of varying origin)
Simplified operation, convenience, safety, com-
fort to the patient and the traditionally rigorous
Burdick engineering standards mark the Burdick
Microwave Diathermy unit as a highly proficient
therapeutic agency.
For a review of the advanced features of this
outstanding unit, see your Burdick dealer.
*Martin, G.M., and Herrick, J. F. : Further Evaluation
of Heating by Microwave and by Infra-red as Used
Clinically, J.A.M.A. 159:1286 (Nov. 26) 1955.
For information write —
THE BURDICK CORPORATION, MILTON, WIS.
THE G. A. INGRAM COMPANY
4444 Woodward Avenue, Detroit 1, Michigan
Correspondence
MEDICARE (Dependents’ Medical Care Act)
Dear Mr. Burns:
It has been brought to my attention that some
of the persons with whom we have negotiated contracts
under the Dependents’ Medical Care Act are of the
opinion that the Program is not one of full service
coverage. This concept may have arisen because the
Act itself is not specific regarding this matter. It may
also have arisen either because certain fees are stipulated
to be paid by the patient or because the contract allows
for an unusual or difficult case an additional fee payable
by the Government to the physician if he makes proper
request under a special report.
Upon inquiry, I have been assured that members of
the negotiating teams have not indicated the contract is
other than for full coverage. Further, no instance has
been found where any member of the negotiating teams
has, in any way, intimated that the Dependents’ Medical
Care Program is not one of full coverage.
In order to clarify this matter and to avoid any im-
proper interpretation of the Dependents’ Medical Care
Act with regard to payments to physicians under a
Schedule of Allowances as provided in our contracts, the
position of the Department of Defense as is being
carried out by my office is submitted for your guidance:
(a) It is intended that civilian medical care autho-
rized under Public Law 569, 84th Congress, will be
on a basis comparable to that provided in uniformed
services medical facilities. Except for specified amounts
to be paid by the patient, the services which are pro-
vided under the law will be furnished by physicians
participating in the program who will receive payment
in full from the Government in accordance with the
published Schedule of Allowances or under a special
report as the case may be. In most instances, this
means that the physician participating in the program
will receive payment for his usual charge or the amount
established in the local schedule of allowances, which-
ever is less.
(b) Section 5, paragraph 507b. of the Joint Directive
promulgated by the Secretary of Defense and the Secre-
tary of Health, Education, and Welfare provides as
follows:
"The Executive Agent (Secretary of the Army) shall
be responsible within the continental United States.
Alaska, Hawaii, and Puerto Rico for the following:
( 1 ) Preparation of the terms and placement of the
contract or contracts to be established to include but
not limited to: Local schedules of allowances to be used
in full payment of bills presented by physicians and
surgeons.” [Italics added ]
A copy of this Joint Directive is an integral part
of every contract and there is no question that the
contract provides for full service coverage.
(c) There may be unusual instances in which the phy-
sician will believe that an allowance greater than that
prescribed in the local schedule of allowances is justified.
In such cases, the physician should look to the Govern-
ment for additional payment, and not to the patient.
Provision is made for the physician to submit a special
report to his state medical society and in turn to the
Government as a request for additional payment. Such
additional payment will be made upon approval by
(Continued on Page 534)
516
Say you saw it in the Journal of the Michigan State Medical Society
JMSMS
Borden's has a fresh dairy food for
almost any dietary requirement
in addition to such familiar items as
Borden's Homogenized Vitamin D Milk,
Borden’s Cream, and Dutch Chocolate
Milk, we’d like to remind you of our
regular and low-calorie Cottage Cheese,
Buttermilk, and Gail Borden Milk and
Skimmed Milk — all helpful in dietary
planning.
THE BORDEN CO. TSorden’s MICHIGAN MILK DIV.
Gail Borden Milk
and Skimmed Milk
Each quart contains 100% of the aver-
age daily requirements of 8 of the 10
essential vitamins and minerals
April, 1957
Say you saw it in the Journal of the Michigan State Medical Society
5
MEMBERSHIP RECORD
Michigan State M edicalJSociety
COUNTY
MEDICAL
SOCIETY
Allegan
Alpena, Alcona, Presque Isle
Barry
Bay, Arenac, Iosco
Berrien
Branch
Calhoun
Cass .
Chippewa-Mackinac
Clinton
Delta-Schoolcraft
Dickinson-Iron
Eaton
Genesee
Gogebic
Grand Traverse, Leelanau, Benzie
Gratiot-Isabella, Clare
Hillsdale
Houghton, Baraga, Keweenaw
Huron
Ingham
Ionia-Montcalm
Jackson
Kalamazoo
Kent
Lapeer
Lenawee
Livingston
Luce
Macomb
Manistee
Marquette-Alger
Mason
Mecosta, Osceola, Lake
Menominee
Midland
Monroe
Muskegon
Newaygo
North Central
Northern Michigan
Oakland
Oceana
Ontonagon
Ottawa
Saginaw7
St. Clair
St. Joseph
Sanilac
Shiawassee
Tuscola
Van Buren
Washtenaw
Wayne
Wexford-Missaukee
Honorary
TOTAL
MEMBERSHIP RECORD— 1956
1956
PAID
1955
SPECIAL MEMBERS
L R AM
I E SI
F T’ S L
EDO
DEATHS
1956 1955
NET
MEMBERSHIP
1956 1955
1956
G
A
I
N
L
O
S
s
UNPAID
1956 1955
20
24
1
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3
21
21
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73
72
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82
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47
.. Part t^le Secretary’s Annual Report for 1956. Please refer to Page 366 of the March number
JMSMS.
Plainuell
£anitaHutn
PLAINWELL, MICHIGAN
Member American Hospital Association
EDWIN M. WILLIAMSON, M.D.
Psychiatrist-in-Chief
Professional care for the nervous
and mentally ill.
Telephone MUrray 5-8441
Restful Six-acre Estate Overlooking the Kalamazoo River
518
Say you saw it in the Journal of the Michigan State Medical Society
JMSMS
In Feeding Prematures
Water
KARO
Evaporal
Water
KARO
milk (haU-skimnv
Dried
Water
KARO
Recent metabolic studies have established
rational feeding procedures for prematures.
The initial feeding, 12 hours after birth,
consists of one dram of 5 per cent dextrose.
This solution is increased by one dram at
2-hour intervals if tolerated and retained.
After twenty-four hours, breast milk or
formula (table below) gradually replaces the
prelacteal feeding at 2-hour intervals. The
volume of a feeding may be increased up to
2 drams daily until maintenance caloric
requirements are fulfilled by the fifth day. If
the infant shows signs of intolerance, the
formula increase is made more slowly and
the fluid requirement fulfilled parenterally.
Successful feeding mixtures consist of dilu-
tions of powdered half-skimmed or evapor-
\ «—»« -“t
Kole lactic acid milk • . \2oz.
jsh or whole m
ated whole cow’s milk, skimmed or whole
lactic acid milk. These formulas contain high
protein, moderate carbohydrate and low fat,
yielding about 120 calories and 150 cc. fluid
per kgm. body weight.
The problems of prematures are always
the same but the solutions differ with each
era. Today the moderate carbohydrate
requirement for normal infants as well as
prematures is fulfilled by Karo® Syrup as
adequately as a generation ago. Whatever
the type of milk adapted to the infant, Karo
may be added confidently because it is a bal-
anced mixture of lower sugars resistant to
fermentation, non-laxative, easily assimilated
and well tolerated by all infants.
Readily available in all food stores.
MEDICAL DIVISION
CORN PRODUCTS REFINING CO.
17 Battery Place, New York 4, N. Y.
v 12x2 hours
Feedings: Vh ox. ^ ,ablespoons
Measures: 1 oz; KAR ^ . CoW*s milk.
*■* “*•; %SS.
ilk"; Bli.lobe'
Equivalents: Red a )^erchangeabiy m a
CARO may he ase
formulas.
Adapted from Nelson's Pedi-
atrics, Saunders, Phila. 1 954
Produced by
Corn Products Refining Co.
Behind Every Bottle... A Generation of World Literature
April, 1957
Say you saw it in the Journal of the Michigan State Medical Society
519
NEWS MEDICAL
MICHIGAN AUTHORS
Stanley Finkel, M.D., Elizabeth Grodzka, B.A., and
Ivan F. Duff, M.D., Ann Arbor, are the authors of an
article entitled, “The Medical Arthritis Clinic of the
University Hospital.” published in the University of
Michigan Medical Bulletin, December, 1956.
A. C. Furstenberg, M.D., Ann Arbor, is the author
of an article entitled “Look to the Future,” presented
at the Sixty-First Annual Session of the American
Academy of Ophthalmology and Otolaryngology,
October, 1956, in Chicago, and published in the Tran-
sactions, American Academy of Ophthalmology and
Otolaryngology, November and December, 1956. This
was the address of the President of the Society.
Melvin M. Figley, M.D., Ann Arbor, is the author
of an article entitled “New Contributions of Radiology
to Ophthalmology and Otolaryngology through Vascular
Visualization,” presented by invitation at the Sixty-First
Annual Session of the American Academy of Ophthal-
mology and Otolaryngology, October, 1956, in Chicago,
and published in the Transactions, American Academy
of O phthalmology and Otolaryngology, November-
December, 1956.
J. P. Gray, B.A., M.D., M.P.H., Detroit, is the author
of an article entitled “Report of Visiting Lecturer on
Medical Writing: On Activities During 1955-1956,”
presented at the 13th Annual Meeting, American
Medical Writers’ Association, Chicago, September, 1956,
and published in the Mississippi Valley Medical Journal,
January, 1957.
Paul de Kruif, Ph.D., Holland, is the author of an
article entitled “Today’s Treatment of Acne,” pub-
lished in Today’s Health, March, 1957.
H. Waldo Bird, M.D. and Peter A. Martin, M.D.,
Detroit, are authors of an original article “Counter-
transference in the Psychotherapy of Marriage Partners”
which appeared in Psychiatry: Journal for the Study of
Interpersonal Processes,” November, 1956.
* * *
New Appointment under H.E.W. — The new Under
Secretary of Health, Education, and Welfare is John
A. Perkins, Ph.D., forty-two-year-old president of the
University of Delaware; he succeeds Herold C. Hunt.
Ph.D., who has returned to Harvard. Dr. Perkins,
one of the youngest university presidents when he took
over at Delaware in 1950, once served as secretary to
the late Senator Vanderburg and was state budget
director for Michigan.
* * *
Why Blue Shield Must Keep on Growing is the title
of an editorial appearing in the January Connecticut
State Medical Journal. The editorial points out that
since Blue Cross and Blue Shield have gained wide
public acceptance — Blue Cross enrollment is now over
50 million and Blue Shield enrollment is near 40
million — “one hears the suggestion that Blue Shield
attempts to ‘stabilize’ its enrollment and relax its efforts
to cover an ever larger cross section of the population.
But the demand for prepaid medical care is now almost
universal; and those who have it are asking for broader
coverage and better contracts.”
The editorial states that, “The continued growth of
Blue Shield is essential to the best interests of both
medicine and the public.” It goes on to explain why
this is so. “First, because Blue Shield is a major factor
in medicine’s economy. Whereas installment buying
creates a debt and mortgages the future, medical pre-
payment creates a credit for the patient, and protects
his future. Again, Blue Shield’s growth safeguards its
actuarial base of operations. As risks are spread ever
more widely, the community and the doctor gain a
surer protection against fluctuations affecting the sub-
scription rates or payments to physicians.
“A third benefit of Blue Shield growth is the oppor-
tunity to reduce operating costs per person enrolled.
This helps the plan to broaden its services or to raise
its payments to doctors — or both. Fourthly, the greater
the number of his patients covered by prepayment, the
fewer for whom the doctor has a collection problem,
and the lighter his load of free or part-pay work.” And
finally, “Medicine’s most significant benefit from the
growth of Blue Shield is the dominant influence of the
medically guided Blue Shield Plans on the shape and
destiny of the voluntary health insurance movement as
a whole. Were it not for Blue Shield, the medical pro-
fession would have no effective control over the basic
economy of private practice.”
* * *
Health Insurance for Older Citizens is the title of an
article by John H. Miller, Monarch Life Insurance
Company, which appeared recently in American
Economic Security magazine. In this article he cites
a recent study by the Bureau of Labor Statistics cover-
ing nearly five million workers under 300 collectively
bargained health insurance plans. The study showed
that hospital and surgical benefits are continued after
retirement for 35 per cent of these workers. It also
showed that for “nearly 80 per cent of the employes
whose coverage continues after retirement, there is no
reduction in the amount of hospital and surgical
benefits.”
Mr. Miller points out that “individual policies cover-
ing older persons have become widely available.”
(Continued on Page 522)
520
JMSMS
“A
VOTRE
SANTE”
(To Your Health)
In any language, the
traditional toast to good
health takes on a meaning
of more than passing significance when wine is
used for its established physiological effects.
The carminative action of wine has been found to whet the sluggish
appetite of the anorexic, post-surgical or convalescent patient: the mild
secretory stimulation that follows the ingestion of wine is beneficial to the
lax and generally achlorhydric stomach of old age; prudent quantities of wine
are helpful in reducing the emotional pressure which aggravates hypertension,
encouraging a generalized vasodilatation and stimulating a mild euphoria,
so gratifying to the hypertensive, the aged, and in the recovery phase of illness.
And for the patient who has difficulty in dropping off to sleep, a small
amount of Port or Sherry taken at bedtime is gently sedative and
sleep-producing — frequently obviating the need for medication.
The Fine Wines of California — California’s 700-mile vineyard belt affords a
range of soils and climate in which can be grown the world’s finest wine
grapes of every variety. Add to this natural advantage the modern wine-
making skills and facilities of a progressive New World industry, and you
have wines of strict quality standards, true to type, moderate in price.
Wine Advisory Board,
717 Market Street,
San Francisco, California.
April, 1957
Say you saw it in the Journal of the Michigan State Medical Society
NEWS MEDICAL
BAND-AID
TRADE MARK
Plastic Strips
• ELASTIC PLASTIC
• FLESH COLORED
• STAYS CLEAN
• THIN, SMOOTH PLASTIC
• GREASE RESISTANT
• WON'T WASH OFF
100’s 1 "x 3"
100’s 3/4"x 3"
Ccnienkntlif iccated
in (jrand Rapid*
• Hospital Equipment
• Pharmaceuticals
• Office Equipment
• Physicians’ Supplies
• Trusses
• Surgical Garments
• Physiotherapy Equipment
Medical Arts Supply Company
233 Washington S. E. Phone GL 9-8274
Grand Rapids 2. Mich.
Medical Arts Pharmacy
20-24 Sheldon S.E. Phone GL 9-8274
Grand Rapids 2. Mich.
(Continued from Page 520)
According to a study made in 1955 by the Bureau of
Accident and Health Underwriters. 106 out of 186
companies participating in the survey would accept new
applications for hospital expense insurance above age
60. Of these, 1 1 imposed no maximum age limit while
others had various limits such as 65, 70, 75 or 80.
With respect to the renewal of policies previously issued,
half of the companies surveyed reported that they had
no maximum age limit.
Occupational medicine was formally recognized and
given certificational basis in February, 1955, by the
American Board of Preventive Medicine. Two years
were allotted to complete the listing of Founder mem-
bers. Eligible were men in this field who were out-
standing in their professional positions, school affilia-
tions, wide acceptance as leaders and with a minimum
of ten years of distinguished service. Three Army
officers were included: Col. John R. Hall, Chief of
Occupational Health. Surgeon Generals Office; Lt. Col.
Edward J. Dehne, C.O. Army Environmental Health
Laboratory, Edgewood, Maryland, and Maj. Gilbeart
H. Collings, specialist in occupational medicine, of the
same laboratory.
* * *
Tuberculosis is becoming more a
problem among older men and less a
problem for young women. A study
of two three-year periods, 1947-1949
and 1953-1955, showed a drop of 9
per cent in the total number of new
tuberculosis cases reported. Only
among the people sixty-five years and
older was there an increase in the
number of cases reported. The number
of new cases during the 1947-1949
period for men sixty-five years and older was 1,247. It
(limbed to 1,590 in the 1953-1955 period. The greatest
decline in new cases reported was among women in the
fifteen to twenty-four year age group. It dropped from
I, 526 in the earlier period to 883 in the latter period.
Men over forty-five years of age accounted for 34
per cent of the new cases found from 1953 through
1955. Men and boys under forty-five ranked second,
making up 29 per cent of the new cases. Women and
girls under forty-five accounted for 25 per cent of the
new cases and women over forty-five only 12 per cent.
Michigan Tuberculosis Association
* * *
World Health Day, April 7, marked the anniversary
of the coming into force of the Constitution of the
World Health Organization in 1948. It afforded an
added opportunity to arouse popular interest in health
needs and to stimulate the people’s participation in the
work of improving health.
There is an intimate relationship between health and
the production of food. Therefore World Health Day
in 1957 was co-sponsored by the Food and Agriculture
Organization.
(Continued on Page 524)
522
Say you saw it in the Journal of the Michigan State Medical Society
JMSMS
among nonhormonal antiarthritics . . .
unexcelled in
therapeutic potency
BUTAZOLIDIN
(phenylbutazone Gkigy)
111 the nonhormonal treatment of arthritis
and allied disorders no agent surpasses
Butazolidin in potency of action.
Its well-established advantages
include remarkably prompt action
broad scope of usefulness,
and no tendency to development
of drug tolerance. Being
nonhormonal, Butazolidin
causes no upset of normal
endocrine balance.
Butazolidin relieves pain,
improves function,
resolves inflammation in:
Gouty Arthritis
Rheumatoid Arthritis
Rheumatoid Spondylitis
Painful Shoulder Syndrome
Butazolidin being a potent therapeutic
agent, physicians unfamiliar with its
use are urged to send for detailed
literature before instituting therapy.
Butazolidin® (phenylbutazone
Geigy). Red coated tablets of 100 mg
Ardsley, New York
April, 1957
Say you saw it in the Journal of the Michigan State Medical Society
523
NEWS MEDICAL
for modern
control of
salt retention
edema
CUMERTIUN*
(Brand of Mercumatilin, Endo)
Tablets
• effective oral diuretic with no sig-
nificant gastrointestinal irritation1
• Suitable for long-term mainte-
nance therapy.
• eliminates need for injections in
certain cases, lengthens interval
between injections in others
• basically different in chemical
structure, extending the therapeu-
tic choice in organic mercurials
DOSAGE: 1 to 3 tablets daily as required.
SUPPLIED: As orange tablets, in bottles
of 100 and 1000. Also available —
CUMERTILIN Sodium Injection, 1- and 2-cc.
ampuls, in boxes of 12, 25, and 100; and
10-cc. vials, individually and in boxes
of 10 and 100.
1. Pollock, B. E., and Pruitt, F. W.: Am J M
Sc., 226:172, 1953.
THE G. A. INGRAM COMPANY
4444 Woodward Avenue, Detroit 1, Mich.
(Continued from Page 522)
A novel exhibit at the Michigan State Fair featured
two contests, each of them educational and challenging.
What fairgoers liked best was that the doctors offered
cash awards to contest winners.
Spotlights were trained on a sign inviting anyone to
“Win a Silver Dollar” by naming a community in
Michigan (population: 500 or more) that does not
have a local resident doctor of medicine. Result? Only
eighty-four silver dollars were given away, an indication
that not many of the thousands in attendance had the
right answer. The companion contest offered a $100
savings bond to the most nearly correct guess on the
total number of medical men in Michigan. That went
to someone whose guess was almost right — 8,206 instead
of the correct total of 8,214-. — AM A Bulletin.
* * *
INGHAM COUNTY MEDICAL SOCIETY
Twenty-ninth Annual “May Clinic”
The twenty-ninth annual May Clinic of the Ingham
County Medical Society will be held at the Olds Hotel,
Lansing, Michigan, on Thursday, May 2, 1957.
Registration opens at 1:30 p.m. A social hour
beginning at 5:15 p.m. will be followed by a subscrip-
tion dinner at 6:30 p.m.
Participants in this year’s clinic include:
George V. Taplin, M.D., Research Physician, Atomic
Energy Project, University of California at Los
Angeles.
Subject: “Recent Developments of New Radioisotope
Techniques for Measuring Liver and Kidney Func-
tions.”
Laurence H. Kyle, M.D., Associate Professor of Medi-
cine, Georgetown University School of Medicine and
Director, Metabolic Clinic and Laboratory, George-
town University Hospital.
Subject: “Hypothyroidism and Hypometabolism.”
Franklin G. Ebaugh, M.D., Clinical Professor of
Psychiatry, University of Colorado School of Medicine,
Denver.
Subject: “Depressive Reactions.”
Willis J. Potts, M.D., Surgeon in Chief, Children’s
Memorial Hospital; Professor of Pediatric Surgery,
Northwestern University, Chicago.
Subject: “Surgical Emergencies in the Newborn.”
The after-dinner speaker will be:
C. Walton Lillehei, M.D., Professor of Surgery, Uni-
versity of Minnesota Medical School.
Subject: “Cardiac Surgery.”
Advance reservations for the dinner, approximate
cost $5.00, may be made with William D. Hayford,
M.D., Chairman, Program Committee, 609 North
Washington, Lansing, Michigan.
* * *
The new Midwest Institute on Alcohol Studies will
hold its second annual session in Kalamazoo, June 24
to June 28, 1957. Co-sponsored by the Michigan State
Board of Alcoholism, Western Michigan College, the
University of Wisconsin, and the Wisconsin Council on
Alcoholism, this course of study will bring to Michigan
its first school of alcohol studies planned to acquaint
professional people with the problems of alcoholism.
* * ■*
A new and safer rabies vaccine, produced in em-
(Continued on Page 526)
524
Say you saw it in the Journal of the Michigan State Medical Society
JMSMS
It's New— It's Here— A Really Portable Aspirator
THE JUNIOR TOMPKINS By Shlar
Weighs only I6V2 lbs.
No. 100-65
Complete with Yankauer
Suction Tube and Utility
Wrench — 115 Volt, 60 Cycle,
A.C. Current
$99.50
FEATURES
• Motor Unit completely enclosed — requires
no lubrication — rubber mounted for quiet
and vibrationless operation.
• Suction Gauge and Regulating Valve
• Simple Filtering System Utilizes Standard
One Inch Gauze Bandage
• 32 oz. Suction Bottle
• Compressor Connected Directly to Motor
• Durable Two-Tone Baked Enamel Finish
NOBLE-BLACKMER, Inc.
267 W. Michigan Ave.
Jackson, Michigan
All important laboratory exam-
inations; including —
Tissue Diagnosis
The Wassermann and Kahn Tests
Blood Chemistry
Bacteriology and Clinical Pathology
Basal Metabolism
Aschheim-Zondek Pregnancy Test
Intravenous Therapy with rest rooms for
Patients
Electrocardiograms
Central Laboratory
Oliver W. Lohr, M.D., Director
537 Millard St.
Saginaw
Phone. Dial 2-4100—2-4109
The pathologist in direction is recognized
by the Council on Medical Education
and Hospitals of the A.M.A.
Pfizer'
longest acting
motion-sickness
preventive
•Trademark
April, 1957
Say you saw it in the Journal of the Michigan State Medical Society
NEWS MEDICAL
(Continued from Page 524)
bryonated duck eggs, is now available to physicians and
pharmacists. It has been shown in tests to be free of a
“paralytic factor” that sometimes has caused paralysis
and death during rabies treatment.
Found in conventional rabies vaccines made of rabbit
brain tissue, the “paralytic factor” appears to be
related to myelin, the covering of brain nerve fibers.
The exclusion of myelin from the new vaccine is made
possible by the use of duck embryos in processing.
The annual conference on Industrial Health will be
held in St. Louis, Missouri, April 20-26, 1957. Michigan
men presenting papers will be: John C. Soet, Michigan
Department of Health; George Hanna, Detroit Depart-
ment of Health; H. R. Hoyle, D. D. McCollister and
V. K. Rowe, of the Dow Chemical Co., Midland; J.
C. Radcliffe, Ford Motor Co., Detroit; K. E. Robinson,
General Motors Technical Center, G.M.C., Detroit; and
Helen DeCoursey, R.N., Kelsey-Hayes Wheel Company,
Detroit.
* ■*• *
American Academy of General Practice. — Are chil-
dren’s ears and feet neglected? Is a laboratory report
always accurate? What’s new in the world of tran-
quilizers? These and hundreds of other important
questions were answered during the American Academy
of General Practice Ninth Annual Scientific Assembly,
March 25-28, 1957, in St. Louis Kiel Auditorium.
The Academy has more than 21,000 family doctor
members and is the nation’s second largest medical
association. There were 25 prominent physician-
authorities who appeared on the four-day scientific pro-
gram, among them the following Michigan men: J.
Lewis Dill, Henry Ford Hospital, Detroit, who will
review diagnostic criteria, methods of treatment and
rehabilitative procedures; Thomas Francis, Jr., M.D.,
Ann Arbor, who for months has been evaluating the
effectiveness of the Salk polio vaccine program, and
brought his report up to date.
Opening ceremonies included a call to order by
Academy President Dr. John S. DeTar, Milan. This
was followed by an invocation and welcoming address.
* * *
Plastics Industry. — The advertisements of the General
Motors Corporation in the last several weeks have
featured the efforts of John S. DeTar, M.D., Milan, to
bring a plastics industry to Milan.
* * *
The Wayne State University Medical Alumni As-
sociation will hold its 71st Annual Alumni Reunion and
Clinical Program Tuesday and Wednesday, April 30
and May 1, 1957. The “Clinic Days” will be climaxed
by an Alumni Reception and Banquet in the main
dining room of the Hotel Fort Shelby.
* » *
The National Resuscitation Society, Inc., in co-opera-
tion with the Councils and Specialty Sections of the
(Continued on Page 528)
H. G. Fischer & Co. ULTRASONIC Generator
Manufactured Solely in Franklin Park, III.
M. C. HUNT
14001 Fenkel, Detroit 27, Michigan
Phone: BRoadway 3-5403
Distributor for
H. G. FISCHER & CO.
1. Federal Communications Commission Type
Approval U-106
2. Underwriters’ Laboratories Approval
3. Light Weight
4. One Control Operation
5. Easy-to-Read Meter Accurately Show*
Amount of Ultrasound the Patient is Re-
ceiving
6. Extra Large Active Crystal Surface of 10
Square Centimeters
7. Output of 3 Watts per Square Centimeter —
30 Watts Total
8. Accurate Treatment Timer
9. Highly Efficient Oscillating Circuit
10. Accurate Calibration
11. Beautiful Chrome-Plated Cabinet
12. Operates from the Usual Office Wall Outlet
of 110 Volts, 50-60 Cycles
13. Very Reasonably Priced
526
Say you saw it in the Journal of the Michigan State Medical Society
JMSMS
There are many short periods of time
which, if measured correctly, are considered valuable
diagnostic durations — such as the P-R interval in ECG interpretation,
and the minutes during which a patient consumes oxygen in
a BMR test. If the readings related to these measurements are to be used
with complete confidence, it is wise to consider another important
measure of time — and that is the background of the
instruments which
produced them.
TESTED
diagnostic team,
Sanborn
Metabulator
No one understands
better than a physician
that it takes time to
become suitably proficient
in a chosen work. The unmatched
background of knowledge and experience making possible
such fine instruments as the Viso-Cardiette and Metabulator
did not come about overnight, and is the result of almost
40 years of successful medical instrument development. Such
a background assures you that it is safer to select Sanborn.
SANBORN COMPANY, WALTHAI
54, MASSACHUSETTS
Detroit Branch Office 13136 Puritan Ave., University 4-6336, 4-6337
April, 1957
Say you saw it in the Journal of the Michigan State Medical Society
527
NEWS MEDICAL
(Continued from Page 526)
American Medical Association, is presenting an intensive
week end course in Clinical Hypoxia, beginning March
1 and ending June 8, 1957. These courses have been
presented monthly in New York City as well as in
southern, mid-western and western cities. More than
1.000 physicians and dentists have received personal
instruction in exposing the death zone of the respiratory
tract. Further information may be obtained by writing
to the Secretary, N.R.S., Inc., 2 East 63rd St., N.Y.C.
21, N. Y.
* * *
Clifford D. Benson, M.D., Detroit, was one of the
guest speakers at the November 13 and 27 meetings of
the Indianapolis (Marion County) Medical Society in
the White Cross Guild auditorium at Methodist Hos-
pital. The subject of Dr. Benson’s talk was “Anomalies
of the GI Tract in the Newborn and Infant.”
* * *
“Clinical Memoranda on Economic Poisons.”- — The
United States Public Health Service has prepared the
latest revised edition of “Clinical Memoranda on
Economic Poisons,” and it is being distributed by the
National Agricultural Chemicals Association as a public
service to doctors, hospitals and poison information
centers. Copies of this booklet are available on request
from the National Agricultural Chemicals Association,
1 145 Nineteenth Street, N.W., Washington 6. D. C.
The University of Pittsburgh School of Medicine
Department of Surgery and Section on Anesthesiology
announces a postgraduate symposium on “The Basic
Sciences Related to Anesthesiology,” June 10-14, 1957,
at Hotel Webster Hall, 4400 Fifth Avenue, Pittsburgh
13. For registration and full particulars write Chairman
of Committee on Postgraduate Medical Education, 3941
O’Hara Street, Pittsburgh 13, Pa.
* * *
The American Foundation for Allergic Diseases an-
nounces the availability of three Fellowships in Research
and Clinical Allergy, for a period of two years each,
carrying a stipend of $4,500 for the first year, $4,750
for the second, plus a total of $750 for laboratory and
travel expenses during the two-year period. Applications
must be received by May 10, 1957. Write Frederick
G. Germuth, Jr., M.D., The Johns Hopkins University
Medical School, Baltimore 5, Maryland.
* * *
The American Goiter Association’s annual meeting
will be held at the Hotel Statler, New York, May 28-30,
1957. For program and information write John C.
McClintock, M.D., Secretary, 149)4 Washington
Avenue, Albany 10, New York.
* * *
Cancer talks sponsored recently by the Michigan
Cancer Co-ordinating Committee include: George H.
Ruggy, M.D., Grand Rapids, before the Muskegon
(Continued on Page 530)
FERGON
high
hemoglobin
response
excellent tolerance
VlUUb Hub MUbm/j
FROM
IRON INTOLERANCE
BRAND OF FERROUS GLUCONATE
FOR ALL SIMPLE IRON DEFICIENCY ANEMIAS
SUPPLIED: Fergon tablets of 5 grains, bottles of 100 and 500.
Fergon tablets of 2'/i grains, bottles of 100.
iasosaiories Fergon elixir 6% (5 grains per teaspoonful),
ww »om iin< bottles of 16 fl. oi.
528
Say you saw it in the Journal of the Michigan State Medical Society
JMSMS
C I B A
Summit, N, J.
integrated relief . . .
mild sedation
visceral spasmolysis
mucosal analgesia
TABLETS (yellow, coated), each containing
50 mg. Trasentine® hydrochloride (adiphenine
hydrochloride CIBA) and 20 mg. phenobarbital.
Zt 2228M
!*29
April, 1957
Say you saw it in the Journal of the Michigan State Medical Society
NEWS MEDICAL
FOI&T LAU DE RDAL
ACH CHIOS P> 0 TAL
125 N. BIRCH RD.t FORT LAUDERDALE, FLORIDA
GERIATRICS (care of the aging)
REHABILITATION . . . CONVALESCENT CARE
A private hospital especially planned for the medical care and rehabilitation of the
CHRONICALLY ILL, the AGED, and the HANDICAPPED.
Departments of Medicine, Radiology, Laboratory, Dietary, Dentistry, Rehabilitation,
Occupational and Physiotherapy.
Patients accepted for long or short term care under direction of private physician.
MEDICAL RESIDENT STAFF
FOR information write to
Louis L. Amato, M.D., Medical Director
P.O. Box 2323, Fort Lauderdale, Florida.
(Continued, from Page 528)
County Medical Society, March 15, on “Early Diagnosis
of Cancer.”
James H. Beaton, M.D., Grand Rapids, before
the Manistee County Medical Society, May 6, on
“Early Diagnosis and Treatment of Cancer of the
Cervix.” James A. Ferguson, M.D., Grand Rapids,
before the Northern Michigan Medical Society, May 9,
on “Early Diagnosis and Management of Cancer of the
Large Intestine.” Howard G. Benjamin, M.D., Grand
Rapids, before the Allegan County Medical Society,
March 12, on “Early Diagnosis and Management of
Malignancy of Large Intestine.” James G. Watt, M.D.,
of Toronto, Canada, before the Kent County Medical
Society, May 14, on “Chemotherapeutic Treatment of
Advanced Cancer.” William T. Collins, M.D., Grand
Rapids, before the Edmore Schools and Community
Health Council of Edmore, Michigan, April 12, on
“The Nature of the Cancer Problem Today.”
* * *
1 he American College of Chest Physicians will hold
its twenty-third Annual Meeting at the Hotel Com-
modore, New York, May 29- June 2, 1957. For pro-
gram write ACCP, 112 East Chestnut Street, Chicago
11, Illinois.
* * *
The International Voice Conference will be held in
Chicago, May 20-22, following the International Con-
gress of Otolaryngology (to be held in Washington,
D. C.). Subjects treated each day will be: (a)
Research on Physiology of Voice Production; (b)
Clinical Procedures in Diagnosis and Training; (c)
Relation of Hearing to Voice.
For information and detailed program write Hans
von Leden, M.D., 30 North Michigan Avenue, Chicago
2, Illinois.
* * *
Cerebral Palsy Clinics will be held by Meyer A.
Perlstein, M.D., of Chicago, for the Michigan Society
for Crippled Children and Adults and the Michigan
Crippled Children Commission on April 30 and May 1
in Flint, Michigan.
* * *
John R. Rodger, M.D., Bellaire, is the author of a
feature article published in Parade magazine of February
24 entitled “How to Avoid Falling Asleep at the Wheel.”
Dr. Rodger is Chairman of the Committee on Study of
Prevention of Highway Accidents of the Michigan State
Medical Society. Parade magazine has a circulation of
1 7,500,000 in the United States.
* * *
Tuberculosis death rates generally are high in the
large cities. Cities of 100,000 population and over have
a tuberculosis death rate approximately 80 per cent
higher than that of the remainder of the country. —
Robert J. Anderson, M.D., Public Health Reports,
February, 1956.
* * *
Traffic deaths for Michigan in 1956 were 276 lower
than for 1955, and 89 lower than for the average of the
(Continued on Page 532)
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530
Say you saw it in the Journal of the Michigan State Medical Society
JMSMS
Both
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S. J. TUTAG and CO.
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Detroit 34, Michigan
April, 1957
Say you saw it in the Journal of the Michigan State Medical Society
531
NEWS MEDICAL
Flint Medical Laboratory
633 Mott Foundation Building
Flint
Phone CE. 4-9312
E. G. Murphy, M.D.
W. T. Hill, M.D.
W. L. Eaton, M.D.
C. J. Flanagan, M.D.
J. D. Wheeler, M.D.
W. Caraway, Ph.D., Biochemist
COMPLETE SERVICES IN LABORATORY
MEDICINE
Tissue diagnosis
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Protein bound iodine
Exfoliative cytology
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Electrocardiograms
Pregnancy tests
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Urinalysis
Autopsies
BRAND OF MECLIZINE HYDROCHLORIDE
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(Continued, from Page 530)
5-year period 1951-55. The 1956 toll was 1,728 as
compared to 2,004 for 1955. Michigan was the only
industrial state to show a substantial decrease in traffic
deaths in 1956.
The State Safety Commission has picked a goal for
the state of a reduction of 10%, or 174 persons under
the 1956 figures for the current year. If achieved, this
will get our fatality-per 100 million mile rate in close
conformance to that of New York and Pennsylvania,
which have the best records of the larger states.
* * *
GRACE HOSPITAL REUNION
Saturday, June 15, 1957
Afternoon Session — Main Hospital — 1 to 5 o’clock
Subject Presentations, Round Tables, Panel Dis-
cussions, and Exhibits
In the evening for alumni and their wives —
Sheraton-Cadillac Hotel — 7 : 30 to 1 o’clock
Cocktails, Dinner, and Dancing — $10 per person
Please contact Howard C. Pugh, M.D., 1735 David
Whitney Building, Detroit 26, for reservations.
* * *
MEDICAL TELEVISION SHOWS
Produced by Michigan Health Council
WJBK-TV, Detroit
February 3 — Subject: How the Doctor Examines Your
Heart — Guests: John G. Bielawski, M.D., E. A.
Irvin, M.D., and Ernest Guy, all of Detroit, and
E. H. Wiard, Lansing.
February 10 — Subject: Operation Armor — Guests: Arch
Walls, M.D., Detroit and Otto K. Engelke, M.D..
Ann Arbor.
February 17 — Subject: M.D. Qualities (Film, “Even
For One”).
February 24 — Subject: Fire Safety (Film, “Too Young
to Burn”).
WKAR-TV, East Lansing
February 14 — Subject: Child Dental Health — Guests:
Robert L. Overholt, D.D.S., East Lansing, H. E.
McClenathan, D.D.S., Robert W. Root, D.D.S.,
and John Root, all of Lansing.
February 28 — Subject: Responsibility for Alcoholics —
Guests: T. Sidney Conover, M.D., Flint, Virginia
Schroeder, Highland Park, Barbara Soderquist,
Lansing, Rev. Walter Geske, Howell, Ralph Daniel,
Lansing, and “John,” Grand Rapids.
MSMS ANNUAL MEETING
September 25-26-27, 1957
Civic Auditorium, Pantlind Hotel,
Grand Rapids
Make Your Hotel Reservation Now
532
Say you saw it in the Journal of the Michigan State Medical Society
JMSMS
the creamy antacid
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ST. JOSEPH’S RETREAT
Member: American Hospital Association
Catholic Hospital Association
National Association of Private
Mental Hospitals
The Central Neuro-Psychiatric
Hospital Association
Under the direction of the
Daughters of Charity of St. Vincent de Paul
Serving Metropolitan Detroit
and Michigan almost a century
Martin H. Hoffmann, M.D.
Medical Director
23200 West Michigan Avenue
Dearborn
Logan 1-1400
April, 1957
Say you saw it in the Journal of the Michigan State Medical Society
533
CORRESPONDENCE
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in dress style
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• Insole extension ond wedge at inner corner of
heel where support is most needed.
• The patented arch support construction is guaran-
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• Foot-so-Port lasts designed and the shoe construc-
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• We make more shoes for polio, club feet and dis-
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Send for free booklet , "The Preservation of the Function of the
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SAMMOND PLEASANT LODGE
Offers to the elderly and chronically ill
Peace and quiet. Freedom of a large and richly
furnished home and acres of lawns and wooded
rolling grounds, scientifically prepared tasty
meals, congenial companionship. A real
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the Lodge.
For further information write to:
SAMMOND PLEASANT LODGE
124 West Gates Street
Romeo. Michigan
the medical society’s review board and by the Govern-
ment’s contracting officer.
Paul I. Robinson,
Major General , MC
Office of the Surgeon General
Washington, D. C.
Dear Dr. Haughey:
On behalf of the Michigan Committee on Trauma
I want to thank you very kindly for your generosity in
offering the facilities of the Michigan State Medical
Society Journal for papers from the Trauma Committee
last year.
I placed the August issue of the State Journal in
my annual report to the National Committee and was
extremely pleased when the National Committee gave
the Michigan report first place in the nation.
Homer M. Smathers, M.D.
Detroit, Michigan Chairman, Michigan Regional
February 11, 1957 Committee on Trauma
•
Dear Dr. Haughey:
I have just received my copy of the January issue of
The Journal of the Michigan State Medical
Society. To say the least, we in the Michigan Heart
Association are indeed grateful to you for your splendid
co-operation in making this issue on our Association and
its activities available. It was a real pleasure getting the
material together for you, and I wanted to take this
opportunity to express our sincere appreciation for your
generosity in this matter.
Ernest T. Guy,
Detroit, Michigan Executive Director
February 13, 1957 Michigan Heart Association
•
Dear Dr. Haughey:
I wish to take this opportunity of personally thanking
you for your many courtesies and for your co-operation
in the development of the January (Heart) number of
the Journal for this year. I felt that this was an out-
standing issue and hope that you, too, were pleased
with it. You might be interested to know that we are
already at work on attracting high quality papers in this
field for the next Heart issue.
John G. Bielawski, M.D.
Detroit, Michigan Medical Director
February 22, 1957 Michigan Heart Association
A PAGE FROM MEDICAL HISTORY
(Continued from Page 488)
4. Encyclopaedia Britannica.
5. Finegan, Jack: Light From the Ancient Past. The
Archeological Background of the Hebrew-Christian
Religion. Princeton, N. J, : Princeton University
Press, 1948.
6. Guthrie, Douglas: A History of Medicine. Phil-
adelphia: J. B. Lippincott Co., 1946.
7. Holy Bible: Old and New Testaments. King
James Version.
8. Meek, T. J.: Hebrew Origins. New York:
Harper and Bros., 1936.
9. Williams, M. O. : Home to The Holy Land.
National Geographic (Dec.) 1950.
534
Say you saw it in the Journal of the Michigan State Medical Society
JMSMS
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Sulfacetamide— eliminates mixed infections rapidly because of its unusual
solubility in acid urine common to bacterial invasion of the urinary tract. No
renal damage, concretions or anuria.
...and when Spasmolysis is essential
, 1957
Say you saw it in the Journal of the Michigan State Medical Society
THE DOCTOR’S LIBRARY
Acknowledgment of all bonks received will be made in this column,
and this will be deemed by us as full compensation to those
sending them. A selection will be made for review , as expedient.
BOOKS RECEIVED
LITERATURE REVIEW CIBA. Produced by the
Medical Information Service for internal circulation.
Vol. I, No. II. Basle: November, 1956.
Protection against loss of income from
accident and sickness as well as hospital
expense benefits for you and all your
eligible dependents.
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CLINICAL MEMORANDA ON ECONOMIC
POISONS. Prepared by Technical Development
Laboratories, Technology Branch, Communicable Dis-
ease Center, P.O. Box 769, Savannah, Georgia. (Re-
vised April 1, 1956). U. S. Department of Health.
Education, and Welfare. Public Health Service,
Bureau of State Services. This information has been
reproduced as a public service by National Agricul-
tural Chemicals Association.
UNITED STATES ATOMIC ENERGY COM-
MISSION. Twenty-first Semiannual Report of the
Atomic Energy Commission. Washington, D. C.:
United States Government Printing Office, 1957.
THE MENTALLY RETARDED PATIENT. By-
Harold Michael-Smith, Ph.D., Chief Clinical Psycho-
logist, Flower and Fifth Avenue Hospitals, New
York; Research Associate in Pediatrics, New York
Medical College: Consulting Psychologist, City of New
York, Children's Center, Bureau of Child Welfare:
Consultant, United Cerebral Palsy Association; Ad-
junct Professor, Graduate School, Long Island LTni-
versity. Philadelphia, Montreal: J. B. Lippincott
Company, 1957. Price $4.
THE ROCKEFELLER FOUNDATION ANNUAL
REPORT, 1955. 49 West 49th Street, New York.
OCCUPATIONAL HEALTH NURSING. By Mary
Louise Brown, R.N., M.A., Assistant Professor of
Public Health, Yale University School of Medicine, in
association with John Woster Meigs, M.D., Associate
Professor of Public Health, Yale University School of
Medicine. New York: Springer Publishing Company,
Inc., 1956. Price $4.50.
This very interesting book describes the application
of public health principles and medical, nursing and
engineering practice for the purpose of promoting, con-
serving and restoring the effectiveness of workers through
their place of employment.
It aims to orient the student nurse or the graduate
who is interested in a career in industry, and it also
gives standards and plans to guide the practicing
occupational health nurse.
The book deals with the field and scope of occupa-
tional health nursing, functions of the program and the
participation of the nurse as regards industrial hygiene
and safety; workmen’s compensation: labor unions and
health services; special programs of dental health, hear-
ing and eye programs, older workers, problem drinkers
and problems pertaining to women workers; first aid,
etc. There is also a discussion of part-time occupational
health nursing service to a small plant.
536
Say you saw it in the Journal of the Michigan State Medical Society
JMSMS
THE DOCTOR’S LIBRARY
NOTES ON ATOMIC ENERGY FOR MEDICAL
OFFICERS. An Introduction to the subject for Serv-
ice and other Medical Officers who may be con-
cerned with defence against atomic bombs and similar
problems. By The Royal Navy Medical School. 169
pages. Hampshire, England: Alverstoke, 1956. New
York: Philosophical Library. Price: $4.75.
This is a small book of 169 pages prepared by the
staff of the British Royal Naval Medical School. The
first chapter is a review of introductory physics be-
ginning with the simple electric circuit and electrons
while other chapters deal with the physics of x-rays,
atomic structure, natural radioactivity, transmutation
of elements (basis for the cyclotron), ionization and re-
lease of atomic energy.
There is further discussion of what happens when an
atomic bomb explodes, the effects of radiations on cells
and on the body. From a more practical standpoint, the
treatment of radiation casualties, monitoring instruments
and protection against radiation are dealt with.
CIBA FOUNDATION SYMPOSIUM ON PAPER
ELECTROPHORESIS. Editors for the Ciba
Foundation — G. E. W. Wolstenholme, O.B.E., M.A.,
M.B., B.Ch., and Elaine C. P. Millar, A.H.-W.C.,
A.R.I.C. Boston: Little, Brown and Company, 1956.
Price $6.75.
This is another of a long list of Ciba Foundation
Symposia. Since 1948, this International Foundation
has been gathering groups of scientists interested in
medical or chemical research, in London for a two-day
to four-day intensive conference with prepared papers
and informal general discussion.
This particular conference met on July 27-29, 1955,
with twenty-one present, and twenty-one prepared
papers are published herewith. There are three from
the United States.
The context is completely scientific, factual, and the
discussion developed many interesting angles. This
Symposium features the use of paper in electrophoresis.
CONNECTIVE TISSUE IN HEALTH AND DIS-
EASE. Edited by G. Asboe-Hansen, M.D., Con-
nective Tissue Research Laboratory, University
Institute of Medical Anatomy, Copenhagen. Copen-
hagen: Ejnar Munksgaard; New York: Philosophical
Library, 1957. Price $15.00.
This is a very comprehensive and thorough review of
a subject which has come into prominence in recent
years. The twenty-three contributors live in various
parts of the world giving the book an international
viewpoint. New thoughts on healing, infection, cancer
invasion and aging processes are brought out. For the
physician in private practice, the details presented re-
garding connective tissue morphology, histochemistry of
:onnective tissue, ground substances and collagen,
metabolism of the mucopolysaccharides and sulphate
exchange may not be too interesting. But the chapters
3n aging, wound healing, influence of hormones and
infection, arteriosclerosis and collagen diseases will be
more practical use. There are chapters pertaining
:o Dermatology, Ophthalmology and Rheumatology.
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April, 1957
Say you saw it in the Journal of the Michigan State Medical Society
537
IN MEMORIAM
(Continued from Page 514)
Robert Joseph McClellan, M.D., seventy-six, Detroit
physician for forty-seven years. A graduate of the
Detroit College of Medicine, he was a member of the
Wayne County Medical Society and a Life Member
of the Michigan State Medical Society. He died
January 20, 1957.
* * *
Harold G. McLean, M.D., sixty, Detroit physician
and vice chief of surgeons at Grace Hospital. A native
of Wheatley, he graduated from the Detroit College
of Medicine in 1920 and practiced in Detroit for thirty-
seven years. He was a member of the Wayne County
Medical Society. He died February 8, 1957.
* * *
Robert S. Taylor, M.D., thirty-five, Bay City physician
for six years. Born in 1921 in Lansing, Michigan, he
was a graduate of the University of Michigan Medical
School. Doctor Taylor was a member of the Bay-
Arenac-Iosco County Medical Society. He died August
2, 1956.
* * *
Edward C. Warren. M.D., eighty-six, retired Bay City
physician. Born in 1870 in Canada, he was a member
of the Bay-Arenac-Iosco County Medical Society and
of the Michigan State Medical Society. He died
August 13, 1956.
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PRINTING: GUMMED LABELS ON THE ROLL
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PHYSICIAN wanted for medical director of District
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search group, near-esat side of Detroit. Liberal vaca-
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Street, Detroit 26, Michigan.
CALIFORNIA CAREER OPPORTUNITIES FOR
PHYSICIANS AND PSYCHIATRISTS
Employment available as a result of interview only-
interviews at the APA Conference May 13-17, in Chicago
and in such other locations as New York, Boston, St.
Louis, Philadelphia , and Minneapolis during May and June.
Assignments in State hospitals, juvenile and adult correc-
tional facilities, or a veterans home. Three salary groups:
$10,840-12,000; $11,400-12,600; $12,600-13,800. Citizenship,
possession of, or eligibility for California license required.
Write Medical Recruitment Unit, Box A, State Personnel
Board. 801 Capitol Avenue. Sacramento 14, California.
538
Say you saw it in the Journal of the Michigan State Medical Society
JMSMS
THE JOURNAL
of the Michigan State Medical Society
VOLUME 56 MAY, 1957 NUMBER 5
Contributors to This Issue
F. C. Swartz, M.D.
Vice Chairman
Geriatrics Committee
F. F. Yonkman, M.D.
May, 1957
Table of Contents
Preventive Geriatrics
Geriatrics Committee, Michigan State
Medical Society 589
The Changing Scene
Fredrick F. Yonkman, M.D 611
Chronic Disease — A Challenge to the
Medical Profession
Otis L. Anderson, M.D 615
Chronic Disease — A Challenge to Public Health
Otis L. Anderson, M.D 619
President’s Message:
Evidence on Aging 623
Editorial:
Geriatric Medicine 624
June is Multiple Sclerosis Month 624
Basic Blue Shield Principles 625
The Changing Times 625
Government Care 625
Faults and Remedies 626
Veterans’ Care 626
Blue Shield Commission 627
Heart Spectacular ... 628
Record Set! — MCI Success Story 630
Report of Knostman & Smith, CPA — 1956 634
Michigan Foundation for Medical and Health
Education — President’s Annual Report and Report
of the Secretary 638
Michigan’s Department of Health 640
In Memoriam 642
News Medical 646
Correspondence 659
The Doctor’s Library 660
You and Your Business 550
What the Future Holds for General Practice 560
Heart Beats 562
AMA Washington Letter 566
AMA News Notes 568
Editorial Opinion 572
© 1957 by Michigan State Medical Society
543
THE JOURNAL
of the Michigan State Medical Society
“VOLUME 56 MAY, 1957 NUMBER 5 =
PUBLICATION COMMITTEE
G. B. SALTO NST ALL, M.D., Chairman Charlevoix
WILLIAM BROMME, M.D Detroit
B. M. HARRIS, M.D -..Ypsilanti
O. B. McGILLiCUDBY, M.D Lansing
W. S. STINSON, M.D Bay City
T. P. WICKLIFFE, M.D Calumet
Office of Publication
2642 University Avenue
Saint Paul 14, Minnesota
Editor
WILFRID HAUGHEY, M.D.
610 Post Bldg., Battle Creek, Michigan
Secretary and Business Manager of THE JOURNAL
L. FERNALD FOSTER, M.D.
Thorne Bldg., 919 Washington Ave.
Bay City, Michigan
Executive Director
WM. J. BURNS, LL.B.
606 Townsend Street, Lansing 15, Michigan
All communications relative to exchanges, books for review, manu-
scripts, should be addressed to Wilfrid Haughey, M.D., 610 Post
Bldg,, Battle Creek, Michigan.
All communications regarding advertising and subscription should
be addressed to Wm. j. Burns, 2642 University Avenue, Saint
Paul 14, Minnesota, or 606 Townsend Street, Lansing 15, Michigan.
Telephone Ivanhoe 57125.
© 1957, by Michigan State Medical Society.
Published monthly by the Michigan State Medical Society as its
official journal at 2642 University Avenue, Saint Paul 14, Minnesota.
Entered at the post office at Saint Paul, Minnesota, as second
class maiter. May 7, 1930, under the Act of March 3, 1879.
Acceptance for mailing at special rate of postage provided for
in Section 1103 Act of October 3, 1917, authorized August 7, 1918.
Yearly subscription rate, $6.00; single copies, 60 cents. Additional
postage; Canada, $1.00 per year; Pan-American Union, $2.50 per
year; Foreign, $2.50 per year.
PRINTED IN U S A.
OFFICERS OF THE SOCIETY
1956-1957
President ARCH WALLS, M.D Detroit
President-Elect G. W. SLAGLE M.D Battle Creek
Secretary L. FERNALD FOSTER, M.D Bay City
Treasurer W. A. HYLAND, M.D .Grand Rapids
Speaker K. H. JOHNSON, M.D Lansing
Vice Speaker J. J. LIGHTBODY, M.D Detroit
Editor WILFRID HAUGHEY, M.D Battle Creek
THE COUNCIL
D. BRUCE WILEY, M.D., Chairman, Utica
W. B. HARM, M.D., Vice Chairman, Detroit
L. FERNALD FOSTER, M.D., Secretary, Bay City
T erm
District Expires
A. E. SCHILLER, M.D 1st Detroit 1961
O. B. McGILLICUDDY, M.D 2nd Lansing 1960
H. J. MEIER, M.D 3rd Coldwater 1960
RALPH W. SHOOK, M.D 4th Kalamazoo 1961
C. ALLEN PAYNE, M.D 5th Grand Rapids 1961
H. H. HISCOCK, M.D 6th Flint 1961
H. B. ZEMMER, M.D 7th Lapeer 1957
L. C. HARVIE, M.D 8th Saginaw 1957
G. B. SALTONSTALL, M.D 9th Charlevoix 1957
W. S. STINSON, M.D 10th Bay City 1957
W. M. LeFEVRE. M.D 11th Muskegon 1958
B. T. MONTGOMERY, M.D 12th Sault Ste. Marie.... 1958
T. P. WICKLIFFE, M.D 13th Calumet 1959
B. M. HARRIS, M.D 14th Ypsilanti 1959
D. BRUCE WILEY, M.D 15th Utica 1960
G. THOMAS McKEAN. M.D 16th Detroit 1960
W. B. HARM, M.D 17th Detroit 1958
WILLIAM BROMME, M.D 18th Detroit 1959
ARCH WALLS, M.D President Detroit
G. W. SLAGLE, M.D President-Elect Battle Creek
K. H. JOHNSON, M.D Speaker Lansing
J. J. LIGHTBODY, M.D Vice Speaker Detroit
L. FERNALD FOSTER, M.D Secretary Bay City
W. A. HYLAND, M.D Treasurer Grand Rapids
W. S. JONES, M.D Past President Menominee
EXECUTIVE COMMITTEE OF THE COUNCIL
D. BRUCE WILEY, M.D Chairman
W. B. HARM. M.D Vice Chairman
W. M. LeFF.VRE, M.D Chairman, County Societies Committee
G. B. SALTONSTALL, M.D Chairman, Publication Committee
RALPH W. SHOOK, M.D Chairman, Finance Committee
K. H. JOHNSON, M.D Speaker, House of Delegates
J. J. LIGHTBODY, M.D Vice Speaker, House of Delegates
ARCH WALLS, M.D President
G. W. SLAGLE, M.D President-Elect
L. FERNALD FOSTER, M.D Secretary
IV. A. HYLAND, M.D Treasurer
Dermatology and Syphilology
Wm. T. Kruse, M.D Grand Rapids
Chairman
Coleman Mopper, M.D Detroit
Secretary
Gastroenterology and Proctology
N. D. Nigro, M.D Detroit 1
Chairman
E. J. Tallant, M.D Detroit
Secretary
General Practice
F. P. Rhoades, M.D Detroit 2
Chairman
F. C. Brace, M.D Grand Rapids
Secretary
Gynecology and Obstetrics
J. II. Beaton, M.D Grand Rapids
Chairman
R. W. McClure, M.D Detroit 26
Secretary
Medicine
J. M. Kaufman, M.D Detroit 26
Chairman
J. W. Hall, M.D Traverse City
Secretary
SECTION OFFICERS
Nervous and Mental Diseases
W. R. Slenger, M.D Ann Arbor
Chairman
S. C. Mason, M.D Ann Arbor
Secretary
Occupational Health
O. J. Johnson, M.D. Bay City
Chairman
P. B. Rastello, M.D Detroit 9
Secretary
Ophthalmology and Otolaryngology
B. C. Wildgen, M.D Muskegon
Chairman (Ophth.)
W. K. Locklin, M.D Kalamazoo
Co-Chairman ( Oto.)
H. A. Dunlap, M.D Detroit 14
Secretary (Ophth.)
H. L. LeVett, M.D Lansing
Co-Secretary ( Oto.)
Pediatrics
C. E. Booher, M.D Grand Rapids
Chairman
A. M. Hill, M.D Grand Rapids
Secretary
Public Health and Preventive
Medicine
J. D. Monroe, M.D Pontiac
Chairman
J. K. Altland, M.D Lansing 4
Secretary
Radiology, Pathology, Anesthesiology
R. B. Sweet, M.D Ann Arbor
Chairman (Anes.)
E. R. Jennings, M.D Detroit
Vice-Chairman (Path.)
E. O. Pearson. M.D Kalamazoo
Secretary (Rad.)
Surgery
E. T. Thieme, M.D Ann Arbor
Chairman
H. M. Bishop, M.D Saginaw
Secretary
Urology
R. P, Lytle, M.D Detroit 1
Chairman
J. F. Harrold, M.D Lansing
Secretary
Delegates DELEGATES
W. A. Hyland, M.D., Grand Rapids, Chairman 1957
J. S. DeTar, M.D., Milan 1957
C. I. Owen, M.D., Detroit 1957
W. D. Barrett, M.D., Detroit 1958
W. H. Huron, M.D., Iron Mountain 1958
R. L. Novy, M.D., Detroit 1958
Section
G. C. Penberthy, M.D. (Surgical
TO A. M. A. Alternates
W. W. Babcock, M.D., Detroit
E. F. Sladek, M.D.. Traverse City
O. J. Johnson, M.D.. Bay City
William Bromme. M.D.. Detroit
J. R. Rodger, M.D., Bellaire
G. W. Slagle, M.D., Battle Creek
Delegate
Section) Detroit
1957
1957
1957
1958
1958
1958
544
JMSMS
MSMS COMMITTEE PERSONNEL 1956-1957
ADVISORY COMMITTEE TO MICHIGAN STATE
MEDICAL ASSISTANTS SOCIETY
David Kahn, M.D., Chairman
401 American State Bank Bldg., Lansing
Ralph W. Shook, M.D., Vice Chairman
136 E. Michigan Ave., Kalamazoo
E. R. Sherrin, M.D
17555 James Couzens Hwy., Detroit
T. J. Trapasso, M.D
521 Ashmun St., Sault Ste. Marie
Otto van der Velde, M.D 35 W. Eighth St., Holland
J. E. Webber, M.D 310 E. Fulton St., Grand Rapids
BEAUMONT MEMORIAL COMMITTEE
Otto O. Beck, M.D., Chairman ....
280 W. Maple, Birmingham
L. R. Leader M.D., Vice Chairman
1129 David Whitney Bldg., Detroit
C. T. Ekelund, M.D 906 Riker Bldg., Pontiac
J. H. Fyvie, M.D 202 S. Cedar St., Manistique
S. W. Hoobler, M.D 2228 Belmont Rd., Ann Arbor
W. M. LeFevre, M.D 289 W. Western Ave., Muskegon
A. H. Whittaker, M.D 1427 E. Jefferson, Detroit
H. C. Fritsch, Advisor Parke, Davis & Co., Detroit
MEDIATION COMMITTEE
L. R. Leader, M.D., Chairman
1129 David Whitney Bldg., Detroit 26
D. R. Boyd, M.D 17.35 Peck Street, Muskegon
A. E. Gamon, M.D 2004 Court St., Saginaw
E. B. Johnson, M.D 412 Water St., Allegan
W. Z. Rundles, Sr., M.D 304 1st Nat. Bk. Bldg., Flint
R. W. Teed, M.D 215 S. Main, Ann Arbor
Charles TenHouten, M.D Paw Paw
STUDY ON PREVENTION OF HIGHWAY
ACCIDENTS COMMITTEE
J. R. Rodger, M.D., Chairman Bellaire
G. H. Agate, M.D Michigan Dept, of Health, Lansing
H. E. DePree, M.D
216 Bronson Med. Center, Kalamazoo
J. M. Dorsey, M.D 65 Moss, Highland Park
H. F. Falls, M.D 408 First Natl. Bldg., Ann Arbor
A. Z. Howard, M.D 825 David Whitney Bldg., Detroit
H. T. Johnson, M.D 1439 E. Michigan Ave., Lansing
R. F. Powers, M.D 529 W. Genesee, Saginaw
C. L. Straith, M.D 2605 W. Grand Blvd., Detroit
H. J. Meier, M.D., Advisor Coldwater
STUDY COMMITTEE ON FEE SCHEDULES FOR
MICHIGAN MEDICAL SERVICE
L. W. Hull, M.D., Chairman
1701 David Whitney Bldg., Detroit
E. B. Cudney, M.D Pontiac Motor Division, Pontiac
H. C. Hansen, M.D 417 Post Bldg., Battle Creek
J. R. Heidenreich, M.D Daggett
W. J. Herrington, M.D Bad Axe
W. M. LeFevre, M.D 289 W. Western, Muskegon
F. E. Luger, M.D 303 N. Jefferson, Saginaw
E. A. Osius, M.D 901 David Whitney Bldg., Detroit
C. A. Payne, M.D
Blodgett Memorial Hospital, Grand Rapids
Ralph W. Shook, M.D
611 Amer. Natl. Bk. Bldg., Kalamazoo
W. S. Stinson, M.D 101 W. John St., Bay City
C. K. Stroup, M.D 2002 E. Court St., Flint
R. W. Teed, M.D 215A S. Main, Ann Arbor
T. J. Trapasso, M.D.,. ...521 Ashmun, Sault Ste. Marie
J. M. Wellman, M.D 301 Seymour, Lansing
Flint Medial Laboratory
633 Mott Foundation Building
Flint
Phone CE. 4-9312
E. G. Murphy, M.D.
W. T. Hill, M.D.
W. L. Eaton, M.D.
C. J. Flanagan, M.D.
J. D. Wheeler, M.D.
W. Caraway, Ph.D., Biochemist
M. Dumoff. Ph.D., Microbiologist
COMPLETE SERVICES IN LABORATORY
MEDICINE
Tissue diagnosis
Serology
Chemistry
Bacteriology
Protein bound iodine
Exfoliative cytology
Basal Metabolism
Electrocardiograms
Pregnancy tests
Hematology
Urinalysis
Autopsies
Pfizer
a proven
suppressor of
postoperative
nausea and
vomiting . . .
BRAND OF MECLIZINE HYDROCHLORIDE
*Trademark
May, 1957
Say you saw it in the Journal of the Michigan State Medical Society
549
You and Your Business
MICHIGAN NOT ALONE
The “Blue Cross investigation bill” that had
been adopted unanimously by the Indiana Senate,
was adopted by the House this month without a
dissenting vote.
The bill established a special, non-partisan, joint
house-senate committee to “conduct a study of the
operations of all companies or associations or oth-
ers engaged in the business of providing hospital-
ization or prepaid hospital expense plans.”
The resolution itself does not specifically men-
tion Blue Cross, but it was introduced by Senator
Townsend, who had been previously quoted fol-
lowing an announcement of Blue Cross rate in-
creases as saying that “perhaps the whole situation
needs investigating.” As a result the bill has been
tagged in the press as a “Blue Cross Probe.”
The resolution calls for the special committee to
file a report with the legislative advisory commis-
sion on or before September 15, 1958, for trans-
mission to the next session of the assembly, which
will open January, 1959. — National Underwriter,
March 14, 1957.
DOCTOR AMENDMENT TO
DRAFT ACT
The Defense Department preparing for expira-
tion of the special doctor draft act next .June 30,
is moving ahead with legislation to amend the
regular draft act so that physicians may be called
up selectively. The bill is now before the Budget
Bureau, which is expected to clear it soon for
presentation to Capitol Hill.
The proposed amendment, in effect, would
waive the Selective Service Act’s prohibition
against discrimination to the extent that physi-
cians, dentists and allied scientists could be called
up by their professional classification. Thus these
men, because they are in the particular profes-
sional groups, would be subject to special calls and
not necessarily inducted in the same order as
others in their same age group.
One phase of the situation that is causing some
concern in the medical profession is the possibility
that June 30 will see the end not only of the spe-
cial doctor draft act, but also the expiration of the
National Advisory Committee to Selective Service
(the Rusk committee) and its affiliated volunteer
state and local committees. The Defense Depart-
ment Amendment setting up the new doctor pro-
curement mechanism under the regular draft has
no provision for continuing the committee. Selec-
tive Service had not recommended retaining the
committee.
The national, state and local committees, made
550
up of physicians and dentists, have been the
liaison between the military services and Selective
Service on the one hand and the medical profes-
sions and medical schools on the other. — AMA
Washington Letter.
CHANGES IN “INTERMEDIARY”
HOME-TOWN SYSTEM
It is neither the desire nor the intention of Vet-
erans Administration to eliminate the “inter-
mediary” system for administering the home-town
care program, an arrangement in which a third
party (a state medical agency) receives billings
and makes payments. This was the gist of a state-
ment by VA’s chief medical director. Dr. William
S. Middleton, at a Washington meeting attended
by representatives of eight states and Hawaii,
where the “intermediary” system remains in effect.
Also present were representatives of the AMA’s
Washington Office and the national Blue Shield.
Dr. Middleton said he felt sure that by mutual
consideration of the problems involved agreement
could be reached that would be acceptable to all.
It was decided that contracts would be continued,
based on the following major points:
1 . Contracts uniform for the eight states and
Hawaii, and generally modeled on the Michigan
state plan.
2. Authorization for extended care treatment to
be made by VA, with a copy of the authorization
going to the contractor.
3. Contractors to continue their audits and re-
ceive invoices (doctors’ monthly bills) with med-
ical reports.
4. Physicians’ summary reports, generally quar- ;
terly, to go directly to VA. — AMA Washington ,
Letter, March 29, 1957.
(The eight states are California, Colorado, Michigan,
North Carolina, Oregon, South Dakota, Washington, and
Wisconsin.)
ANNUAL MEDICAL GOLF
TOURNAMENT
The American Medical Golfing Association will 1
hold its forty-first tournament June 3, 1957 at the :
well-known Westchester Country Club, Rye, New 1
York. It is a championship layout, with beautiful- '
ly cared for greens and fairways. This famous re- ,
sort provides two eighteen-hole courses, a Beach
Club on Long Island Sound, tennis courts and
even a polo field.
As in the past few years, eighteen-hole compe-
tition will determine championships and will be
the basis for the awarding of prizes. The New
( Continued on Page 554 )
.TMSMS
Harmonyl
*
(Deserpidine, Abbott)
iquilizer. For instance, following an eight-month study of
>nic, hospitalized mental patients, Ferguson1 reported:
'armonyl benefited at least 15% more overactive patients
1 oral reserpine.
armonyl was more potent in controlling aggression,
firing only one-half to two-thirds the dosage of reserpine.
number of patients experiencing side reactions on
rpine were completely relieved when changed to Harmonyl.
fis summary Ferguson concluded: “ The most notable im-
;sions were the absence of side effects and relatively rapid
•t of action with Harmonyl.”
rmonyl in hypertension
Dertension studies show that the average reduction in blood
ssure obtained with Harmonyl compares closely to that ob-
ied with reserpine. The tranquilizing effect of the two drugs
> appeared similar, except that few cases of giddiness,
;igo, sense of detached existence or disturbed sleep were
3rved with patients receiving Harmonyl.
iages In mild anxiety, as little as 0.1 mg. of Harmonyl a
may be effective. In institutionalized psychiatric patients,
less than 2 to 3 mg. a day is likely to be beneficial.
nild essential hypertension, treatment may be started with
0.25-mg. tablet three or four times a day. After about ten
s (or sooner, depending upon response), dosage may be re-
ed. A maintenance dose of 0.25 mg. daily is often sufficient.
cautions, As with other forms of rauwolfia, Harmonyl
st be used cautiously in peptic ulcer and epilepsy and in
ients about to undergo surgery or electroshock treatment,
ipite infrequent reports involving depression, patients with
story of depressive episodes should be watched carefully.
fessional literature is available upon request.
iplied: Harmonyl is supplied in
mg., 0.25-mg. and 1-mg. tablets.
QMrott
Reference: 1: Ferguson, J. T.: Comparison of Reserpine and Harmonyl in Psychiatric Patients:
A Preliminary Report, Journal Lancet, 76:389, December, 1956 . * Trademark
May, 1957
Say you saw it in the Journal of the Michigan State Medical Society
553
YOU AND YOUR BUSINESS
ANNUAL MEDICAL GOLF TOURNAMENT
(Continued from Page 550)
York Committee, headed by James T. Daniels,
M.D. has made excellent arrangements for a full
day of good golf and relaxation for all golfing
medics.
The Westchester Country Club located some
thirty miles from Grand Central Station, can be
easily reached by train or bus to Rye, or, if sev-
eral golfers join together, by Carey Car Service
or Rent-a-Car Service. Colfers wishing to have
quarters closer to the Club can secure reservations
at nearby hotels in Rye or Harrison, New York,
or in Greenwich, Connecticut.
Tournament play will start at 8:30 a.m. Play-
ers may tee off up to 2 : 00 p.m. Buffet luncheon,
banquet, prizes and green fees are included in the
cost of the day’s activities. The banquet will be
served promptly at 7 : 00 p.m. followed by award-
ing of prizes. All male members of the American
Medical Association are eligible to participate in
the tournament. Notice of further details and ad-
vance registration card may be secured by writing
Bob Elwell, 3101 Collingwood Blvd., Toledo 10,
Ohio.
Players should present verification of their home
club handicap, signed by their club secretary,
otherwise handicap is set by the AMGA Handicap
Committee.
The following New York doctors will assist Dr.
Daniels, Walter Heldmann, Robert Warren, Leon-
ard Goldman, Samuel Thompson and Frank La
Gattula.
The AMGA is under the direction of the fol-
lowing officers: Joseph Corr, President, New
York; Paul Wyne, First Vice President, San Fran-
cisco; John Growden, Second Vice President,
Kansas City, Mo.; and D. H. Houston, Seattle,
Permanent Chairman of the Advisory Commit-
tee.
SEVENTH AMERICAN CONGRESS
ON MATERNAL CARE
A comprehensive review of Complete Maternity
Care will be presented by The American Commit-
tee on Maternal Welfare at the Seventh American
Congress on Maternal Care (formerly known as
the American Congress on Obstetrics and Gyne-
cology) to be held at the Palmer House, Chicago,
July 8-12, 1957.
The five-day Congress — under the leadership of
F. Bayard Carter, M.D., Professor and Head of
the Department of Obstetrics and Gynecology at
Duke University, Durham, North Carolina, and
Samuel B. Kirkwood, M.D., Commissioner of
Public Health for the Commonwealth of Massa-
chusetts and Professor of Maternal Health at Har-
vard Medical School — will present topics dealing
554
with the interprofessional approach to maternal
and infant care. The Program Committee, com-
posed of organizational representatives from ob-
stetrics-gynecology, general practice, pediatrics,
anesthesiology, nurse anesthesia, nursing, nutrition,
public health, hospital administration, mental hy-
giene and social service, has developed a program
to afford maximum opportunity for audience par-
ticipation.
Speakers and registrants at the panel discus-
sions, luncheons, round tables, breakfast confer-
ences and Laymen’s Forum will examine and pur-
sue the questions: “WHAT is Complete Mater-
nity Care?” “WHO Provides It?” “HOW is
Complete Maternity Care Provided?”
Four thousand are expected to attend.
Further information can be attained by writing
The American Committee on Maternal Welfare,
116 South Michigan Avenue, Chicago 3, Illinois.
NURSING SCHOLARSHIPS
The College of Nursing at Wayne State Uni-
versity recently announced that six scholarships
for student nurses are again available for the 1957-
1958 academic year.
Five Helen Newberry Joy scholarships are avail-
able to students in the metropolitan Detroit area,
and an alumni grant is available to students
throughout Michigan.
These scholarships offer $850 to cover the major
part of tuition costs for the eight semesters and
one summer session of the basic professional pro-
gram. The grants are offered on a competitive
basis to selected students who wish to enter the
College of Nursing in September, 1957.
Applicants face no age, sex, race or creed re-
striction when applying for the scholarships. For
information, write Dean Katharine Faville, Col-
lege of Nursing, Wayne State University.
HIGHLIGHTS OF EXECUTIVE
COMMITTEE OF THE COUNCIL
Meeting of March 12, 1957
• Medicare Program. Jay C. Ketchum reported
that to date some 1,100 claims have been re-
ceived; also that re-negotiation is necessary so
that x-ray billings will be paid by Michigan
Medical Service rather than by Michigan Hos-
pital Service as at present. A letter from the
Michigan Society of Anesthesiologists re Medi-
care was read and referred to Secretary Foster
for reply.
• Michigan Medical Service. Executive Vice
President Ketchum reported that the marked
increase in utilization would force an increase
in rates, soon. The Executive Committee no-
tified Michigan Medical Service that so far it
has no recommendations to Michigan Blue
(Continued on Page 556)
JMSMS
Like oil on troubled waters...
Formula
DONNATAL TABLETS
DONNATAL CAPSULES
DONNATAL ELIXIR (per 5 cc.)
DONNATAL EXTENTABS®
(Extended Action Tablets)
Each Extentab (equiva
lent to 3 Tablets) pro'
provides superior spasmolysis
through provision of natural belladonna
Hyoscyamine Sulfate 0.1037 mg.
Atropine Sulfate 0.0194 mg.
Hyoscine Hydrobromide..0.0065 mg.
Phenoliarbital (Vi gr.).... 16.2 mg.
vides sustained X-tablet
effects... evenly, for 10 to
12 hours — all day or all
night on a single dose.
alkaloids in optimal ratio, with phenobarbital
A. H. ROBINS CO., INC., RICHMOND 20, VA.
YOU AND YOUR BUSINESS
HIGHLIGHTS OF THE COUNCIL
(Continued from Page 554)
Shield concerning the adoption of the revised
$5,000 Fee Schedule.
• 1957 Michigan Clinical Institute. The record-
breaking total of 3,247 persons registered at the
March 13-14-15 MCI included 1.654 doctors of
medicine. A report on the promotion of this
meeting, developed and executed by the MSMS
Executive Office, was reviewed.
• 1957 MSMS Annual Session, September 25-26-
27 in Grand Rapids. C. Allen Payne, M.D. of
Grand Rapids was appointed as General Chair-
man for this Session. A page in the Annual
Session Program, seeking the registrants’ atti-
tudes on the convention, was authorized.
• The name of A. Hazen Price, M.D., of Detroit,
was nominated to the Governor for the State
Hospital Advisory Council. The names of Wil-
liam Bromme, M.D., Detroit, William M. Le-
Fevre, M.D., Muskegon, and D. R. Smith,
M.D., of Iron Mountain, were nominated, as
MSMS representatives, to the Board of Trus-
tees of Michigan Hospital Service.
• Ethics. The appeal of a member of the Wayne
County Medical Society, from an order of dis-
cipline, was referred to the MSMS Ethics
Committee.
• Councilor Conferences, which proved so suc-
cessful in 1956, were authorized throughout
Michigan for the summer of 1957.
• Advisory Committee of Michigan Hospital Serv-
ice. The following names were nominated to
Blue Cross for its proposed Advisory' Commitee:
C. W. Colwell, M.D., Flint; L. Femald Foster,
M.D., Bay City; W. S. Jones, M.D., Menomi-
nee; W. M. LeFevre, M.D., Muskegon; J. D.
Miller, M.D., Grand Rapids, and Ralph W.
Shook, M.D., of Kalamazoo.
• Documentary Film of New Wayne County
Medical Society Building. The Council Chair-
man appointed the following committee to de-
velop this film: W. B. Harm, M.D., Chairman;
L. J. Bailey, M.D., L. R. Leader, M.D.; A. E.
Schiller, M.D., and W. W. Babcock, M.D., Ex
Officio.
• Legal Counsel Lester P. Dodd presented opin-
ions on (a) use of the word “clinic”; (b) a
hospital problem in Oakland County.
• House of Delegates Speaker Kenneth H. John-
son, M.D., Lansing, announced that he had
called a special session of the MSMS House
of Delegates in Detroit for Saturday, April 27,
1957, by request of The Council.
• Committee Reports. The following were re-
viewed: (a) Home Town Medical Care Pro-
gram, meetings of January 26 and February
10; (b) Tuberculosis Control Committee, Jan-
uary 11; (c) Site Committee (special report
of Chairman K. H. Johnson, M.D.); (d) Pub-
lic Relations Committee, January 26; (e) Joint
Committee to Meet with Michigan Society of
Neurology and Psychiatry and Michigan Psy-
chological Association, January 30; (f) National
Defense Committee, January 30; (g) Vene-
real Disease Control Committee, January
31; (h) Michigan Cancer Co-ordinating Com-
mittee, January 31; (i) Rheumatic Fever
Control Committee, February 6; (j) Compre-
hensive Prepaid Insurance Plans Committee,
February 6-27 and March 6 and also joint
meeting of February 6 with Committee on
Michigan Medical Service and separate meet-
ing of the latter committee on March 3;
(k) Geriatrics Committee, meeting of February
7; (1) Advisory Committee to WCMS Docu-
mentary Film, February 7; (m) Rural Medical
Service Committee, February 21; (n) Arbitra-
tion Committee, February 22; (o) Mental
Health Committee, February 28; (p) Healing
Arts Study Committee, February 10; (q) Liai-
son Committee with Michigan State Board
of Registration in Medicine, February 21.
• Proposed Fire Regulations for Hospitals — report
of L. A. Drolett, M.D., Lansing, was presented
and received with thanks to Dr. Drolett for an
excellent report.
• American Medical Education Foundation. Plan
of promotion by Michigan Chairman C. E.
Umphrey, M.D., Detroit, was considered, and
a vote of thanks to Dr. Umphrey was placed
on the minutes.
MEDICAL MEETINGS AND CLINIC DAYS
A list of known medical meetings and clinic days, sponsored by county medical societies and
other physician groups in Michigan, follows:
1957
June 21-22
July 11-13
July 25-26
Sept. 25-27
Upper Peninsula Medical Society
Mid-Summer Session of The Council, MSMS
Coller-Penberthy Medical Conference
MSMS Annual Session
Calumet
Mackinac Island
Traverse City
Grand Rapids
556
JMSMS
tie only one of its kind”
l„.
w ■ ■ m
£D WITH SODIUM METAPHOSPHATE
6REATER ANTIBIOTIC ABSORPTION FASTER BROAD-SPECTRUM ACTION
Urine ExcretionIStudy demonstrates
that more Tetracycline, is absorbed from
ACHROMYCIN V
I 140 one 250 mg, capsule ;
= ,20 uSSl <24 h0Ur Peri0d>
Average Blood Levels at 1, 3 and 6 hours
ACHROMYCIN V vs. ACHROMYCIN
one 250 mg. capsule
tl
& o
I «-
i 20-
0-
52.5 mg.
ACHROMYCIN V
.24
.868
■
.823
■
.216
t
J
ACHROMYCIN V H ACHROMYCIN
chemically
conditioned
or greater clinical
efficiency
achromycin v admixes sodium metaphosphate with
tetracycline, achromycin v provides greater antibiotic
absorption/faster broad-spectrum action and is indicated for
the prompt control of infections, seen in everyday practice,
hitherto treated with other broad-spectrum antibiotics.
Available: Bottles of 16 and 100 Capsules.
Each Capsule (pink) contains:
Tetracycline equivalent to tetracycline HCI.. 250 mg.
Sodium metaphosphate 380 mg.
achromycin v dosage: 6-7 mg. per lb. of body weight
per day for children and adults.
LEDERLE LABORATORIES DIVISION
AMERICAN CYANAMID COMPANY
PEARL RIVER, NEW YORK
♦Reg. U.S. Pat. Off.
What the Future Holds for General Practice
At the Symposium on Trauma in Lansing,
Michigan, March 6, 1957, Austin Smith, M.D.,
Editor and Managing Publisher of The Journal of
the American Medical Association, delivered a
significant address at the noon luncheon. Ap-
proximately 400 members of the Michigan
Academy of General Practice and their wives
attended.
ical socialization, but stressed that organizations
could do only so much.
“The footwork must be done by the individual mem
bers,” he said. “In Sweden, the family doctor has ceased
to exist. In Norway, physicians are limited in their use
of drugs. In Japan, medical affairs are divided among
various departments of the government with the result
that the doctors are forced to follow a multitude of
(Left to right ) Arch Walls, M.D., President MSMS and Moderator of Symposium;
Austin Smith, M.D., Editor JAMA and Luncheon Speaker, “What the Future Holds
for General Practice” ; F. P. Rhoades, M.D., President-Elect MAGP and Chairman
of Symposium on Trauma.
Dr. Smith stressed the fact that the future of
the general practice of medicine rests primarily in
the hands of the generalists. In other words, the
future will be what the general practitioners of
medicine work to make it. He pointed out that
since the majority of practicing physicians of the
country are general practitioners, it follows that
the future of the general practice of medicine will
be the future of the practice of medicine in gen-
eral. He made a strong plea for all doctors and
all segments of medicine to resolve their differ-
ences and join hands in a united front to prevent
the catastrophe that has overwhelmed the profes-
sion in many other countries. As examples, he
cited the current spectacle of the doctors of Eng-
land having to threaten a strike in order to secure
sufficient recompense to keep pace with the in-
creased cost of living.
Dr. Smith’s address is significant because, due to
his position in organized medicine, it cannot but
reflect the official thinking and attitude of the
hierarchy of the AMA. He spoke of the work of
the World Medical Association in combating med-
560
policies. In Chili, all doctors are state employes.” Doc-
tor Smith charged “the International Labor Organiza-
tion and the International Social Security Organization,
with offices in Geneva, Switzerland, are actively engaged
in a concerted effort to bring about government control
of medicine in all nations. If their program is adopted,
all physicians would become mere technicians subject to
the absolute control of government bureaucrats.” He
pointed out that “the W.M.A., of which the A.M.A. is a
member, stands for (1) Freedom of choice of physician;
(2) Freedom of choice of hospital; and (3) No re-
striction on type of medication used or mode of treat-
ment by the physician.”
Dr. Smith concluded by saying,
“As long as the family doctor continues to play a
dominant role in the medical picture, he will, in a
large measure, insure the survival of medical freedom.”
Dr. Smith was introduced at the noon luncheon
by Dr. F. P. Rhoades, Chairman of the Sym-
posium. Dr. John W. Rice, President of the
Michigan Academy of General Practice, mod-
erated the morning session, and Dr. Arch Walls,
President of the Michigan State Medical Society,
( Continued on Page 564)
JMSMS
perhaps the safest ataraxic known
Tablets-Syrup
(brand of hydroxyzine)
safety highlighted in every clinical report.
Depending on the condition treated, the effec-
tiveness of atarax has ranged from 80 to
94%. But clinicians have agreed unanimously
on its safety. After more than 85,000,000
doses — many on long-term administration
at high dosage — no evidence of addiction,
blood dyscrasias, parkinsonian effect, liver
damage, depression or other serious side ef-
fects have been reported.
calms tense patients.
atarax produces its calming, peace-of-mind
effect without disturbing mental alertness.
In the tension/anxiety conditions for which
it is intended, you will find atarax effective
in about 9 of every 10 patients.
prescribe atarax as follows:
Adults: usually one 25 mg. tablet,
or two tsp. Syrup, three times daily.
Children: (over 3 years) : usually
one 10 mg. tablet, or one tsp. Syrup,
twice daily.
Supplied: Tablets, tiny 10 mg.
,7. At/' (orange) and 25 mg. (green), bot-
jSjbsagv ties of 100. Syrup, 10 mg. per tsp.,
Pint bottles.
Since response varies from patient
Patient, dosage should be adjust-
hi p&fj ed accordingly. Prescription only.
Chicago 11, Illinois
‘MAi
May, 1957
Say you saw it in the Journal of the Michigan State Medical Society
561
Heart Beats
HEART ASSOCIATION ELECTS OFFICERS
M. S. Chambers, M.D., a Flint internist, was
elected President of the Michigan Heart Associa-
tion on March 15, 1957, at the Association’s an-
nual board meeting which was held in Detroit
at the time of the Michigan Clinical Institute.
Dr. Chambers was one of the original incorpora-
tion. The Dodrill-GMR Mechanical Heart, which
was designated one of the top ten scientific devel-
opments in 1952 by the National Association of
Science Writers, was the first device of its kind
in medical history to be used successfully on hu-
man patients undergoing heart surgery. Dr. Dod-
Heart Association Honors Charles E. Wilson and Charles F. Barth
(Left to right ) M. S. Chambers, M.D., Flint, looks on as Secretary of Defense
Charles E. Wilson and Mr. Charles F. Barth, Jr., accept special honorary life mem-
bership plaques in the Association from E. A. Irvin, M.D., Dearborn. The presen-
tations were made at the Association’s annual dinner meeting held in Detroit, on
March 14, 1957, in conjunction with the Michigan Clinical Institute. Mr. Wilson
was honored for his efforts in organizing the Michigan Heart Association in 1948-
1949 when he was head of General Motors. He served as Association Board Chair-
man for seven years. Mr. Barth, now ninety and a retired Chevrolet vice president,
did not appear personally, but his son, Charles F., Jr., accepted his plaque. Mr.
Barth has supported several heart research projects.
tors of the Association in 1949 and he has served
on the Board ©f Trustees and numerous commit-
tees since that time. He is also serving a three-
year term as a member of the Board of Directors
of the American Heart Association.
F. D. Dodrill, M.D., a Detroit surgeon, who
headed a medical and engineering research team
which developed the first successful mechanical
heart, was elected President-Elect of the Associa-
rill, also, was among the original incorporators
of the Michigan Heart Association.
Mr. George A. Jacoby, GM Director of Per-
sonnel Relations and a former Flint resident, was
re-elected for a second term as chairman of the
Board of Trustees.
The retiring MHA President, E. A. Irvin, M.D.,
Medical Director of the Ford Motor Company,
(Continued on Page 564)
562
JMSMS
specifically for reduction of overweight
(brand of phenmetrazine hydrochloride)
. .a highly effective and safe appetite suppressant . .
Based on clinical reports, Preludin produces more than twice the weight loss
achieved by patients receiving a placebo.2 It is singularly free of tendency to
produce serious side actions, as well as stimulation.1'3 Preludin imparts a
feeling of well-being that encourages the patient to cooperate willingly in
treatment.1-3
The reduced incidence of side actions with Preludin makes losing weight more
comfortable for the average patient, facilitates treatment of the complicated
case and frequently permits its use where other anorexiants are not tolerated.3
Recommended Dosage: One tablet two to three times daily one hour before
meals. Occasionally smaller dosage suffices. On theoretical grounds, Preludin
should not be given to patients with severe hypertension, thyrotoxicosis or
acute coronary disease.
(1) Holt, J. O. S., Jr.: Dallas Med. J. 42:497, 1956. (2) Gelvin, E. P.; McGavack, T. H., and Kenigsberg, $.:
Am. J. Digest. Dis. 1:155, 1956. (3) Natenshon, A. L.: Am. Pract. & Digest Treat. 7:1456, 1956.
Preludin® (brand of phenmetrazine hydrochloride). Scored, square, pink tablets of 25 mg. Under license from
C. H. Boehringer Sohn, Ingelheim.
GEIGY
Ardsley, New York
May, 1957
Say you saw it in the Journal of the Michigan State Medical Society
563
HEART BEATS
(Continued from Page 562)
was appointed chairman of the Community Serv-
ice and Education Committee, one of the Associa-
tion’s major committees. He will continue to
serve on the Board of Trustees and the Executive
Committee.
Other Association officers elected were :
Vice President — Mr. Frank N. Isbey, Detroit
Vice President — Mrs. James McEvoy, Detroit
Vice President— Mr. J. William Hagerty, Detroit
Vice President — Mr. Cyrus H. King, Detroit
Vice President — Donald S. Smith, M.D., Pontiac
Vice President — Milton Shaw, M.D., Lansing
Secretary- — Robert E. Fisher, M.D., Battle Creek
Treasurer — Mr. Alfred T. Wilson, Detroit
The following persons were elected to the Board
of Trustees for a three-year term:
Mr. Don Ahrens, Bloomfield Hills
J. K. Altland, M.D., Lansing
Mr. Earnest Bennett, Detroit
Muir Clapper, M.D., Detroit
Moses Cooperstock, M.D., Marquette
Leon DeVel, M.D., Grand Rapids
F. D. Dodrill, M.D., Bloomfield Hills
Douglas Donald, M.D., Detroit
H. M. Golden, M.D., Flint
John Keyes, M.D., Pleasant Ridge
Mr. Richard Krafve, Dearborn
Mrs. Fred Miner, Flint
Donald S. Smith, M.D., Pontiac
Members of the Board of Trustees elected to
serve on the Executive Committee were:
M. S. Chambers, M.D., Chairman, Flint
Paul S. Barker, M.D., Ann Arbor
Sidney E. Chapin, M.D., Dearborn
Warren B. Cooksey, M.D., Detroit
F. D. Dodrill, M.D., Bloomfield Hills
Mr. J. William Hagerty, Detroit
E. A. Irvin, M.D., Dearborn
Mr. Frank N. Isbey, Detroit
Mr. George A. Jacoby, Detroit
F. D. Johnston, M.D., Ann Arbor
L. Paul Ralph, M.D., Grand Rapids
Donald S. Smith, M.D., Pontiac
Henry L. Smith, M.D., Detroit
Frank Van Schoick, M.D., Jackson
Mr. Alfred T. Wilson, Detroit
Dr. Chambers, following his election, made the
following Standing Committee Appointments:
RESEARCH COMMITTEE
Donald S. Smith, M.D., Chairman, Pontiac
F. D. Johnston, M.D., Vice Chairman, Ann Arbor
Paul S. Barker, M.D., Ann Arbor
Bert M. Bullington, M.D., Saginaw
Muir Clapper, M.D., Detroit
F. A. Coller, M.D., Ann Arbor
Douglas Donald, M.D., Detroit
John Keyes, M.D., Pleasant Ridge
John Littig, M.D., Kalamazoo
COMMUNITY SERVICE AND EDUCATION COMMITTEE
E. A. Irvin, M.D., Chairman, Dearborn
Sidney E. Chapin, M.D., Vice Chairman, Dearborn
Muir Clapper, M.D., Detroit
Robert E. Fisher, M.D., Battle Creek
Scott T. Harris, M.D., Ypsilanti
L. Paul Ralph, M.D., Grand Rapids
D. Emerick Szilagyi, M.D., Detroit
Silas Wiersma, M.D., Muskegon
Mr. Paul F. Witte, Grosse Pointe
FINANCE COMMITTEE
Mr. Frank N. Isbey, Chairman, Detroit
Mr. J. William Hagerty, Vice Chairman, Detroit
F. D. Dodrill, M.D., Bloomfield Hills
E. A. Irvin, M.D., Dearborn
Mr. George A. Jacoby, Detroit
Mr. Cyrus H. King, Detroit
Donald S. Smith, M.D., Pontiac
Henry L. Smith. M.D., Detroit
Mr. Alfred T. Wilson, Detroit.
WHAT THE FUTURE HOLDS FOR
GENERAL PRACTICE
(Continued from Page 560)
was the moderator for the afternoon session. The
six nationally known authorities who discussed
traumatic injuries and their treatment were:
Kenneth H. Abbott, M.D., Professor of Neuro-
surgery, Ohio State University; Edward J. Beattie,
Jr., M.D., Professor of Surgery, University of Il-
linois; John H. Powers, M.D., Professor of Sur-
gery, Columbia University; David M. Bosworth,
M.D., Professor Orthopedic Surgery, New York
Polyclinic; Allen S. Russek, M.D., Professor of
Clinical Physical Medicine, New York University;
and Harry H. Wagenheim M.D., Director, Psy-
chosomatic Service, Temple University.
At the conclusion of the scientific program, there
was an elaborate cocktail party and reception,
with strolling musicians, for the guest speakers,
Officers of the Academy, and all registrants.
MSMS ANNUAL MEETING
September 25-26-27, 1957
Civic Auditorium, Pantlind Hotel,
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564
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. .the objectives of therapy in pruritus ani can be listed
under 3 headings:
(1) relieve itching: [Hydrolamins produced immediate relief
of intractable itching in 98% of patients. The anti-
pruritic effect of one application lasts about twenty-four
hours.1!
(2) accelerate healing, [Hydrolamins rapidly and com-
pletely healed reddened, fissured, macerated and ridged
perianal lesions in 88% of cases.1!
(3) allow natural healing without trauma due to physical,
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ing while the ointment protects the perianal area from
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Due to the rapidity of action of Hydrolamins, it is believed that protein-precipitating
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1. Bodkin, L.G., and Ferguson, E.A., Jr.: Successful Ointment Therapy for Pruritus Ani, Am. J. Digest. Dis.
18:59 (Feb.) 1951.
2. Fromer, J.L.: Dermatologic Concepts and Management of Pruritus Ani, Am. J. Surg. 90:805 (Nov.) 1955.
AFTER
Same case after treatment with Hydro-
lamins. Note healing of the inflamed,
fissured and excoriated areas and of the
whitened anal folds.
BEFORE
Reddened, fissured and excoriated peri-
anal skin, and whitening of the anal
folds, accompanied by intense burning
and itching of 3 years' duration.
May, 1957
Say you saw it in the Journal of the Michigan State Medical Society
565
AMA Washington Letter
THE MONTH IN WASHINGTON
By approximately the mid-term point in its
first session, the 85 th Congress had shown enough
interest in health legislation to hold a variety of
hearings, but there was no evidence that many
major bills would be passed before adjournment.
Actually, it was not until three months after the
session opened that the Administration sent up to
Congress two bills it regards as important — one
would change the doctor draft act and the other
would authorize small commercial companies to
pool part of their resources to stimulate expansion
and experimentation in health insurance.
Even then, the Department of Health, Educa-
tion, and Welfare had not released its draft of
legislation for federal grants to medical, dental
and osteopathic schools for construction and
equipment. On this, there was some reluctance to
act until Capitol Hill had decided on the admin-
istration’s bill for U. S. aid to general education.
Of all these bills, indications were that progress
was assured on only one, that providing some re-
vised arrangement for the selective draft of phy-
sicians, dentists and “allied specialists.” The spe-
cial doctor draft act, in effect for almost seven
years, is scheduled to expire on July 1. Because
Defense Department insists it still needs special
authority to draft physicians and other profes-
sional health personnel by professional classifica-
tion, the alternative was continuation of a modified
doctor draft act or changing the regular draft act.
Meanwhile, a number of other bills had been
studied at hearings. They include:
Changes in Medical Aspects of Civil Aviation
Regulations. — Witnesses are widely divided on
this measure that would set up an Office of Civil
Aviation Medicine within the Civil Aeronautics
Administration and give the Air Surgeon General
who would head the office considerably more
authority than now is exercised by U. S. medical
officials in this field. There was no official spon-
sorship of this from the federal governmental level.
It was opposed by the Department of Commerce
(where CAA is located) and the Civil Aeronau-
tics Board. However, support came from the out-
side, including testimony from Dr. Jan Tillisch of
the Mayo Clinic, Dr. William Ashe, chairman of
the department of preventive medicine, Ohio State
University, and Dr. Herbert F. Fenwick, president
of the Civil Aviation Medical Examiners. Dr. Til-
lisch headed an AMA ad hoc committee that had
started a study of the problem, but he testified as
an individual.
Veterans Medical Care. — The House Veterans
Affairs Committee had held extensive hearings on
a bill to further restrict admission of non-service
connected cases to Veterans Administration hos-
pitals, but there were no developments beyond
that to encourage sponsors of this legislation.
Civil Defense Reorganization. — Here again a
wide split developed at the hearings on just how
to reorganize the federal government’s participa-
tion in civil defense. The Administration wanted
to strengthen the U. S. civil defense arm (the
Federal Civil Defense Administration), but with-
out going to the extent of making a cabinet-rank
Department of Civil Defense, which is the goal of
Chairman Chet Holifield (D., Calif.) of the sub-
committee that had studied civil defense for more
than a year.
Control of Barbiturate and Amphetamine
Drugs.— The objective of bills before the House
Interstate health subcommittee is to extend fed-
eral control to take in the manufacture, com-
pounding, processing, distribution and possession
of habit-forming barbiturates and amphetamines.
This would be achieved by demonstrating that
intrastate control of the drugs is essential to
achieve interstate control, a philosophy advanced
for years by some federal officials.
While manufacturers, compounders, processors
and handlers would have to list their names and
places of business with HEW and to maintain
complete records, physicians would not have to
comply with these regulations.
Pressures for economy that had been evident
early in the session seemed to lose their effective-
ness when Congress really set to work on the bud-
get for the Department of Health, Education, and
Welfare. Whereas in first (non-record) votes the
House cut scores of items, it simply reversed it-
self when roll-call votes were demanded in the
final go-around.
As an example, no reductions at all were made
in funds for the research institutes, $50 million
was restored for grants to help build water pollu-
tion treatment plans, $1.3 million was restored
to the Food and Drug Administration. A $5 mil-
lion cut in money for general public health grants
to states was sustained by the House — but this
money will have to be provided later if the House
(Continued, on Page 568)
566
.TMSMS
Overeating is a bad habit—
you can help your patients
to break it
May, 1957
Say you saw it in the Journal of the Michigan State Medical Society
567
AMA WASHINGTON LETTER
( Continued from Page 566 )
estimate of the extent of the obligation proves too
low.
Economy advocates tried without success in the
House to cut $21 million off money for the Hill-
Burton hospital construction program.
While in theory the Senate is privileged to make
its own cuts in a money bill coming to it from the
House, in practice the Senators generally restore
much of the money cut by the House and oc-
casionally (as last year) vote large boosts over
House figures. So the possibility now is for even
higher health and medical budgets before the ap-
propriations bills finally are enacted.
AMA NEWS NOTES
DAVID ALLMAN TO ASSUME
PRESIDENCY IN JUNE
The American Medical Association’s presidential oath
of office will be administered to David B. Allman, M.D.,
of Atlantic City, N. J., in impressive ceremonies at 8:30
p.m., Tuesday, June 4, in the grand ballroom of the
Waldorf-Astoria Hotel, New York. Besides Dr. Allman’s
inaugural address, the program will also feature musical
selections by the United States Army Chorus, Washing-
ton, D. C.; remarks by out-going President Dwight H.
Murray, M.D., of Napa, Calif., and presentation of the
Distinguished Service Award to the recipient selected
by the House of Delegates.
A portion of the inaugural ceremony — from 9 p.m. to
9:30 p.m. — will be telecast over New York station
WABD, Channel 5.
Immediately following the ceremonies, Dr. and Mrs.
Allman will receive physicians, exhibitors and guests at
the annual reception in the east ballroom. The presi-
dential ball will begin at 10 p.m. and continue until
1 a.m. in the grand ballroom.
CIVIL DEFENSE CONFERENCE IN JUNE
Medical aspects of radiation hazards will be the prin-
cipal topic of discussion at the fifth annual National
Medical Civil Defense Conference to be held Saturday,
June 1, in the Sert Room of the Waldorf-Astoria Hotel,
New York. Sponsored by the AMA’s Council on Na-
tional Defense, the one-day meeting has been designed
primarily for representatives of state, local and national
civil defense committees, physicians and other leaders
of health and medical care facilities. A special feature
of this year’s program will be reports by Federal Civil
Defense Administration officials on plans for handling
national civil defense programs and meeting radiation
hazards.
Also on the program will be presentations on the
effects of radiation and the medical management of
radiation casualties, an FCDA film on “Treatment of
Nerve Gas Casualties,” and an FCDA radiological
exhibit.
Physicians planning to attend the AMA’s 106th An-
nal Meeting are urged to come a day or two earlier
for this worthwhile civil defense meeting. Further de-
tails may be secured from the Council.
WIVES PLAN BANG-UP NEW YORK SESSION
More than 3,000 physicians’ wives are expected to
gather at New York’s Roosevelt Hotel, June 3-7, for
the 34th annual convention of the Woman’s Auxiliary
to the AMA. An interesting program, combining busi-
ness with pleasure, is being arranged by the committee
on arrangements, under the direction of Mrs. Harry
F. Pohlmann, Middletown, N. Y., and Mrs. Elliott V.
B. Vurgason, Baldwin, N. Y. National committee
meetings and round table discussions will be conducted
June 1-3 with the formal opening of the convention
slated for Tuesday morning, June 4.
Business sessions on Tuesday and Wednesday will be
devoted to state and national committee reports and
discussions of current health projects. Tuesday’s lunch-
eon, honoring past presidents, will feature an address
on “Sick People in a Troubled World” by Dr. Howard
Rusk, professor and chairman of the department of
physical medicine and rehabilitation, New York Univer-
sity, Bellevue Medical Center.
Principal speaker at Wednesday’s luncheon in honor
of the president (Mrs. Robert Flanders of New Hamp-
shire) and president-elect (Mrs. Paul C. Craig of
Pennsylvania), will be Dr. Dwight H. Murray, imme-
diate past president of the AMA. At this session, Mrs.
Flanders will present the Woman’s Auxiliary contribu-
tion to the American Medical Education Foundation,
and Dr. George F. Lull, AMEF vice-president, will
present AMEF awards to auxiliaries.
Election and installation of national officers will be
held on Thursday morning with adjournment scheduled
for noon. Climax of the convention activities will be
the annual dinner for members, husbands and guests
in the grand ballroom of the Roosevelt Hotel, Thursday
evening. Mr. Allen Richard Foley, professor of history
at Dartmouth College, will speak on “Vermont Humor.”
The latest population figures for Michigan are
7,300,000, making her the seventh among the states.
Michigan ranks fourth in tourist and resort business —
$600,000,000.
In Lansing
HOTEL OLDS
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400 ROOMS
568
Say you saw it in the Journal of the Michigan State Medical Society
TMSMS
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Vitamin D 600 U.S.P. Units
Thiamine Mononitrate (Bj) . . 3 mg.
Riboflavin (B2) 3 mg.
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Editorial Opinion
BLUE SHIELD LEAVES
LOW-VAULTED PAST
In February, 1942, when the Council of the
Massachusetts Medical Society approved the rec-
ommendation of the Committee on Public Rela-
tions to establish a fee table for Blue Shield service
benefits, an income level of $2,500 per family was
set as a ceiling. Subscribers with family incomes
over $2,500 a year would be reimbursed up to the
scheduled amount, and pay the surgeon the bal-
ance of his normal fee out of their own pockets.
This ceiling of $2,500 family income was chosen,
not on the basis of medical indigency or inability
to pay, but as a selling device. It was necessary
to enroll the largest possible number of persons.
A study of family-income levels had shown that
in the period 1935-1939, which was assumed to be
“normal” (although actually it was a period of
severe depression), 91.4 per cent of the wage-
earning group had a family income of less than
$2,500 a year (40.6 per cent received from $750
to $1,000 a year, 42.8 per cent from $1,000 to
$2,000, and 8 per cent from $2,000 to $2,500) .
Thus if enrollment of all families earning less
than $2,500 was permitted. 91.4 per cent of the
wage-earning population (about 1,200,000 per-
sons) could be included as a potential market for
prepaid medical-insurance policies.
Instead of returning to “normal” after World
War II, wages and prices continued to' increase,
and in February, 1947, the Council agreed to set
the ceiling at $3,000, in view of the higher cost of
living, although no corresponding increase in fees
(to correspond with the coincident increase in
wages) was voted.
By 1950, it was apparent that something was
wrong. At the February meeting of the Council
figures were presented showing that in 1948 the
number of families with incomes of less than
$1,000 had dropped from the 1935-1939 level of
40.6 per cent to 8 or 10 per cent, and that those
with incomes of $1,000 to $2,000 had fallen from
42.8 per cent to about 14 per cent. The cost of
living had gone up at least 6 or 8 per cent since
1935-1939, and wages had risen correspondingly,
so that more than half the population now had
annual family incomes between $2,000 and $5,000
To reach even 80 per cent of wage earners, service
benefits would have to be extended to all persons
earning up to $5,000 a year.
A blue-chip group was therefore set up, and on
February 1. 1950, the Council approved a second-
ary fee schedule of service benefits 50 per cent
higher than the old one, for persons with incomes
over $2,500 but under $5,000, to be known as
Plan B. This would cover 80 per cent of the
population and only the 20 per cent with incomes
over $5,000 would be subject to additional charges
by the surgeon, to meet his standard fee.
It is now again proposed to raise the family-
income ceiling for service benefits to $7,500, be-
low which the physician will accept the Blue Shield
fee as his total fee. The Executive Committee of
the Massachusetts Medical Society (voting mem-
bers of Blue Shield) have approved raising the
ceiling to this figure, and the increase has been
accepted by the Council.
Department of Commerce figures show that
families with incomes under $1,000 (as of 1955)
constituted only 1 per cent of the population (as
contrasted with 40.6 per cent in 1935-1939), and
those with incomes of $1,000 to $2,000 only 3 per
cent (as compared with 42.8 per cent of all fam-
ilies in 1935-1939). To reach 1,200,000 persons
today. Blue Shield must cover 60 per cent of the
working population. But 60 per cent of families
now enjoy incomes between $3,000 and $15,000.
Only 9 per cent have less than $3,000 a year; 49
per cent have between $3,000 and $7,500, and 42
per cent have incomes in excess of $7,500.
Average family income, which was $2,340 in
1930, had risen to $5,520 in 1955, an increase of
136 per cent. The cost of living rose over a similar
period about 90 per cent.
Blue Shield fees to doctors under Plan A, in
spite of these tremendous rises in family income
and in the general cost of living, have remained
constant, and until now there has been little
change in the Plan B schedule since its authoriza-
tion in 1950. Although the consumers’ index
shows an increase in cost of living of 12 per cent
over the period 1950-1956, there has been no such
general rise in Blue Shield Plan B fees.
Careful study and re-evaluation of cost-of-living
indexes, fee schedules and subscribers’ rates must
accompany the proposed rise in the ceiling for
service benefits to $7,500. Otherwise, dissatisfac-
tion with Blue Shield fees will continue to in-
crease, and it will become increasingly difficult to
explain to Blue Shield subscribers why their in-
surance does not cover their medical and surgical
bills.
Fortunately, this process of study and re-evalua-
tion is under way, and to some extent already in
effect. For example, the Medicare table of fees,
which the members of Blue Shield have accepted
as a basis for a new Plan B schedule, includes in-
stead of the meager current fees for medical (as
distinguished from surgical) care, such items as
(Continued on Page 658)
572
TMSMS
n°k£ JOU R M A L
of the Michigan State Medical Society
Issued Monthly Under the Direction of The Council
VOLUME 56 MAY, 1957 NUMBER 5
Preventive Geriatrics
Importance of Good Nutrition and Exercise in the Aged
HE GERIATRICS Committee of the Michi-
gan State Medical Society has by meeting,
study, consultation and collaboration accumulated
some important information and opinion that it
feels should be made available to the men of
medicine in the State of Michigan. This series
began in 1954 with the first group article entitled
“Preventive Geriatrics.”
The Committee believes that its most impor-
tant work is in the field of prevention. Since
the concept of prevention stands out in the mate-
rial to be presented, it was decided to continue
the group article again under the heading of
“Preventive Geriatrics.” Instead of ranging
through the entire field of medicine, as was done
in the last article, it was decided to limit the
discussion to nutrition, physical development, edu-
cation and exercise. A panel discussion was con-
ducted by mail between the members of the Com-
mittee and outstanding authorities in their respec-
tive fields. What follows is the thinking of this
Panel. The members of the Panel and the Com-
mittee are appended.
A discussion of nutrition fits “hand in glove”
with a discussion of physical exercise. In many
of the opinions expressed below, there is a distinct
overlapping of these two fields. This is the type
of thing that we expect and encourage; but for
purposes of simplification the first part of this
paper will deal largely with physical education
and physical exercise, the second part will deal
with nutrition.
In the “Preventive Geriatrics” number of The
Journal of the Michigan State Medical So-
May, 1957
ciety of May, 1954, Dr. Michael M. I)acso and
Howard A. Rusk as a part of their contribution
to the panel discussion offered the following:
“In a previous publication, ‘Clinical Problems in Geri-
atric Rehabilitation’; one of us gave a practical, clinical
classification of the geriatric patients who can benefit
from rehabilitation:
1. Obviously handicapped patients (hemiplegia, arthri-
tides, fractures, amputations, and neuro-muscular
disease) .
2. Those chronically ill without signs of manifest dis-
ability (chronic cardiac disease, chronic pulmonary
diseases, et cetera).
3. The elderly persons who are not obviously ill, but
have impaired physical fitness.
“It is in the third group that the preventive aspects
of rehabilitation are presently most neglected. In many
cases, the self-imposed, illogical and unnecessary physical
inactivity, together with an insufficient diet will cripple
the older patient without any underlying pathologic
condition. The physical medicine and rehabilitation
specialist is prepared to evaluate objectively the pa-
tient’s physical capabilities and. if need be, improve
them with properly applied and graded physical activi-
ties.
“A more intensive concentration on this third group
of patients could prevent a great number of them from
needlessly crossing the line between a useful and physio-
logic senescene and a useless and burdensome senility.
In the treatment of the above-listed groups,
good nutrition, various types of mechanical de-
vices and prosthesis and surgical procedures are
necessary to bring a degree of improvement. The
one item of treatment that is common to all three
groups is graded, passive and active exercises to
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PREVENTIVE GERIATRICS
improve the tone and the function of the parts
affected. Accepting the last statement of the quota-
tion, as an obvious truth, it would seem that an
earlier application of the same principle to the
youth of the land would be helpful in providing
longer, more healthful years for the human body.
Dr. Laurence E. Morehouse of the University
of California, participating in a radio broadcast
entitled “The Sitting Man,” aided in making the
following contribution :
“Ring Lardner once said, ‘The only exercise I get is
when I take the studs out of one shirt and put them
into another.’ It can be assumed that this was in-
tended as a facetious remark, but there are a good many
American adults who could honestly match it with a
record of physical activity not much more rigorous.
The officer worker in the big city rides to work in the
morning by auto, streetcar, or bus. If he drives, he
may lose his temper a few times, but that isn’t exercise.
At the office he sits at his desk most of the day. Perhaps
his principal exertion is picking up the telephone. He
rides back home in the evening, and reads the paper
before dinner. After dinner, he may watch television,
listen to the radio, read, or lie down on the sofa for a
nap. On the week end his recreation often consists of
taking a ride into the country — in an automobile.
“The increasing use of automobile transportation has
worried some observers, and some years ago one prophet
predicted that eventually our legs would wither away
in a few generations if we didn’t use them more. So
far this hasn’t happened, but apparently the modern
conveniences have made some inroads on our general
stamina. In a recent issue of the New York Times,
Jean Mayer of Harvard University has stated flatly that
Americans are getting soft. He points to the fact that
rejection by the draft on grounds of general lack of
fitness reached fifty per cent, and he says that American
men are steadily growing heavier for their height and
age — reflection of rich diet and easy living. Even
children show this trend toward softness. Our success
at sports can be partially written off when the small
number of men on the football or baseball team is com-
pared to the huge crowd sitting in the stands or slouched
in an easy chair at home watching the little screen.
“If physical stamina and health were of no impor-
tance, the unfavorable statistics could be disregarded.
But most people realize the need for keeping in reason-
ably good physical condition even if they don’t do any-
thing about it.”
Farther along in the radio script it was pointed
out that Dr. Morehouse had learned that young
management executives in conference felt that the
lack of physical fitness handicapped them in their
deal with labor. They admitted that lack of stam-
ina worked against them in long and grueling
bargaining sessions with labor leaders. When
they met these men across the bargaining table,
the labor leaders would bring up minor points
in the proposed contracts and haggle over them
for hours at a time. Although the executives tried
to keep alert by drinking coffee from time to time,
eventually they grew tired and reached the point
of fatigue. It was then that the labor leaders
introduced the critical bargaining points and
forced the major concessions. When labor repre-
sentatives were later asked about this strategic
technique, they freely admitted that it was often
used to great advantage. Both labor and man-
agement executvies recognized that if they were
in better physical shape, they might be better able
to withstand physical and mental fatigue in the
long bargaining sessions.
This problem raised the question of whether
or not physical condition is a critical factor in
the ability to preserve mental alertness and effi-
ciency under stress. In an attempt to find the
answer, a small research program was established
in Harvard’s Fatigue Laboratory using twenty pro-
fessors as the subjects of the experiment. The men
were first given a complete physical examination,
which included the functioning of their nervous
systems and blood circulation. Then they em-
barked on a prescribed program of light exercise,
work, and rest. Attention was also given to such
factors as proper nutrition.
Again the results were favorable. Part of the
estimate of these results depended on subjective
evidence — that is, the self-evaluations of the sub-
jects engaged in the experiment. But measure-
ments in the laboratory bore out this personal
testimony. When the experiment began, the sub-
jects were thrown off balance by the slightest
stress. As the program progressed, it was found
that the subjects reached the point where they
could undergo certain amounts of stress without
becoming mentally upset.
Dr. Morehouse found in this and in other ex-
periments that many executives are as much a
slave to routine and detail as the youngest ap-
prentice in the business. They are adrift on an
endless sea of paper work, and they never seem
to reach shore. They accept whatever responsi-
bilities are placed on them without any self
analysis of their time or ability to fulfill them
adequately. Thus they are constantly harassed
and have little time for creative thought and ef-
fort. One of the results is that executives fail
to take out enough time for recreation or for doing
the things they really want to do. Often they
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look forward to retirement as a time when they
can do what they have always wanted to do. But,
unfortunately, some of them never reach the re-
tirement age.
Dr. Morehouse is a strong advocate of enjoying
life as you go along, even though this requires a
bit of organization and planning. It involves
allowing time for rest periods and for reasonably
leisurely meal times. And, it involves some atten-
tion to physical fitness, even if the time devoted
to exercise is no more than two or three ten-
minute periods a week. It isn’t necessary for the
sedentary white collar man to be in the same kind
of physical condition as the professional football
player. An office worker who attempted to keep
in this kind of shape would be considerably over-
trained. But his physical condition should be
slightly in advance of his actual needs. Just as
a baseball player can’t keep in shape just by show-
ing up for the games, neither can a file clerk stay
in condition merely by opening and closing the
files. There is no clear cut relationship between
exercise needs and age. A person who has been
accustomed to vigorous physical activity all of his
life may still be as capable of exercise at seventy
as the sedentary man of forty.
Dr. A. Hazen Price, Chairman of the Geriatrics
Committee, in his introduction of the topic for
discussion, had this to say regarding physical
exercise :
“Even though there is overwhelming evidence to
indicate that graduated, physical exercise is essential for
the maintenance of a healthy body, there are very few
people who regularly follow this practice. We all recog-
nize that some form of activity out of doors stimulates
the appetite and promotes more restful sleep. It pro-
vides a sense of well-being unequaled by any other
type of exercise. When this type of activity is not
possible, then some type of setting up exercise indoors
helps increase total body metabolism as well as accelerate
our general circulation, increase body temperature and
prevent a great deal of mental sluggishness. Nerve
tension is lessened, exercise serving as an outlet for
pent-up pressure. We are all aware of what happens
to the arm or leg kept immobilized too long in a cast.
Sitting or standing for long periods without some ac-
tivity creates a stiffness and aching of joints when
motion is attempted. Early ambulation, postopera-
tively and following childbirth, decreases the period
of convalescense, as well as lessening the likelihood of
peripheral phlebothrombosis and pulmonary stasis. Less
prolonged bedrest after cardiac infarction has likewise
decreased the incidence of thrombo-embolic complica-
tions to say nothing of improving the patient’s outlook
psychologically.
“If we admit that these statements are true, would
it be unreasonable to apply the principles involved in
order that we keep well? It must be stressed that the
type and the amount of exercise should be adapted to
the age and physical fitness of the individual. If it is
done in the form of recreation, particularly with one or
two companions, it will not only improve muscular
tone but also have an excellent tonic effect on morale.
Exercise should be fun, and not done just because it is
good for us.
“Those people who have always been active physically
should be encouraged to continue some form of activity,
regardless of age, decreasing, of course, the intensity of
the physical effort with the years, or if disability inter-
venes. Some regular and systemic exercise each day
will help the individual ‘meet daily tasks with a better
body and a more alert mind.’ ”
Dr. C. Howard Ross, a member of the Geriatrics
Committee, adds:
“Activity brings joy to the heart and solace to the
mind. In many rehabilitation programs, every muscle
and joint, that has the power to wiggle, must be made
to wiggle more, and eventually bring the patient to the
level of self-care. With very few exceptions, there
should be a daily physical exercise program for every
one in this world.”
Dr. C. Etta Walters of Department of Physical
Education for Women of the Florida State Uni-
versity, Tallahassee, Florida, writes:
“During World War II, when bed space was limited
and medical care needed to be expedited, we evoked a
well known, but much neglected principal in exercise
physiology, e.g., that structure demands function, while
disuse promotes atrophy. Instead of prolonging the bed
rest after the acute phases of treatment, patients were
put on their feet as soon as possible and exercise was
the usual recovery procedure. DeLorme’s ‘Progressive
Resistance Exercise Program’ came into vogue, and the
work of Hellebrandt and Kabat as well as those of
others did much to provide and explain the physio-
logical mechanism upon which these exercises rest. Thus
the physiological basis of the ‘Overload principle’ or
‘Progressive Resistance Exercises’ has provided the ra--
tionale for the treatment of the physically incapacitated
and the maintenance and achievement of strength and
endurance in the normal. This principal demonstrates
that the organ systems of the body that are pushed to
levels beyond those which can be easily met are the
ones that develop the capacity to perform more effi-
ciently. An experimental demonstration of this in regard
to the cardiovascular system was performed by Christen-
sen some years ago. He trained men to perform pro-
gressively heavier work on the bicycle ergometer and
studied the heart rate and the stroke volume response.
If, after having reached a constant value for heavier
load the subjects returned to the lighter one, it was
performed with a lower heart rate and a larger stroke
May, 1957
591
PREVENTIVE GERIATRICS
volume than when the same work had been performed
initially. This is such a commonplace occurrence in
the development of cardiorespiratory endurance and
muscular strength that we are apt to ignore its implica-
tion for the importance of activity in daily living. The
literature in the past ten years has pointed out some
of the evils of prolonged bed rest and, therefore, has
shown further the dangers inherent to inactivity.
“Inflexibility can be as incapacitating as can inade-
quate strength and endurance and some of the pains
associated with advancing age can be trained to muscle
tightness. Tight muscles can always cause irreversible
changes in body structure and thus a functional defeat
can become a structural one.
“Whether we exercise for the sake of activity or
whether we do so by indulging in a favorite pastime
which employs it. the important fact is that exercise
when properly directed does increase the efficiency of
the body in performing normal every day activities and
enables it to meet emergencies with a minimum change
in the homeostatic functions of the body. Although it
is not essential, and sometimes inadvisable, that the
older person indulge in strenuous activities of his youth,
Jokl has shown that the deterioration of performance
usually accompanying age can be prevented by regular
training. We are conditioned by our interest and habits
acquired in childhood and, therefore, it is important to
develop early a love for activity and skills that will give
to us good behavior patterns in terms of exercise in
later life.
“It is important to educate the older person in the-
value of exercise and recreational interest. We must
also provide opportunities for him to pursue such activi-
ties and our cultural pattern must recognize that
senescence and inactivity are not synonymous.”
Since the type and amount of physical exercise
tolerated by any individual should be in the
form of a prescription to fit that individual, and
should be continued with appropriate modifica-
tion throughout life, Dr. C. H. McCloy of the
Division of Physical Education and Intercollegiate
Athletics of the State University of Iowa thinks
that "there should be more emphasis on medical
examinations than is common at present.” He
suggests :
First, I think that the medical societies should make
a point of making clear to medical practitioners what
it is that constitutes an adequate examination. I have
had medical examinations myself covering the last twenty
years, and some of them were so poor that they were
not worth the time spent on them. Some were excellent.
I think that some practitioners either do not know
what constitutes an adequate examination or they feel
that they cannot charge enough for an examination to
justify their giving it and, hence, give the individual
examined the full sense of security although they do
not do a thorough job. I think the medical society
could well go on record as to what constitutes an
adequate physical examination.
“Along these lines, I think that one thing should
be added to the examination, probably starting about
the age of forty. This item is the examination for
blood cholesterol ... in view of the large number
of deaths due to coronary occlusion, I think this item
could very well be added. I realize that most prac-
titioners in small communities have no facilities for
analyzing the blood for cholesterol, but it is quite
possible to draw the blood and preserve it and send
it to the state laboratory.
“I think it would be a distinct service to indicate
what aspects of a medical examination need to be done
each year or oftener (for example, as one gets oldei,
it is perhaps desirable that the prostate be examined
every six months). Dr. C. Ward Crampton believes
that certain aspects of the medical examination need
not be done very frequently. Others need to be done
with a great deal of care, quite frequently. It would
seem that this possibility should be explored. If the
same physician is doing the examination, has access
to his previous records, a great deal of time and ex-
pense could be saved.
In this part of the panel discussion which had
to do largely with generalities of the whole prob-
lem, Dr. Ernest D. Michael of the University of
California said:
“If aging is concerned with both the physical and
the mental processes, it seems that some form of pre-
ventive medicine should be tried that will stimulate
the physical vigor as well as the mental desire for
activity. This implies that the physical activity which
I feel is necessary for healthful living, must be pleas-
urable. Of the many forms of physical activity, the
best from the standpoint of interest usually concerns
combination of exercise and a duty. Competition is
found in almost all sports, particularly fishing, bowl-
ing, archery, etc. To combine exercise with duty
involves a selection of activities, hiking^ bicyling and
garden activities, which takes a person outdoors in
nature.
“A club or organization would be conducive to
bringing together people of like interests so that they
could participate in these physical activities.
“In addition to the above, there are other means
to retard deterioration that recent studies verify.
Weight-lifting, done to the rhythm of music might be
used to glamorize a sometimes dull activity. Cold
showers have been found to stimulate the circulation
and reduce fatigue. This also may be a means to
stimulate the mental activity and add to the picture.”
Dr. Henry J. Montoye of the Michigan State
University states:
“My field of interest is the physiology of exercise
and I am very much interested in the role for reg-
ular physical exercise among middle-aged and older
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people. There is no question in my mind that regular
exercise of the proper intensities and duration can
do much to postpone the deterioration which com-
monly occurs as the individual gets older. There are
all kinds of cases in the sports world where amazing
physical feats have been performed by people well up
in years. We do not expect that the average man or
woman will in the later decades of their lives accom-
plish similar feats, but some regular exercise, I am cer-
tain, could maintain the physical capabilities of these
people at a very much higher level. Furthermore,
I think that such regular exercise would affect not
only the physical capacity, but their interest in other
people and the world about them, their energy for
doing mental work and in general, their vim and
vigor for carrying out everyday activities.
“There are in the literature age curves permitting
physical activities, as for example, a grip strength,
flexibility, reaction time, et cetera. However, I am
certain these curves can be modified with regular exer-
cise, diet control and other activities. However, I
think the two mentioned, namely, regular exercise and
diet, can play the greatest part in preventive geriat-
rics.
“We have an experiment underway at the present
time among middle-aged men who are very much
out of condition. These data being collected will
contribute to our knowledge in this area. However, I
think the most dramatic effects of regular exercise among
older people insofar as their physical capacities are con-
cerned, will be demonstrated in the cardiovascular area
and to a lesser extent in strength, flexibility, co-ordina-
tion, reaction time and certain other areas.
Dr. C. Etta Walters further adds:
“While physiologic involution is an inevitable con-
comitant of aging, proper or improper use of the body
can delay or hasten the process in certain cases, and
parts of the body. Incorrect body mechanics can
cause unnecessary wear and tear. Although people
probably stand in the most economical posture in
terms of energy cost, it does not follow that they use
the best mechanical principals in active postures such
as lifting heavy objects, in carrying, reaching, pushing
and other similar activities. The high incidence of j
slipped disks with their accompanying pain attest to
this fact. Recent electromyographic evidence has shown
that when the trunk is bent forward and a weight
lifted, the erector spinae muscles do not participate
in the lift, and other muscles of the lower trunk do
not seemingly function. Thus the strain is borne by
the intervertebral ligaments which cannot often stand '
the weight imposed. When the trunk is kept upright
and centered over the object to be lifted or aligned
with the direction of the reach, pull, et cetera, the leg
muscles bear the brunt of the weight with help from
the back muscles, thus relieving the tension on the -
ligaments.
“The capacity to maintain an effective homeostasis
while performing work has been defined as a meas-
ure of physical fitness, Judicious physical training has
been demonstrated to contribute to the maintenance
of a more effective homeostasis and there is no rea-
son to believe that it is hot as important in the aged
as in the young. Physical activity with its resulting
effects would have a bearing on any physical exam-
ination that included any response to physical stress.
Thus, if one kept in good physical condition by exer-
cise, it would be possible for him to maintain a cer-
tain degree of fitness with a less rigorous program as
he became older.
“It has been known that the psychomotor skills that
are developed early and kept in training can be retained
by the aged to such a high degree that the older „
person can surpass a much younger age group in this
skill.
“It would appear, therefore, that continued exercise
of a skill can be of benefit to the aged as it is not
lost, and since physical capacity and endurance can
be maintained to a high degree in the aged by regular
training, it would seem that exercise and training would
be an attribute of all ages. Recreational hobbies such
as fishing, gardening, or golfing, brisk walks, and count-
less others provide a means of maintaining a certain
degree of acquired physical fitness. For those unable
to participate in this manner, it would be advisable
for them to indulge in some form of an exercise pro-
gram even if within the confines of their home. Phys-
ical fitness and endurance can be developed by this
method as well as a desirable amount of flexibility of
muscles and joints maintained.”
From the Department of Physical Education
for Women at the University of Wisconsin, Dr.
Lawrence Rarick opines that:
“The problem of the aging is at last receiving the
thoughtful attention which it rightfully deserves. As
has been frequently stated, the first twenty years of
life are spent in gaining physiologic equilibrium, the
next five to ten years in maintaining the peak level
of physical efficiency, followed by the gradual, but
continuous process of the physiologic deterioration.
Our concern is to lengthen the span of optimal-efficiency
and retard the processes of physical deterioration.
“While much remains to be learned concerning the
process of aging, we see its symptoms in many persons
prior to the middle-adult years. While disease and
hereditary factors cannot be disregarded as important
factors in bringing on the characteristics of early aging, v
there is little question that little factors over which the
individual has control may predispose him to this con-
dition. A considerable body of evidence now points
to unwise dietary habits and physical inactivity as fac-
tors which must be given careful consideration.
“There is an increasing body of evidence which indi-
cates that a life of physical inactivity is detrimental
to the health of men in the age range of forty-five
to sixty-four. This is borne out by data reported
by Morris in which it was found that the mortality rate
from coronary heart disease for English males was more
than twice as high for light workers as compared to
May, 1957
593
PREVENTIVE GERIATRICS
heavy workers in the forty-five to sixty-four age range.
Similar, but not so dramatic, differences were found by
Morris in regard to the mortality rate from diabetes.
According to Krause, 80 per cent of low back pain
among persons in middle-adult life is due to inade-
quate physical activity.
“If the aim of those responsible for guiding the
health of the people in the middle and later years of
life is to maintain a vigorous, active and productive life,
then the importance of an exercise program, suited
to the organic capacity of the individual should not be
overlooked. Careful medical supervision must be em-
phasized and assurance given that the organic condi-
tion of the individual is appraised regularly. Studies
of German men who were athletic in their youth, indi-
cates that continuation of a physically active life can
postpone many of the symptoms of aging by as much
as twenty to thirty years, with apparently no harmful
effect to the individual. These men were able to
continue effective performance in their forties, fifties
and some in their sixties and early seventies. "While
the evidence is not clear concerning the effects of
'exercise on longevity, there is strong support for the
belief that the person will have a healthier, happy and
more productive span of years late in life, by including
a regular program of physical activity in his regimen
of living.”
Recognizing that this problem involves more
disciplines than just the medical, Dr. Janet A.
Wessel of Michigan State University writes:
“We need education in our schools and in our
clinics for the development of the physical potential
of mankind. This is the role of physical education in
the schools, to provide guidance, direction, and oppor-
tunity for the development of the movement potential
for all children. It should be the role of physical edu-
cation to provide the same for adult education. Phys-
ical education should develop within each individual
the concept of movement through the years . . . how
it changes, the effect of physical activity upon the
body, the mind and the motions, why movement or activ-
ity seemingly plays such an important part in total
fitness or health, in that movement — efficient skillful
movement — is not a way of life; but it is life. Move-
ment should be understood from its earliest beginning,
through childhood, adolescence, adulthood and the other
years. Each person should be aware of his physical po-
tential through the years. Each person should be
physically aware of a feeling of being in good physical
condition . . . being physically fit. And man must
realize that to be truly educated, he must develop his
potential in all aspects of his life . . . the mind, the
body, the emotions and the spirit. We must begin teach-
ing movement — not games or sports or dance. These
things will come as the way of developing the physical
potential of man. But games and sports and dance
must never take the place of man’s understanding of
the fundamentals of all movement and the need for
movement through the years.
“And what is of more importance to this whole pic-
ture is the way one moves . . . adherence to basic
principles of movement is important at all ages, and
plays a great part in the effect of movement upon the
individual. I believe that two-thirds of the people must
be taught and directed how to move with ease and
grace . . . and this must be done in terms of the
life of each individual . . . his particular problems
and his inherited capacity. As far as glamour and
exercise are concerned . . . what woman, regardless of
age, is not interested in her form and figure? Her
energies? What man, regardless of age, is not inter-
ested in his physique and proud of his muscular ex-
ploits as he grows older? His energies? Exercise
. . . all movement should be approached from this
angle, as well as efficiency and skill. However, I think
that attacking the problem of the physical potential
in the aging should not be from the prescribed exercise
standpoint; but from the broader aspect of movement
through the day and the year. I believe that a pam-
phlet should be put out on Movement Through the
Years . . . how it changes . . . and maybe a series of
articles on movement in the later years dealing with
^postural changes, muscular tone, efficiency, energies,
movement principles, and ways to adapt yourself to
the changing times . . . through your work, your
hobbies, your interests, et cetera.
“Maybe some day a Movement Clinic will be set
up for the aging to determine their movement needs
in life of the total individual. A movement specialist
will analyze the individual’s total life situation and with
consultation of the medical doctor, make recommenda-
tions for the improving of the physical potential of his
patient . . . this should come from the medical doctor
. . . but someone must show the individual how and
give him opportunity to practice and this would be
the physical educator and/or the physical therapist.”
The value of sports to the individual is empha-
sized in an article titled “The Aging of Athletes
and Athletic Longevity” by Dr. A. Bidon, trans-
lated from Le Viellissement Des Athletaes Et La
Longevite Sportive, Medicine, Education Physique
Et Sport, 2 : 187-198, 1949, translated by Ross
Macnab. Dr. Bidon speaks of his own re-educa-
tion by means of sports after being discharged
from the military service with five major wounds
and also his experience of intimate contact and
physical examination and observation of some 150
veterans whom he studied, followed and advised.
The following quotations from his article con-
veys the gist of his experience and thinking:
“One may conclude from these examinations that
prolonged participation in sports has no detrimental
effect on the body.”
The men under observation at this time varied
in age from thirty-five to sixty-five. Among the
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older athletes that were examined. Dr. Bidon
noted one point in common:
“All seemed to be fearful of overweight.
“At the onset of the forties or fifties, sport can be
an extremely important means of therapy. It may be ),
as a preventive, by strengthening the individual, or
as a therapy in certain cases. What are the biggest
enemies of people of all ages? They are overweight and
cardiovascular or renal conditions.
“Participation in sport after age forty, therefore,
must be very progressive. The individual must re-
educate his skeletal muscles, as well as his heart, change
his way of life, and readapt his body to physical effort. |,
“A similar danger exists in regard to vacations. So
many people feel that they can regain in fifteen days
at the beach or in fresh mountain air that which they
have lost in 350 days of clogging up and stiffening.
Result: The vacation ends with the individual in a
horrible physical state. A word here to physicians who
will supervise athletic neophytes. The vacation period
should be a period of mental rest and discreet physical
readaptation, and not a period of athletic debauchery.
“Excesses, such as overeating, causes a much heavier
burden than does sport participation.
“I repeat what I said at the National Congress of
Physical Education in 1914. Medical control of sports,
so necessary in youth, is even more vital in old age.”
Dr. Bidon further says:
“I owe much to sport which educated me, and
which aided in my re-education after war wounds, just
as it has rehabilitated many others. I am confident, on
the basis of data I have collected — low blood pres-
sures, the stronger hearts, the slow pulse rate and
resistance to overweight — that sport is beneficial. One
can easily see that the heart of an athlete will beat fewer
times in a lifetime than a heart not conditioned by
activity.”
Ernest D. Michael of Santa Barbara College,
University of California, finds that:
“Regular exercise programs have been found to en-
hance the body in regard to muscular strength, motor
skills, and circulatory improvement. Increases in strength
and motor skill has improved the efficiency of move-
ment and helped prevent fatigue caused by physical
exertion. The increase in muscular tone also aids the
venous return of the blood which in turn augments the
circulation. The improvement in circulation is reflected
in the slowing down of the pulse rate during training,
in the faster return to normal of the pulse rate after
exercise and in the improved blood pressure response
following the training program.
“Along with the general improvement in fitness, a
sense of well-being or a feeling of good health is usually
found as a result of exercise. The measure of this is
subjective and, therefore, is not accepted by many as
reliable data. It is possible that this sense of well-being
is emotional in nature and, therefore, is the result of
an adjustment concerning the autonomic nervous sys-
tem. If this is true, then exercise may prove to be
important in man’s adjustment to stress involving the
autonomic system.”
Dr. Edward F. Crippen of the Committee re-
ports :
“I am repeatedly impressed in all age groups by the
difference in work capacity or desire to work in indi-
viduals with the same physical defects. Thus, physical
appraisal is too closely integrated with mental state to
be separated.
“More and more as I see patients, I feel one family,
‘Brown’ clan, can expect more physical fitness at sixty-
five than the ‘Holcombs,’ and if I know the family
then I know whether Joe Brown is up to standard.
I presume in certain areas the standards at sixty-five
change, that must be in the countries or localities with
extra long life expectancies.
“ ‘Good for the age’ is a crutch used by me and many.
It reassures the patient and allows the physician an
out should succumb in two weeks. Of course, it doesn’t
work at twenty, so we don’t use it. We always should
expect more, for it gives us hope as well as the patient.
The answer is whether the added diet, drugs, exercise,
et cetera, are worth the effort. Yet the returns may be
minute, in comparison to the efforts to obtain them.”
In discussing the problem before the panel, Dr.
Walter S. McClellan of the University of North
Carolina writes:
“All suggested measures of the functional response of
older people fail because of the lack of soundly estab-
lished norms. The functional performance of any test
to evaluate function is influenced by so many factors,
such as training, ability to co-operate, desire to co-
operate or the development of fear and apprehension,
that it is very difficult to give a fair and sound evalua-
tion to the test. Again, one may find a considerable
variation in the response of the individual under study
in repeated tests. No statistical analysis will reveal the
reasons for these variations any more than we can give
a logical reason for the changes in the function of the
joints of an arthritic patient on different days and under
conditions of climate and weather. There are no good
ways to measure the total functional response of older
individuals.
“The variations in functional responses in patients
with similar structural defects resides in the initiative
of the individual. Everyone is familiar with the great
difference in the performance of patients with hemiplegia
who show essentially similar lesions. One patient may
be confined to bed, another is found in a wheelchair, a
third is walking with the aid of a crutch or cane. The
main factor which accounts for these variations is the
motivation of the patient, which may be called ‘desire to
get well.’ All experts in the field of restoration therapy
for these patients recognize the importance of this fac-
tor and can show patients who have progressed up the
scale of improvement much faster than their structural
May, 1957
595
PREVENTIVE GERIATRICS
defects would seem to indicate was possible when then-
treatment started. This may be the teachability of the
patient, or it may be the degree to which fear com-
plexes can be eliminated by the patient. The physician,
the family and friends of the patient can either add to
these fear complexes or they may be of the greatest aid
in removing these blocks from the patient’s therapy path-
way.
“Heredity undoubtedly plays a role in the physical
status of older citizens. Barring intercurrent acute dis-
ease or accident, heredity likely determines, more than
purely environmental factors, the length of our life.
Our hereditary environment can be influenced by en-
vironmental factors toward the shortening of our life
span or conversely with the observation of good health
habits, it may be possible to lengthen the life span.
“Physical exercise can only contribute to a person’s
physical state at the time of examination if it has been
a regular part of his life’s habits, for many years.
“A regular plan of physical exercise properly followed
through young adulthood and middle-age, I believe, will
provide the older person with a better physical machine.
“Organ systems function more normally when posture
is good ; i.e., they are sometimes impeded by the me-
chanical inefficiency of poor posture.
“The motivation required to get people to exercise
may be either a desire for perfection or a fear of dis-
ability. In older people, the calloused attitudes which
largely act toward maintaining the status-quo will pre-
vent the development of any general health exercise
program.
“The one exercise which I consider the most bene-
ficial is regular deep breathing. It raises shoulders and
chest, improving our posture and our sense of well-
being. It helps return the venous blood to the heart,
it fills more of the lung alveoli with air and results in
improved oxygenation of the blood. This exercise can
be done in any place and at any time and so has a
wide applicability for many people. It, therefore, has
both psychologic and physiologic effects when prac-
ticed.”
v:
A
A program of exercises should accomplish two
purposes, according to Dr. McCloy of the State
University of Iowa:
“First, the development of strength and endurance,
and second, the development of flexibility. As individuals
become older, they tend to do much less in the line of
physical activity and as a result they deteriorate mus-
cularly and become considerably rigid. The individual
soon finds his strength is inadequate for a regular, very
active life. An illustration like the following analogy
will bring this a little more clearly in focus. Suppose
someone were to ask you (for example) during the cold
weather of winter, to wear under your clothing, a
jacket weighted with lead, let us say of thirty pounds.
Your response to the individual would probably be that
it would be silly to wear a pack of thirty pounds all
day. You would probably be exhausted by noon. If,
however, your muscular strength is just adequate to
handle a man thirty pounds lighter than you are, but
still be at your present weight, you can see that you
would be undermuscled thirty pounds instead of being
overweight thirty pounds. This would seem to me to
make it clear that an individual needs enough strength
and muscular endurance to do his daily work easily
without undue fatigue, so that normally he would come
to the end of the day sleepy, but not tired. Where the
individual lets himself undergo a process of muscular
atrophy, he soon gets to this point where he is under-
muscled for his weight. This would mean perhaps that
the individual should get his exercise regularly, three
times a week, which would keep him up to normal.
This does not mean that he should be made into the
physique of a professional weight lifter or anything like
that. He should be normal for his weight.
“Indeed, the other matter is the item of flexibility.
As an individual sits a great deal, the fascia surrounding
and interpenetrating his muscles becomes shorter. These
fascia can readily be stretched by certain types of exer-
cise.”
The exercises outlined by Dr. McCloy for the
older age group begin when the patient is in bed.
The purpose of this is as follows:
“One often wishes to exercise in the morning, it is
convenient, he is undressed, and he does not need to go
someplace to exercise later in the day or to exercise at
night when he is tired before going to bed, when it
might also awaken him too much. However, most peo-
ple upon arising in the morning, feel extremely un-
willing to exercise. What has happened is that during
the night the blood has collected in the splanchnic
area, hence there is less blood out in the general cir-
culation. When the individual gets out of bed, gravity
pulls some of this blood out of his brain and he has a
temporary brain anemia, with a feeling of no energy.
“By doing the first few exercises in bed he gets the
blood squeezed out of the splanchnic area into the
general circulation and when he arises to do the other
exercises, he feels fine.
“There is another possibility relative to exercise
which would be particularly applicable to individuals
who have made recovery from coronary occlusion and
things like that. A team of German research workers,
Hettinger and Muehler, have reported something that is
quite remarkable. If an individual puts a tension on
muscle that amounts to as much as two-thirds of the
maximum that the muscle can lift and does this for six
seconds a day, the muscle will increase in strength as
much as five per cent per week up to its maximum.
The theory behind it is that this effect is brought about
by the phenomenon of anoxia brought by this sustained
isometric contraction.
“For example, if you will raise your upper arm for-
ward to a right angle and flex your forearms so that
the two forearms are in line and place a fist within the
other palm, by simply pressing the two hands together
hard for six seconds, at the same time breathing nor-
mally. you keep the glottis open, you can see that you
can put the pectoralis major group on a tension with
very little extra trouble. I have seen exercises of this
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PREVENTIVE GERIATRICS
kind prescribed by a leading cardiologist for an in-
dividual who had a coronary occlusion and was still in
bed from that occlusion. Obviously, the coronary oc-
clusion was not a very severe one. But the cardiologist
checking on the blood pressure and pulse rate of the
patient decided that the exercises were well within his
powers and would be beneficial.”
Dr. McCloy finds that:
A/
“There is no one posture that is suitable for everyone.
As the human race has evolved, different people have
gone farther away from aboriginal ancestors than others.
Numerous people have skeletons, particularly the spine,
the head, the feet and the pelvis, that very much re-
semble the ape. Others, and these constitute the vast
majority, might be termed the average human type. A
few have gone still farther away from the anthropoid
and exhibit what I have called an ultra-human type of
posture. This is hard to determine without an x-ray.
However, the method of achieving a good posture — -
good, functionally — is about the same for all. The bene-
fits of such good posture have been made here by Gold-
thwaite, Brown and others. One of the things that most
of them would need would be that since they have
achieved the poor posture, (as many of them have)
there would need to be a considerable amount of
stretching and things of that kind, to get back to what
might be a good posture.”
From the radio script “The Sitting Man,” the
ideas of Dr. Laurence Morehouse are further
elaborated in the following:
“Many persons can correct their posture appreciably ^
by remembering one of two simple tricks. The first is to
level the pelvis; the second is to raise the breast bone.
Difficulty with the pelvis arises largely from the fact
that we sit down so much. In a sitting position, the
body adapts itself to the situation. The body ligaments
in the front tend to shorten, while those in the back
lengthen to accommodate the greater distance from hip
to knee. The long periods of sitting accentuate this
stretching. When the individual rises, the ligaments
tend to remain long, thus permitting the pelvis to tip
forward. The contents of the abdomen spill forward
against the front wall, producing the business man’s
paunch. This potbellied effect can be seen even on
people who are otherwise not overweight. In fact, some
people who have it try to remove it by reducing when
the only thing wrong with them is their posture.
“If you think of the pelvis as a bowl you can see
^<»w its contents fall forward when it is tipped toward
the front. If you tip the pelvis back to its correct posi-
tion, you balance the contents of the bowl properly, and
they no longer fall forward. The paunch may dis-
appear altogether if you are not overweight. It is actual-
ly possible to take two inches off the waist just by
making this postural correction.
“At first it may be difficult to get the pelvis back
where it belongs. At least it is hard to hold it there
because it puts a strain on other muscles and ligaments
which are involved. One good way to start is to give
special attention to it while you are walking. Every
step helps, and soon it may become a habit. Dr. More-
house suggests that whenever you have a little walking to
do, make a posture walk out of it thus making every
step a corrective exercise.
“The second point to remember in posture is to raise
the chest slightly — elevate the breast bone and allow the
head and shoulders to relax. Bringing the breast bone
up half an inch or so is not especially difficult, and it
results in a comfortable and easy posture. The shoulders
automatically fall into the right position, so they can be
forgotten. The neck can be relaxed so that you won’t
look and feel as stiff as a ramrod.
“These two minor adjustments — the level pelvis and
the raised breast bone- — not only improve the mechanics
of walking and digestion and other bodily processes, but
they immediately give the appearance of a more vital
and vigorous person. People who have participated in
these reconditioning programs have stated that standing
erect in this way has really helped them to change their
outlook on life and become more positive and optimistic.
“The sedentary person may have become so flabby in
muscle strength that opening a jar is something of a
feat and opening a difficult window may require a
major effort. Perhaps if he has to hurry upstairs, he
sees spots before his eyes. If he has to climb to the top
of a football stadium, he has to stop a couple times on
the way up to rest. Such difficulties are indications
that muscles are not accustomed to being used very
rouoh and then even the reactions of the blood vessels
have grown rusty from disuse. This does not refer, of
course, to the symptoms of people with heart disease, but
to those who are otherwise healthy but who have lost
their stamina because they never make any demands
upon it.
“When muscles are not used, they tend to waste away.
As the individual notices a decrease in strength, he may
respond by protecting himself even more and taking it
even easier than before. He uses his body less and less
and becomes more and more sedentary. Before long he
reaches the point where he doesn’t like any kind of
physical effort, such as that involved in bowling or
dancing or playing golf or even walking.
“The first thing the sedentary person can do is just
to decide to be more active. A good way to begin is to
start walking more. Instead of driving the car to the
nearby grocery or drug store, take a walk — not just a
stroll, but a reasonably brisk walk — remembering to hold
the pelvis level and the breast bone up. This will not
only begin to increase the general muscle tone, but will
help blood circulation and other processes of the body.
“After a few weeks, add some further physical activity
— bowling, dancing, golfing, or any of the lighter kinds
of pleasant exercise. Any activity of this kind helps to
reverse the process of deterioration. If you don’t care
for sports, or if it isn’t convenient to engage in them,
it is possible to keep in good condition by a regular
program of calisthenics. For sedentary people these
exercise programs may be as short as ten minutes each.
“Exercise of the neck will frequently prevent the
headaches and burning sensations that is complained of
in this area.
“Another problem of the sedentary worker is that of
l/
v<--'
597
May, 1957
PREVENTIVE GERIATRICS
relaxation. You might suppose that anyone sitting down
is relaxing, but that is often far from the truth. The
sedentary man may be feeling very tense. He may have
walked no more than fifty feet during the day and yet
find himself unable to relax and go to sleep when he
climbs into bed. One technique for releasing this ten-
sion is simple but often very effective. As you are lying
in bed, tense every muscle in the body and then let go
as much as possible. Allow the tension to be released
slowly, preferably by a count. When you have released
as much as possible continue to count slowly a half a
dozen times more, each time trying to relax even more
completely.
“Some people are tense because they are breathing \/
unnaturally. In natural breathing, the abdomeriTnoves
out as the breath is taken in. Some people develop a
habit of chest breathing in which the abdomen moves
in as they inhale. Sometimes this results in consider-
able tension and vague discomfort. Correction of his
breathing habits sometimes gives tremendous relief.
“Week-end sports can be dangerous unless they are
followed rather faithfully from week to week. If you
are used to playing thirty-six holes of golf every week-
end, you will stay in fair condition from Saturday to
Saturday. But if you haven’t played golf for several
months it isn’t a good idea to try for seventy-two holes
on your first week-end on the course. This same thing
applies to skiing and other active sports.
“Finally, here is word to the housewives. Housework
is exercise, all right, but it isn’t enough to keep your
body trim. Even the best football player can’t keep in
condition just by playing the game. He has to exercise
between games and he performs other conditioning exer-
cises. The housewife should have some kind of outside
exercise which is a little more interesting than scrubbing
the floor or vacuuming the rug. Otherwise she becomes
fatigued, not only from the housework but from bore-
dom.”
Taking just a little different slant on this exer-
cise problem, Dr. Janet A. Wessel of Michigan
State University said:
“I do not believe that special exercise prescriptions is
the answer. I would rather see individual’s activities for
the day analyzed to see what can be done to improve
his movement patterns through his daily activities. I
believe that through such analysis we can make the in-
dividual aware of his movements, of how they influence
his physical and mental condition. I would use special
exercises only when one s movement patterns are limited
through trauma, through disease or illness — mental or
physical which 'incapacitates the individual to such an
extent that he needs special consideration.
“I believe that every patient treated in hospital or
doctor’s office over a period of time should be shown
simple postural exercises for sitting, standing and walk-
ing. If the nurse is taught the need for keeping the
patient in good postural alignment, why shouldn’t the
patient know what it is all about? These simple exer-
cises for balancing the body in different activities can be
taught by nurse and/or physical therapist. Whenever
feasible instruction in balance body positions can be part
of the total treatment of the patient. And, the patient
should be educated to the value of exercise and physical
activity upon the recovery process and the prevention of
deconditioning phenomena. If he understands the value
of physical movement upon his recovery, maybe he will
begin to realize its importance for maintenance of
optimal physical condition in everyday life.
“I believe that movement . . . not just prescribed
exercise ... is what is important to life. No one exer-
cise done at specific times in a specific place is the an-
swer. But the examination and analysis of one’s total
life activities through a typical day and week should be
made ... it may be that changing a simple movement
pattern . . . kind, amount, and the way it is done . . .
may be sufficient to maintain one’s physical potential.
Maybe by walking a little more than usual, by develop-
ing a hobby that demands physical activity appropriate
for the physical level of the individual is the answer.
Only when one’s work and play cannot maintain the
physical potential of the individual would I suggest the
‘flat on the back approach to physical fitness’ . . . pre-
scribed EXERCISE.”
In order to elaborate more fully on Dr. Mc-
Cloy’s reference to the work of Hettinger and
Muehler, we asked Dr. H. Montoye to summarize
their article which appeared in Arbeitsphysiologie
15:111-116 (1953), entitled, “Muskelleistung und
Muskeltraining”. The summary follows:
“Seventy-one separate experiments performed on nine
male subjects over a period of eighteen months pro-
vided data on how the development of strength in a
muscle was related to the intensity and frequency of
training activities. All training was in the form of static
contraction held for a measured length of time against
a spring scale, and most of the observations were made
on the flexors and extensors of the forearm held
horizontally at right angles to the upper arm. On Sat-
urdays maximal strength was measured. The higher
reading of two trials was recorded. Sunday was a day
of rest. Mondays through Fridays were spent in train-
ing sessions in which the intensity of contraction, the
amount of time held, and the number of practices per
day were varied. The study revealed the following
findings :
1 . Muscle strength increases an average of 5 per
cent per week when the training load is as little
as one-third, or even less, of maximal strength.
2. Muscle strength increases more rapidly with in-
creasing intensity of training load up to about
two-thirds of maximal strength. Beyond this, in-
crease in training load has no further effect.
3. One practice period per day in which the tension
was held for six seconds resulted in as much in-
crease in strength as longer periods (up to full
exhaustion in 45 seconds) and more frequent
practices (up to seven per day).
598
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PREVENTIVE GERIATRICS
4. The cause of the increase in strength (training
stimulus) they believe is neither the intensity of
contraction nor the degree of exhaustion of a
muscle fiber, but rather a condition in which the
oxygen supply to a muscle fiber ceases to be
enough for its needs. A further oxygen deficit
is not a stronger or more effective stimulus. This,
they postulate, is an “all or none” characteristic
of the “training stimulus” or stimulus to hyper-
trophy. The observation that strength grows
more rapidly as the training load increases from
about one-third to two-thirds maximal strength is
to them only an apparent contradiction. They be-
lieve that due to the internal arrangement of
fibers within a muscle not all fibers are equally
taxed, so that not until the training load is about
two-thirds maximum are all fibers suffering some
oxygen deficit.
5. From measurements of biceps diameters in max-
imal contraction they calculate a maximal con-
traction strength of 6.6 kg/cm., (about 95 pounds
per square inch) of muscle cross section. They
found that the calculated muscle cross section
increased in accord with this factor as strength
increased. Thus, they conclude that the effec-
tive training stimulus extends from somewhere
below 2 kgs. to somewhere under 4 kgs. per
square cm. of cross section.
6. They found a correlation of +.77 + 0.09 between
(a) maximal increase in strength due to training
and (b) the speed of this improvement, when
twenty different muscle groups were compared.
Finger muscles increased maximally 33 per cent
and showed an increase of 3.2 per cent per week.
For hip flexors the corresponding figures were (a)
177 per cent and (b) 22.1 per cent.
7. When tension per square cm. of cross section is
held constant, endurance (holding time) is un-
changed with increase in total strength. This is
attributed to improvement in capillarization
paralleling hypertrophy.
8. The rate of increase in strength sometimes varied
considerably in the same period when two com-
parable training periods, separated by a long
rest period, were compared.
9. There is a ceiling on the development of strength
in every muscle. This is usually accompanied by
pain resulting from some injury within the muscle
that stops further increase in effort.
10. They postulate that the maximal strength of any
muscle in the body is probably about three times
the tension demanded of it in everyday activities.”
Dr. M. S. D. Michael of Santa Barbara College,
University of California, quotes a number of
authorities to indicate that physical activity has a
beneficial effect on the autonomic nervous system
in relation to the rest of the body.
“Richter reports that the wild rat has large adrenals
compared with the domestic rat and that surgical
trauma along with ACTH has little influence upon the
ascorbic acid content, indicating maximum stimulation.
When the adrenals were removed, the wild rat died
more easily than the domestic, as if the active animal
were more dependent on the adrenals.
“Hoagland, in reporting on the 1 7-ketosteroids as a
measure of adrenal response, points out that the higher
skilled and less fatigued men have less adrenal activity.
The production of the 1 7-ketosteroids declines with age
in this study and also with fatigue during the afternoon.
It seems that the more active and less fatigued have
better adrenal functioning.
“Van Liere in 1954 was one of the first to find a
direct relationship between physical training and the
autonomic nervous system. He showed that exercised
rats had increased propulsive motility of the small intes-
tine compared to nonexercised rats. The possible ex-
planation was a dominance of the parasympathetic
system.
“Taylor reports that forced bed rest has been found
to reduce the body to a dangerous state similar to starva-
tion. It is possible, then, that we have a means of
strengthening the adaptive mechanism of the body.
Exercise might well be a pleasant means of increasing
the survival potential in a mechanical, emotional age.
“Persky discusses the difference between physical ac-
tivity and psychologic (emotional) stress in pointing out
that blood eosinophil and glutathione levels are affected
only by psychologic stress. Thus exercise can affect the
adaptive mechanism without itself increasing the re-
action caused by emotions. The advantage of exercise
lies in the fact that it stimulates the defense mechanism,
not that it is similar to other stresses.
“Exercise in itself is a form of stress and can cause
fatigue along with breakdown if not done under con-
trolled conditions. For this reason, the following pre-
cautions should be noted:
1. Exercise should be strenuous enough to stimulate,
but not completely fatigue the body.
2. The exercise should be spaced so that rest periods
follow the activity.
3. The exercise should be regulated to the in-
dividual’s genetic makeup.
4. The exercise should involve the entire body, not
specific areas only; i.e., endurance, strength,
agility and flexibility.
5. The exercise should be altered to prevent bore-
dom and maladjustment.
6. The exercise should be continuous throughout
life, particularly in middle and old age, when
society places greater demands upon the emo-
tions.
Physical activity under these circumstances appears to
serve a two-fold function:
1. During an emotional stress, exercise would tend to
relieve the tensions built up by the body, prepar-
ing for action.
2. Repeated amounts of exercise might elicit the
adaptive mechanism which keeps the internal en-
vironment in balance and thus improves the
ability to adjust stress.”
May, 1957
599
PREVENTIVE GERIATRICS
Dr. Leon W. McCraw of the University of
Texas says:
“In my opinion the value of physical activity in pre-
venting deterioration is conditioned both by the extent
to which an individual has developed prior to maturity '
and by the degree to which he continues vigorous phys-
ical activity during adulthood. This latter is perhaps of
more importance particularly in view of the fact that
very few people continue to engage in physical activity
after reaching maturity. This belief is substantiated
somewhat by the research that suggests that there are
no differences in longevity between so-called athletes and
nonathletes, except where the athletes continue to en-
gage in physical activity.
“To insure the attainment of maximum value from
physical activity we must make rather drastic changes in
our present day programs. First, we must include in the
programs activities that will develop fitness. 1 he sports,
rhythms, and more sedentary games that we have for
the most part today will not do so. Perhaps we must
return to some of the more formalized activities. The
football coach does not rely on playing the game alone
to condition his squad. Second, we must give our
students activities in which they can and will participate
in later life in order to keep fit. By this I am not ad-
vocating such recreational activities as tennis, golf and
bowling. These are good and should receive attention,
but we must realize that we can never hope to provide
sufficient facilities and equipment to insure regular par-
ticipation by even one-fourth of our people in such ac-
tivity. What we need are more activities in which peo-
ple can engage at home and in the immediate neigh-
borhood. Third, we must install in each individual a
desire to maintain good physical condition. This is per-
haps the key to our problem. I know many persons in
my own profession who do not engage regularly in
physical activity, even though they are fully aware of
the value of so doing. They just do not have the desire
to stay fit. How to develop this desire is something that
our profession must solve if physical activity is to have
maximum value, particularly in later life.”
Dr. Ernst Jokl, now of the University of Ken-
tucky, in an article written for the Springer Pub-
lishers of Heidelburg, Germany, entitled, “Alter
und Leistung” (Age and Efficiency), stated:
“The first result of this research is that the lifelong
physical exercise program which the subjects had fol-
lowed: namely, apparatus, gymnastics, plus light games
and some track and field training, not only developed
high standards of physical efficiency, but also maintained
them in middle and old age. The evidence proved that
a well trained gymnast of seventy is likely to be superior
in respect to almost all acquired motor activities to an
untrained man of twenty.
“The gymnasts on whom this study was conducted
comprised an age group which, according to morbidity
and mortality statistics for the general population, would
be expected to be affected more than the younger age
group by degenerative diseases of the cardiovascular
system, by neoplastic growth, and by kidney ailments.
The absence of the disabling sequelae of these condi-
tions among the gymnasts is noteworthy. In addition to
the favorable standards of efficiency and health, there
was in evidence a remarkably high level of physique and
strength.
“These findings raise the following question: Does
the lifelong physical training exert a powerful influence
that inhibits the aging process on a broad physiologic
front, including the decline of physique, the decline of
efficiency, and the decline of health? Jokl answers the
question in the affirmative.
“Data reviewed would indicate that the rapid in-
crease of longevity which is embraced in Europe and
the United States during the past fifty years or so has
been accompanied by a general lengthening of the
period of optimal usefulness of men and women.
“The process of maintaining resources or even of un-
folding new resources of physical strength after age
forty, fifty, sixty or seventy is still going on; i.e., the
period of fitness lengthens continually. Impressive per-
formances are indicated which indicate the validity of
this statement for feats of endurance and skill. Per-
formance records from the German Gymnastic Festival
for the Old in Cologne in 1928 were compared with the
1952 results for identical age groups in Marburg. In
spite of the misery of the war, a categorical improve-
ment in performance has taken place between 1928 and
1952 corresponding to a collective retardation of aging
by an equivalent of six to ten years.
“The following figures indicate the magnitude of the
problem under review for this country. Between 1944
and 1952, medical research and improved medical edu-
cation and rehabilitation have reduced the death from
all causes by 9.4 per cent. Five years have been added
to the average life expectancy. As a result of these and
other advances, the lives of 845,014 Americans have
been saved in the last eight years. They earned an
added $1,488,000 to the national income and excise
tax receipts. A corresponding and even greater ma-
terial advancement can be achieved by prolonging the
fitness of the aging population, enabling them to con-
tinue working and postponing the period of dependence
upon family or public support. Indeed, a new, un-
expected and fascinating task presents itself to the pro-
fession.
“We, therefore, have to continue the battle not only
against illness, but also against premature inroads made
by aging. That judiciously applied physical training can
inhibit aging by many years and that the material wel-
fare of the nation and the happiness of the people can
thus be enhanced is shown by this research publication.”
Dr. Jokl concludes another paper on the psy-
chology of exercise by the following paragraph
which is worthy of quotation :
“Decelerative influence of exercise upon the aging
process would be inexplicable without consideration of
psychologic incentives. Great musicians who continue
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performing in their seventh and eighth decades, like
Toscanini, Bruno Walter and Moritz Rosenthal; the
famous mountaineers who climbed the Tibetan peaks
simply because they were there; the Marburg gymnasts
who preserved their fitness well into the second half of
life; they all were inspired by mental concepts, by
human attachments, by social relationships and, at
times, by spiritual convictions. Between the hammer
of dynamic ideas and the anvil of a favorable environ-
ment, exercise forges and maintains their zest for life.”
The thoughts of Leonard A. Larson, Chairman
of the Department of Physical Education, Health
and Recreation at the New York University
School of Education, are summarized very well in
the following quotation :
“I believe that one of the major needs that old peo-
ple have is the absence of physical exercise. So many
have the idea that normal movement during their work-
ing day is sufficient to meet their physical needs. An-
other misconception is that long periods of time are
necessary in order to achieve a state of condition that
will serve a person through the day without reaching
a fatigue point early in the day. After doing some per-
sonal research and experimentation over the last two
years, I am more convinced now than ever that the
‘key’ concept of maintaining good condition is the term
CONSISTENCY, not duration or intensity, although
movements must be intense in order to achieve and
maintain good physical development. I believe that one
of our major problems to solve is one of finding content
of a fifteen minute to one-half-hour-period during the
day for physical activity that will yield an overall con-
ditioning of the body. If the exercises are beyond the
normal requirements of the day, and continue every day,
the human body will develop beyond the normal de-
mand of the exercise, due to the accumulative effects of
conditioning. I sincerely believe that, if we could find
some way of encouraging persons to maintain a good
exercise program, one’s vitality and energy could be
maintained for a longer period of time than is now the
case. I am also convinced that the stresses and strains j
that man must go through in a hurried life are highly
related to the physical organism in this state of condi-
tion. I have also been interested in the therapeutic
effects of exercise and am becoming rather convinced of
the high relationship that exists between exercise and
the state of health of an individual.
“It seems to me that your Society would do well to
devote the major part of your work to the problem of
exercise at all ages. For example, there are some that
believe that the Little League activities are dangerous
to young children because of the physical demand. I
do not believe that physical exercise during the youth-
ful period is truly detrimental ; in fact, hard exercise is
desirable. However, we do need the facts and do need
to have some experimental research programs to gain
necessary information.”
The following summary of the discussions on
physical education and exercise represents a col-
laboration on the part of Dr. Janet A. Wessel and
Dr. Frederick C. Swartz:
All opinion sampled testifies to the benefit of physical
education and physical exercise in the preservation of
health in the aging group. Moreover, it is definitely in-
dicated that the so-called physical stigmata of aging
might be postponed a number of years by the institu-
tion of planned physical education and exercise.
As worthy as these ideas may be, the sales resistance
encountered is great when the plan takes fifteen to
thirty minutes out of each day, or even this amount of
time three days out of each week. Education as to the
continual need of physical exercise for good health and
the prevention of disease may reduce this resistance to
a degree. Each teacher, each physical education major,
each coach of the various sports, each dancing or swim-
ming instructor, as well as the members of this auxiliary
department to medicine and the medical doctors, must
by precept and example attempt to further this educa-
tion.
Patterns of exercise beginning in bed and continuing
into the “up” position certainly have much to recom-
mend them, if the patient will just do the exercises.
In an effort to eliminate the “set-aside” time period, y
another concept was suggested. The needed physical
exercise or “movements” would be woven into the pat-
tern of everyday living so that by minor modifications
of routine activity the objectives of the physical exercise
could be accomplished. This program, enforced by an
appeal to grace, beauty, glamor, physical stamina, and
the prevention of pain and physical tension, might be
more productive than our previous efforts have been.
These patterns of exercise incorporated within the
scheme of daily activities set the design for efficient
movement of all parts of the body, so that in sitting,
standing, lying, walking, running, pushing, pulling, lift-
ing, or carrying, a maximum of work is accomplished
by a minimum of expenditure of effort.
Logically, it follows that if physical exercise possesses
the potential of improving health and prolonging the life
of the average man, might it not do a better job by
studying in addition, our usual methods of locomotion,
sitting and resting to the end that these might be done
with better mechanical advantage and therefore less
expenditure of energy?
This study indicates rather definitely that many of
the so-called stigmata of aging are the result of poor
care of the machine God gave us. This is really not,
therefore, a problem of aging, but one of youth, and it
is at this level or younger that the effort and emphasis
must be laid.
Dr. Janet A. Wessel’s words seem to fit here
particularly well:
“Regardless of where your work takes place — the
home, factory, office, classroom, athletic field, or draw-
ing room,
“Regardless of whether your play takes place on the
dance floor, bridge table, on water, land or in the air,
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“Regardless of how or what form of rest you have
spacing your activities — -
“You are shaping or reshaping yourself every single
second of your life. Your shape and the running order
of your body are being molded on a twenty-four shift —
not during ten minutes a day of specific exercise, or
in a weekend of sports and dances, nor even in outdoor
gardening activities or in daily housework, BUT IN
ALL THESE ACTIVITIES AND MANY MORE.”
In the section of nutrition of the article on
“Preventive Geriatrics” in The Journal of the
Michigan State Medical Society of May, 1954,
Dr. Arthur H. Smith says:
“One cardinal fact stands out; namely, that the
aged malnourished patient is reaping the harvest of
his yesteryears. The results of poor nutrition are more
often than not insidious in their operation, and so by
time old age has arrived there may have been established
functional and even structural lesions which are the
consequence of poor dietary habits begun years ago.”
Dr. Edward F. Crippen, a member of the Com-
mittee, adds here:
“I suppose there will be a day, we shall diet all our
life. I wonder if it is worth it when we know that it
doesn’t make much difference in a head-on collision
whether we had French-fried or boiled potatoes for
supper, but in case we make it to age sixty-five, I
think the old adage as applied to appearance is similar;
i.e., ‘what we look like up to age fifty depends upon
what our parents looked like, but after fifty depends
upon what we did before fifty.’ A major problem in
the nutrition of the aged has been introduced by the
cryptic remark, ‘many oldsters would eat properly if
they would eat.’ ”
Dr. Charles Sellers, also a member of the Com-
mittee says:
“A high percentage of aged persons presents some
primary nutritional disturbance that is so insidious in
its development as to go unnoticed for a long time.
Generally, it revolves around a high carbohydrate and
low protein and vitamin intake. It results in a lessen-
ing of physical strength and, hence, activity, loss of
ability to concentrate, and some behavioral problems.
“Both overnutrition and undernutrition occur in the
aged and come about through long established, faulty
dietary habits. These habits become rigid and diffi-
cult to overcome, because the psychologic pattern and
sociologic implications are deeply rooted. An approach
to optimum weight from either inanition or obesity with
a well balanced diet containing adequate, but not ex-
cessive carbohydrate, protein and vitamin content, would
be a step toward better health in the aged.”
Dr. Hazen A. Price then broadened the discus-
sion by saying:
“Whenever the nutritional status of people past fifty
years of age is being discussed, it should be pointed
out that it has yet to be proved that the nutritional
requirements for optimum health are much different in
the older person than in the other age group. It
should also be remembered that there is a great varia-
tion among older people in their apparent need for the
usual basic elements. Some have adapted themselves
over the years to an intake of the various essentials
consistently below the optimum level, either through
ignorance, for economic reasons, or simply because of
the lessened demand through relative inactivity and yet
they seem to remain in a reasonably good state of health.
“In general, it can be said that as life becomes more
sedentary, decreasing thereby the rate of body metab-
olism, the total caloric need is appreciably lessened.
With this decrease in energy requirement, the demand
for carbohydrate and fat in the diet is thereby much
less. Protein breakdown is also decreased, but to a
lesser degree, for it has been shown that a larger per-
centage of protein is required in the older person to
maintain a positive nitrogen balance than in the younger
individual. Some investigators have shown that a state
of nutritional health can be maintained on as little
as 43 grams of protein daily, while others, who are in
the majority, feel that 65 to 80 grams are necessary.
“When the total caloric intake is too low, the protein
storehouse in the body may be seriously depleted in a
effort to make up the deficit. It is essential, therefore,
that the total number of calories be sufficiently large to
protect against this breakdown and this is best done
by carbohydrate and only a minimum amount of fat
for palatability.
“Fatty foods, particularly the fried variety, are not
well handled by the older person’s gastrointestinal tract
often times creating digestive disturbances with second-
ary ill effects. Then, those persons with a familial dis-
turbance of lipoid metabolism tend to develop coronary
sclerosis, in particular, much more often than other
persons. The role of dietary fat in the production of
arteriosclerosis stands out as a significant factor, and
the evidence of this is becoming more and more sub-
stantiated.
“Mineral requirements in the aged are likewise sub-
stantially the same as in the young adult. Frequently,
the optimum amounts of the diet are not maintained
because of the general low intake of milk and vegetables
by the older person. The need for calcium should re-
quire no emphasis, when osteoporosis is so common later
in life. Iron is seldom a major deficiency, provided there
is no blood loss, for the iron storehouses are usually
adequate to supply all the marrow needs.
“Vitamin deficiencies are not nearly so common as
one might suppose and the need again is no greater
than for the younger adult. Because of the tendency
to assume carbohydrate more than other foods, a lack
of the ‘B’ factors is most often observed. Wilder has
shown that when vitamin B is lacking to a significant
degree in the diet, patients become more forgetful, irrita-
ble, apathetic, confused and depressed. He found, too,
that mental changes, mainly apathy and those of per-
sonality, resulted from prolonged protein deficiency.
Brozek, in extensive control studies at the University
of Minnesota, showed that B complex deficiencies gen-
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(Continued from Page 602)
erated general weakness, incoordination and neuromus-
cular deterioration. He also found that prolonged
dietary deficiencies are apt to affect man’s willingness
and capacity for work. Changes in personality make-
up were sufficiently altered so that motivation, a crucial
factor in all achievement, is readily affected.
“As in all types of medical practice, prevention of
illness is usually easier than correction of the condi-
tion after it is fully developed. So, in nutritional dis-
orders, the establishment of proper eating habits in the
young adult will prevent most often the serious conse-
quences of long continued undernutrition. Overweight
plays a large part in the disabilities of older people and
is a serious drawback in programs of rehabilitation.
Patterns of eating which have been practiced for decades
are not easily broken, and when attempts to change
them are made, frustration may follow. In a recent
study it was shown that with proper diet, great im-
provement occurred in attitudes, physical tolerance, be-
havior and cerebral acuity. All of this resulted in a
far greater self-sufficiency in practically all of those
studied, except, of course, those with irreversible psy-
chiatric or insurmountable social problems.”
Dr. C. Howard Ross, Committee member, says:
“The state of nutrition in the aged varies from very
excellent to very wretched. The wretched state seems
to enter when lonesomeness and worthlessness are ex-
perienced. It has been shown that old people, living
alone, may easily drift into a 25 per cent deficient diet,
without being particularly aware of the departure. One
of the greatest problems of the family physician is to
impress upon the newly-created widow or widower that
there are nutritional factors to be faced. It is his re-
sponsibility to outline one or more physical programs,
and nominate the diet regimen which would match the
activities suggested.”
The status of fact in the problem of nutrition
is further emphasized by Dr. Lawrence Rarick
from the University of Wisconsin when he states:
“Increase in body fat is a characteristic of aging.
While the age-associated increase in fat may be as-
sociated with a decrease in hormonal output, the ac-
cumulation of fat is usually accompanied by a decline
ip the energy output. For example, Brozek at the
University of Minnesota compared a group of physically
active males with a group of physically inactive males
drawn from a large population of healthy, middle-aged
business and professional men, and found that, although
the weights of the two groups did not differ materially,
the estimated content of fat in the inactive group was
substantially higher than in the active group. In many
primitive cultures, where the demand for survival re-
quires much in the way of physical activity, the prob-
lem of obesity is not so evident. Studies on the physical
characteristics of the Yami Tribe living in a small island
south of Formosa, isolated from the influence of mode
in civilization, have shown that after twenty-five years
of age increases in weight are negligible.
“From the data now available, it appears that the
accumulation of body fat is more marked during the
third and fourth decades of life. It has also been shown
to be the period when the human normally assumes a
life of relative physical inactivity. Furthermore, the
process of aging brings on a notable change in the
chemical composition of body fat. The soft fat of
youth tends to be replaced by a higher proportion of
‘hard" fat, with its higher proportion of saturated fatty
acids which Keyes and others believe to be a prominent
factor in bringing on the cardiac involvements of aging.
Repeated observations on animals given an ample exer-
cise throughout the life span have shown that the exer-
cised animals possess relatively more muscle tissue and
less body fat than do unexercised animals.
“The studies at Harvard University show that the
problem of obesity begins early in life and is not so
much a matter of excessive food intake as of under
activity. The observations disclosed that the dietary
habits of the overweight children were not materially
different from the normal children, but the overweight
children were extraordinarily inactive. This pattern of
physical inactivity tends to persist and cannot be ig-
nored as a possible factor in contributing early fat
accumulation with concomitant symptoms of aging. As
Mayer has pointed out, ‘the combination of physical
sluggishness, a high fat diet, and high caloric diet,
and the highest cigarette consumption in the world,
may well be the deadly combination which prevents
half of thirty-five-year-old Americans from reaching
‘three score and ten.’ ”
Dr. R. E. Austin, Committee member, writes:
“It would seem that any discussion of the maintenance
of an adequate physical machine to insure comfort and
longevity in our aging population must of necessity
consider adequate nutritional intake, both in the for-
mative years and in those of the so-called declining
years. The intake of adequate quantities of essential
foods must depend on the general interest of the
individual in his environment and his being in pleasant
surroundings with sufficient activity to stimulate an
appetite.
“During childhood and most of our adult years, the
problem of being able to ingest a balanced diet to
assure good, protein, vegetable, and vitamin intake
does not present much difficulty; but, as our teeth
become carious and absent, our ability to masticate meat,
vegetables with fiber and vitamin content, and a variety
of solid food decreases. This must result in decreased
protein intake so necessary for normal anabolic pro-
cesses in the body, and decreased opportunities for
gainful employment which make an individual feel es-
sential to society, further inhibit his desire and ability
to ingest adequate quantities of food.
“What may we do that will prevent or delay the
onset of nutritional deficiencies in our aging popula-
tion? First, of course, comes maintaining busy hands
and minds for our senior citizens, and making them
feel useful and needed in society. Second, a pro-
gram beginning in childhood and continuing throughout
the remainder of our lives in preventing dental caries
May, 1957
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PREVENTIVE GERIATRICS
and availing ourselves of good dental care (fluoride,
adequate dental consultations, et cetera). Third, sup-
plementation of diets of the older age groups with
sufficient quanities of vitamins to insure adequate in-
take despite changes in eating habits. Fourth, inclusion
in our diet of goodly amounts of proteins in the form
of meat or meat substitutes especially designed for the
increasing proportion of our elder citizens.”
Dr. E. W. McHenry, Professor of Nutrition,
University of Toronto, writes:
“My impression of nutritional conditions among older
people in this area is that, generally, conditions are not
good. They are particularly bad for older people liv-
ing alone. They are better in the case of institutionalized
persons. Senile persons in institutions have been studied
and they can be divided into two groups: those who eat
sparingly and the gluttons. The latter group overeat,
especially bread. I think it is worth while to ensure
that older people are nourished adequately. An im-
provement in health is difficult to prove. At least, it
is possible to prevent digestive upsets with properly
planned meals.
“The main factors influencing the nutritional state
of older persons are :
1. The adherence to long standing food habits and
even the return to the habits and the foods of
childhood.
2. Economic circumstances, particularly with people
living alone.
3. Poorly fitting dentures, or the lack of use of den-
tures.
4. In the case of older persons living alone, the lack
of cooking facilities and the absence of incentive to
prepare and eat meals.
“Various types of corrected measures can be used:
1. The provision of one hot meal a day in a center
to which older people can come for the meal and
companionship.
2. Good meal planning and good cooking in institu-
tions for the elderly.
3. Educational efforts supplied by physicians and
nurses. The best time to ensure adequate nutrition
for elderly people is in childrood, when food habits
are being formed.
“There has been a suggestion that an adequate intake
of nicotinic acid will prevent the onset of senility.
There is no evidence that the administration of the
vitamin will ameliorate senility. This question needs
further study.
“In my opinion, the mental attitude expressed ensures
good nutrition; namely, willingness to try new foods
(or experiences) and the absence of rigidity in outlook
also helps to delay senility. An interest in new things
is highly beneficial both in nutrition and generally.”
Dr. L. B. Pett, Chief, Nutritions Division, De-
partment of National Health and Welfare of
Canada, contributes the following:
“It is frequently stated that many of the aches and
pains, weaknesses, and difficulties associated with grow-
ing old could be avoided by better nutrition. Specific
advice on how to do this is still difficult, since most
of the evidence is inferred rather than established. A
few things may be said :
1. A balanced diet throughout life appears to do
more good than any kind of diet or dietary sup-
plement begun in later years; so start early.
2. Nothing in excess. This aphorism of the Greek
philosopher, Solon, needs to be followed throughout
life. It applies to individual food constituents, such
as fats or vitamins, as well as the foods them-
selves. It is a nutritional signpost on the road to
health, but it needs to be balanced by an idea
that was not stated by the Greeks; namely, keep
up in your older years a little of everything that
you have found to suit you.
3. Eating a variety of foods is certainly the “keynote”
of good nutrition. Continuing to eat a variety of
foods requires conscious effort in old age, when
loss of teeth, economic stress, loss of appetite, gastric
upsets, illnesses and various diseases, work to pro-
duce poor eating habits and ultimate malnutrition.
4. Keeping up physical activity, perhaps of a different
kind, but still enough to flex muscles and improve
the circulation, is just as important as the diet in
avoiding some aspects of senescence. It will help
muscle tone and stimulate appetite and interest
in life, just as eating a variety of foods and keep-
ing up some physical activities becomes increasingly
difficult and requires continuous thought and effort.
5. Since the amount of food must be balanced against
the amount of activity, and since illness and laziness
tend to reduce the amount of activity in old age,
it follows that the foods eaten must provide more
and more essential nutrients and less and less
volume and with fewer calories. To do this, the
empty calories represented by sugar or fat must
be decreased.
6. Some protein of good quality should be eaten at
every meal. The best and cheapest of such protein
comes in milk, cheese or eggs and meats like liver.
7. If the above advice is being followed, weight con-
trol will be achieved at all ages, food habits will
avoid excesses, mental activity and outlook can
be maintained at a suitable level and nutrition will
be making a real contribution toward prevention
or postponement of the diseases associated with the
aging group.”
Dr. Icie G. Macy, Consultant, Merrill Palmer
School, opined that “optimal geriatric nutrition”
was “today’s challenge,” and in support of this
idea offered the following:
“The ultimate goal of the science of nutrition is to
establish a standard of dietary intake that will provide
for the highest obtainable level of health and well-
being for every human being regardless of age, race,
religion, political belief, or economic or social condition.
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Optimal nutrition and an adequate diet are recognized
as the prime factors in the propagation of individuals
with the maximum potential for physical development
and maintenance of physical and mental health through-
out life.
“Our concepts of the composition and role of foods
have changed with the rapid development of medicine
and the science of nutrition. Recent times have been
rich in discoveries which have led to the evaluation of
different foods on the basis of their chemical and bio-
logic properties. In addition to the ‘proximate prin-
ciples’— proteins, fats, carbohydrates, and minerals —
today more than fifty nutrients obtained from food-
stuffs are known to be present in the body and to be
necessary for life and health in varying quantities rang-
ing from macro to micro amounts. A recent publication
quantitates milk — Nature’s most nearly perfect food —
in terms of more than 250 different constituents! We
have reason to believe that other common foods will
be found to contain a similar abundance of individual
nutrients when they have been studied more completely.
Physicians and scientific investigators in many fields re-
spect more than ever before the role of dietary relation-
ships and imbalances among the essential nutrients in
the diet in relation to health.
“The demonstrated importance of nutrition to the
health of population groups everywhere placed modern
evaluations of food on a cost per nutrient basis. Al-
though we still lack complete knowledge of the composi-
tion of common foods in use in the countries of the
world, the United Nations' economic policies with re-
gard to food supply are now being formulated not so
much in terms of dollars and cents as in terms of the
physiologic needs of man. World food supplies and
nutritional ‘targets’ now are considered in terms of a
balanced diet, with food, agriculture, and nutrition
as basic factors in international relations.
“Optimal health and optimal nutrition encompass
broad and more positive attributes, such as stamina,
efficiency, reserve, and capacity. Indeed, the World
Health Organization, with its primary object the highest
possible level of health for all people, has stated in its
constitution, “health is a state of complete physical,
mental, and social well-being, and not merely absence
of disease or infirmity.” Advances in medicine and
science, including nutrition, aided by a better flow of
scientific information to the public, have already con-
tributed to a longer span of life. Therefore, today’s
challenge is to make these later years abundant ones
and to enable aged men and women to enjoy the
fruits of their labors and at the same time maintain
their independence, dignity, and a useful role in society.
“Research has demonstrated the chemical as well as
the physical individuality of people at all ages; hence
a new branch of science has come into being — chemical
anthropology. Studies of life processes also have re-
vealed the dynamic nature of the body. These studies
show that nutrition is truly food in action and is the
chemistry of life, as Professor Lafayette B. Mendel so
aptly proposed more than three decades ago. Much
research remains to be done, however, on the aging
processes and their effect on the utilization of the diet
and metabolism, and on the dietary requirements of
older people.
“As we grow older, we accumulate the results of acci-
dents, infections, malnutrition, and other untoward
conditions, and these scars of living may be carried
over from one epoch of life to succeeding ones and
thereby warp or dwarf the later years. Although these
scars acquired in the adventure of life may not be
obvious and disabling in themselves, they can weaken
the structures and functions of the body to the extent
that, when acute illness, accident, or shock occurs, pro-
longed disability and chronic illness may result. Every
individual has a characteristic capacity to utilize and
store chemical elements from ingested foodstuffs, a ca-
pacity determined by heredity, eating and elimination
habits, and physical and mental states. A diet for an
old person should therefore be based on a knowledge
of his dietary history as well as other factors pertinent
to establishing optimal geriatric nutrition. As Hippo-
crates (460-370 B.G.) recognized long ago, ‘a slender
and restricted diet is always dangerous in chronic dis-
ease and in acute disease where it is not requisite.
And again, a diet brought to the extreme is always
dangerous.’
“In the aged, long standing and persistent bad food
habits are not easily changed, especially in those of
low economic status and in the disinterested groups.
Chronic misfeeding, which may date from birth, fre-
quently results in the body’s becoming ‘conditioned’ to
a poor diet. The results are evidenced by poor nutri-
tional status. There is no doubt that poor nutrition
over extended periods of childhood produces an adult
of inferior physique, less stamina, and the prospect of
premature aging. Food must nourish the body under
all types of conditions and circumstances.
“It is frequently assumed that the dietary patterns
of old people, especially those living alone, are molded
primarily by such factors as economics and the condi-
tion of the teeth. Evidence accumulated from several
recent surveys, in this country and in England, of cus-
tomary food habits of persons of sixty-five years or
older, shows that these two factors are not necessarily
the most important. These subjects were not restricted
in their choice of food; 67 per cent were moderately
active, with the remainder sedentary.
“The results show that more than half of the indi-
viduals did not consume enough yellow and leafy vege-
tables to provide the vitamin intake recommended by
the Dietary Allowances of the Food and Nutrition
Board of the National Research Council. Similarly,
citrus fruits and other foods high in ascorbic acid were
inadequate in 40 per cent of the diets. Forty-three
per cent showed an intake of less than one pint of
milk or its equivalent in cheese per day. There is good
evidence that poor vision in the dark and eye strain in
bright light may have some relation to the diet of
the aged. Low consumption of milk and of vitamins
A, C, and D can contribute to poor calcification and
fragility of bones, and to slower healing of bones and
delayed recuperation of nerves after shock, injury, or
other traumatic experience. A person who has little
physical reserve or stamina, owing to cumulative scars
May, 1957
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PREVENTIVE GERIATRICS
from injury or disease and depletions during life, needs
an individualized diet prescribed by a physician who
knows the patient’s dietary history and nutritive status,
as well as the presence of any disease.
“In the surveys of old people, medical and social
factors were more frequent than economic reasons for
changes in eating habits with advancing age. Laxatives
were taken routinely by 55 per cent, varying from
three times a month to once or more daily. The
laxative habit alone may reduce the body’s ability to
absorb and retain fat-soluble vitamins already in low
supply. The consumption of starches and sweets was
less than what one is frequently led to expect. For
men and women the average caloric intake decreased
with age, probably as a result of a tapering-off of
activity. With deterioration of health there was a
reduction in consumption of meat products and green
vegetables.
“An adequate intake of a balanced diet is thus the
first requisite for obtaining optimal geriatric nutrition.
The body requires the proper proportion of foods that
contain proteins of high quality and minerals for the
upkeep of the body tissues and bones; foods that supply
adequate amounts of each of the vitamins so essential
for regulating and supplementing proteins and minerals
in metabolism of all the tissues of the body; and food
that supplies energy. Inasmuch as investigations of diet-
ary habits of elderly people show a voluntary tendency
to reduce their consumption of the first two classes
of foods (proteins, minerals and vitamins) that are
most essential for body preservation and restoration, it
is important to place greater emphasis on the inclusion
in the diet of more generous portions of milk, meat,
green and leafy vegetables, and citrus fruits or other
vitamin C-containing foods. Caloric intake must be
made adequate for individuals with depressed appetites,
and restricted for those who tend to become obese.
“Our knowledge of the physiologic processes of aging
is incomplete. Life histories are difficult to obtain with a
reasonable degree of certainty and accuracy. And
our knowledge of essential nutrients in common use, and
the extent to which the concentrations are influenced
by modern practices in agriculture, food preservation,
and service, is limited. These are only a few of the
areas of inadequate information that prevent efficient
and effective application of the knowledge we already
possess. No effort should be spared in learning how
to care for our ever-increasing numbers of older people
so that they may continue to play an active and bene-
ficial role in society and not become an added burden
to younger generations.”
The impression of C. G. King. Executive Direc-
tor of the Nutrition Foundation, Inc. of New
York, is as follows;
“Persons in the older age group show most of the
dietary flaws characteristic of our general public, but
in greater degree. Many are overweight, especially in
view of their age, usually show a lesser development
of muscularity and lessened scheduled physical activity.
There is undoubtedly some undernutrition occasioned
in part by low economic levels, a general debility, less
incentive to prepare and enjoy their meals, and often
a degree of despondency or loneliness occasioned by
their social environment. Malnutrition in the severe
form is only an occasional problem, but there is a rea-
sonable amount of nutritional anemia, constipation, and
mild scurvy caused by low intake of fresh and carefully
prepared fruits and vegetables. There is considerable
doubt whether the incidence of osteoporosis presents a
true malnutrition that might be related to low intake
of calcium, protein, Vitamin ‘D’ or other specific nu-
trients and poor dental conditions.
“I believe the primary need for improving the nutri-
tive conditions for older members of the public could
be met by more careful education of the administrative
officers in charge of institutions for the aged and also
a program to reach individual homes in which older
people reside. I do not think that the basic problem
is often economic, although undoubtedly that aspect of
the problem is sometimes serious.
“Convenience and socially favorable living conditions
are important both psychologically and for the good
morale that is important in meeting most of their prob-
lems, including nutrition. Most institutions, whether
for the aged, or otherwise, develop a horrible degree
of lethargy in the preparation and serving of foods.
Of course, this situation prevails in other respects as
well, but I think it may be worse in respect to food
practices than in other areas of responsibility.
“Prevention of premature aging processes can be
importantly effected by good nutrition practices begin-
ning with gestation in infancy. For example, dental
deficiencies apparently are established chiefly in the
very early years, and it appears that the development
of atherosclerosis, liver disease, diabetes, (possibly can-
cer) and other metabolic conditions that afflict old
age severely, may be influenced by poor nutrition prac-
tices in early years.
“There is little doubt that maintenance of ideal body
weight, prevention of dental cavities, and an early
adoption of good nutrition practices would markedly
defer the aging process. With respect to specific nutri-
tion practices, it appears that a consistent intake of
good quality protein foods, such as meat, fish, eggs
and milk, fruits and vegetables, whole or enriched
cereals, and a sufficient caloric intake to maintain the
body weight near the ideal would represent type of
nutrition practice that would afford substantial pro-
tection.
“An educational program beginning with the pre-
school and school years could do much to offset the
present nutritional malpractices that are prevalent.
There is a good prospect that work recently initiated
at Teachers College, Columbia University, and at
Harvard School of Public Health can result in a major
improvement in giving school children and their par-
ents at least a basic understanding of important relation-
ships between food practices and the development of
a healthy physique on the part of the individual. A
further great gain could result in improved education
of the medical and allied health organizations. The
Council of Nutrition of the AMA is increasing its
606
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PREVENTIVE GERIATRICS
interest in this regard and the similar encouraging de-
velopments are underway at the American Dental As-
sociation and the American Public Health Association.”
Dr. Jean Mayer of the Harvard University
School of Public Health has three rules recom-
mended to retard senescence.
1. Eat a varied diet to avoid any chance of nu-
tritional deficiency.
2. Do not eat too much of it so as to maintain the
same weight that you had at the age of twenty-five,
and
3. Continue to exercise regularly no matter how busy
a schedule you have.
From the Department of Physiological Chem-
istry, University of California, Dr. Wendell H.
Griffith says:
“Physical and mental deterioration in senescence might
be postponed or prevented in part by a plan of life,
deliberate or arranged that maintains social contacts,
physical activity and responsibility for the accomplish-
ment of a job of some sort. Preoccupation with ill
health must be avoided at all costs. Specifically, adults
(everyone in fact) should learn the advantage of the
proper eating regimen that keeps one nutritionally fit
and reasonably free from the common ailments of the
alimentary tract.”
On the subject of dietary regimens, Dr. C. H.
McCloy of the State University of Iowa, ex-
pressed himself as follows:
“The average individual knows something about an
adequate diet, but it is often presented in too compli-
cated a way. I believe that this subject should be so
presented that the average layman would know what
to do. As I have stated, many people build up large
cholesterol values with no warning whatsoever. For
example, a man who had apparently been in perfect
health found, at the age of sixty-eight, that he had a
blood cholesterol value of 365 milligrams; this is ex-
tremely high. He was not obese and, in fact, kept his
weight at the normal level all of his life; yet, shortly
after this finding, with no other suspicious signs, he
had a coronary occlusion. Had he known several years
before that he had this amount of cholesterol in the
blood, he could have reduced it markedly by diet. In fact,
this man has reduced it 36 milligrams within one month,
and is still continuing to do so. It would seem to me
that it would be well worth while to indicate that,
if the cholesterol is unduly high, a nonfat diet or
some other diet would be desirable. I realize that this
is a controversial matter, but it would at least seem to
be worth a try; the studies by Keyes would indicate
that this may be a life-saving matter.
“It seems not to be known to most physicians that
some of the nonsaturated vegetable oils, such as corn
oil or soy bean oil added to the diet in appropriate
amounts will greatly aid in reducing serum cholesterol.
This has been brought to my attention within the last
month at the National Institute of Health in Bethesda,
Maryland. Since then I have found a number of car-
diologists who did not know this.
“Along lines of dietary regimens I should like to
suggest that perhaps the American Medical Association
should produce a relatively small and specific manual
on nutrition which might be used by the average phy-
sician as a ‘Nutrition Formulary.’ I have been increas-
ingly impressed as the years have gone on with the
numerous statements in the popular and medical lit-
erature (statements written by physicians) urging the
patient to ‘see his family physician’ when undertaking
any diet, whether for reducing or for some other
purpose. However, nutrition is one of the areas in
which a large majority of physicians have shown a
complete lack of training. I do not think we can
expect most of these people to read a 700-page book
on nutrition, but many would read the germane parts
of a nutrition formulary when giving advice on diets
to their patients. In view of the fact that knowledge
in this field is being rather rapidly extended, I think
that such a formulary should be revised every two
or three years along the lines of geriatric practice,
with the emphasis upon the low fat and high protein
diet.”
Summary
In the line of a summary and with re-emphasis
on certain points already mentioned, Dr. Fred-
erick Swartz, a member of the Committee, had
the following to offer:
“What the physical man is or is to be depends on
what he eats. How foodstuffs are ingested, digested,
absorbed, transported and assimilated for purposes of
growth, repair, storage and energy formation is known
as nutrition. An adequate diet is one that provides
carbohydrates, fats, proteins, vitamins, minerals and
water in adequate amounts and proportions to fulfill the
aims of good nutrition. In good nutrition the car-
bohydrates, fats, and proteins yield energy and provide
growth. They also maintain the tissues subject to wear
and tear, so that the body is kept at ideal weight and
the energy reservoir is adequate for the usual demands.
The vitamins, minerals and water are an essential part
of the chemical mechanism for the utilization of energy
and for the synthesis of various necessary metabolites,
such as hormones and enzymes. The minerals, in ad-
dition to being an integral part of the structure of the
body, play an important part in the acid-weight bal-
ance. As long as life lasts, the preservation of the
physical body in as good a state as possible is one
of the major challenges of the aging. This is the job
of good nutrition and the reason nutrition is one of
the important problems of aging.
“The material for consideration pays tribute to the
classroom and the research laboratory. The real text-
book, however, has been and will continue to be the
members of the aging group and the judgments offered
will be those of the gerontologists, not the nutritionists.
The problem of the nutrition of the aging will be
May, 1957
607
PREVENTIVE GERIATRICS
considered in the setting in which it exists. The heredi-
tary background, the lifelong habits, the work, the home
and the community environment are all facets of the
nutrition problem.
“What do we know about the state of nutrition of
our aging population? What is the size of the under-
nourished group? The malnourished? The ovemour-
ished? Are the groups large enough or important
enough to warrant our attention? If they are, and
we find the solution, will not a larger problem evolve
— that of improving the standards that we now con-
sider good? In any case, the problem of nutrition in
the aging occupies a vital place today and will do
so as long as man has a physical body and an interest
in longevity.
“Brewer and associates studied the hemoglobin, as-
corbic acid, vitamin A, and carotene of the blood of
a group of residents at two county institutions in the
state of Michigan. They report, ‘no mean age differ-
ences were apparent until after the age of ninety, at
which time mean hemoglobin, vitamin A and, to a
lesser extent, carotene values were lower. It was of
interest that there are persons of all ages who appear
able to maintain normal blood concentrations of these
chemicals.’
“Yiengst and Shock found in a study of 126 men,
aged forty to ninety, that the serum vitamin A and
mean carotene levels show no demonstrable age change.
Serum protein concentrations in one Michigan institution
gave a mean value of 7.07 grams per hundred milliliter
for men, and 7.13 grams for women. These values fall
within the normal accepted range.
“Gillum, Morgan, Williams, Kirk and Chieffi indi-
cate that blood concentrations of ascorbic acid, vitamin
A, and carotene are similar for both young and old,
and depend on the consumption of similar quantities of
food supplying these nutrients. About 70 per cent
of the Michigan group did not meet the standards of
ascorbic acid nutrition, and about 25 per cent had less
than 30 micrograms per hundred milliliters of vitamin
A in the plasma, but as pointed out by Brewer and
associates, less than 10 per cent of the residents
studied could be considered to be in poor nutritional
state, with respect to both vitamin A and ascorbic acid.
“The physiologic processes upon which life depends
do not deteriorate with age. This was demonstrated by
Shock in the resting state in his study of the regulation
of the acid base equilibrium, fasting arterial blood sugar,
absorption of vitamin A, eosinophil response to ACTH,
and the patient’s ability to retain nitrogen. In a major
way, these functions are supported by good nutrition.
“Balance studies done by Bogdonoff, Shock and
Nichols indicate that the degree of negativity or posi-
tivity of the calcium balance on the low and high
calcium diets is of the same order in the young and
in the old. Calcium equilibrium can be maintained
in the aged on 850 milligrams of calcium daily. As a
by-product of this work, data are presented to show
that the aged male retains the ability to store nitrogen,
phosphorus and potassium and thereby build protoplasm.
“In any discussion of the nutritional state of the
aged, some thought must be given to the undernour-
608
ished, the malnourished and the overnourished. These
terms override one another and the difference only be-
comes apparent when treatment is instituted. The under-
nourished include those oldsters who are not getting
the required amount of carbohydrate, fats, proteins,
minerals, vitamins and water in the optimum proportion
to maintain the body at ideal weight and function.
This situation is best represented by the victim of star-
vation, caused by one reason or another. The treat-
ment corrects this state by the removal of the cause,
if possible, and by the provision of adequate amounts
of the six essential food groups listed above.
“The malnourished could really include all variations
from the normal standard, more specifically, however,
the food fadists, the misinformed and the dietary tyrant
come into this group. Getting these people to change
lifelong habits is more difficult than getting the under-
nourished to increase his diet. These dietary ideas are
almost as sacred as religious opinions. The malnourished,
as defined above, taxes the ingenuity of the nutritionist,
contributes to the morbidity rate, and probably suc-
cumbs somewhat earlier than the normal because of the
absence of some of the necessary elements of diet.
“In the field of the overweight, the data are more
definite. Authorities agree that obesity increases the
hazards of most of the diseases common to man, and
there are certain diseases, such as cancer, found more
frequently among the obese. Dr. Edward Bortz of the
New Lankenau Hospital says: ‘In our experience, can-
cer occurs three times as often in persons who are 25
per cent overweight as in persons who are normal or
slightly underweight when the first sign of the tumor
has been identified.’
“Overnutrition is largely typified by the overweight
and obese group. Twenty-eight per cent of the United
States population is overweight. There are many good
reasons to show that obesity is not just due to the simple
problems of excessive caloric intake as compared with
output. Future research may reveal some mechanism
of nutritional utilization which may be a factor in
obesity. Work is being done on variations in fat con-
tent of overweight people which may sharpen the focus
on the problems of obesity and its effect on longevity.
The solution of the problem of obesity and its effect on
longevity in the aged, like the solution of the problem
of obesity in the young, depends on the reduction of the
caloric intake and/or an elevation of the caloric output.
This requires a wise selection of a low caloric diet with
adequate vitamin supplements.
“Undernutrition, malnutrition, and overnutrition must
be considered as chronic diseases as we find them in the
older population. Most of these situations will have
existed for many years. It is likely that the graver nu-
tritional effects are not detected in the older group, as
they have probably paid the price of their indiscretions
before they could be included in the aged. There is not
much evidence to indicate whether malnutrition, as de-
fined above, influences longevity, statistically, one way
or another. In the absence of fatal disease, undernutri-
tional states in the aged usually respond well to an
adequate diet.
“In general, these variations from good nutrition,
JMSMS
PREVENTIVE GERIATRICS
either questionably in undernutrition or very definitely
in overnutrition, shorten man’s life span. It therefore
follows that good nutrition, in the light of the present
day knowledge, and subject to such modifications as will
be brought about by advancing our knowledge in the
future, should contribute immeasurably to increase the
longevity.
“What ideally constitutes an excellent nutrition can
be mapped out readily enough, but success in this
science often depends upon factors quite remote from
the utilization of food. From birth to the grave, the
marriage of food to man is beset with more qualifying
and environmental forces than most any human relation-
ship. The following is a partial list of the factors that
influence the nutrition of man as he goes through life:
1. Infant feeding, whether breast or bottle.
2. Too little, too much, or too monotonous food
habits in early childhood.
3. Clean plate clubs.
4. Food fads of the individual race or nation.
5. Diversified methods of preparing food.
6. Luscious pictures of food in current magazines.
7. Unending interest of the obese in anybody’s re-
duction diet.
8. The capriciousness of appetite.
9. The willingness to buy anybody’s vitamins.
10. Faulty mineral intake.
11. The social implications of mealtime.
1 2. Overeating associated with anxiety.
13. Overeating associated with gluttony.
14. Overweight and its consequences.
15. The effect of responsibilities at home and position
on food intake and digestion.
16. Limitations or excesses afforded by budgets.
17. Vacant chairs around the dinner table.
18. The status of the endoctrine system.
19. The presence or absence of chronic illness.
20. The effects of bed rest.
21. Happy, satisfactory employment.
22. Motivation for living.
“Those factors that tend to impair or enhance good
nutrition are, by and large, beyond the field of training
of the nutritionist. The nutritionist or physician who
wishes to accomplish the end of good nutrition will have
to broaden his field of activity. The other alternative, to
attack these problems as an interdisciplinary one, would
include all of the fields of human endeavor.
“In general, this survey of the nutritional problems of
the aged can be distilled down to one concept. The
nutritional problems of the aging are merely the nutri-
tional problems of man. The nutritional status of the
aged person, as observed in practice, is the result of all
of the factors influencing nutrition that have been ap-
plicable during his lifetime.
“The nutritional derelicts found among the aged
should be treated in the light of modern dietetics inso-
far as possible, irrespective of age. It is a common ex-
perience among physicians that the barrier of dietary
habits and tyrannical ideas about food are almost im-
possible to overcome. Here is a field where most can be
accomplished by those who can effect the wisest and
simplest compromise. We usually have to settle for less
than an ideal arrangement, because more strenuous ef-
forts at treatment cause the patient to break off his
relationship with the physician, thus destroying any
chance for improvement.
“The attention drawn to nutrition by discussion of
the problems of aging brings to light anew and with
emphasis, the fact that more attention must be paid to
nutrition in the formative years, by a better under-
standing of all the facts which influence nutrition. By
the employment of all the involved disciplines in a
great team effort, we should be able to change the food
habits of the growing young and bring to advanced
years a man who will be more rugged physically with
each advancing generation.”
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A. H. Price, M.D., Chairman
F. C. Swartz, M.D., Vice Chairman
F. W. Baske, M.D.
H. B. Bennett, M.D.
T. H. Bottomley, Jr., M.D.
J. R. Brink, M.D.
W. P. Chester, M.D.
GERIATRICS COMMITTEE
E. F. Crippen, M.D.
R. E. Dustin, M.D.
G. S. Fisher, M.D.
P. C. Gittins, M.D.
W. D. Harrelson, M.D.
E. J. Kulinski, M.D.
W. M. LeFevre, M.D.
Jack Rom, M.D.
Herbert Rosenbaum, M.D.
C. H. Ross, M.D.
L. F. Segar, M.D.
C. W. Sellers, M.D.
S. C. Wiersma, M.D.
H. W. Woughter, M.D.
PANEL MEMBERS
Arthur H. Steinhaus. Professor of Physiology, George
Williams College, Drexel at 53rd Street, Chicago 15,
Illinois.
Leonard Larson, New York University, Washington
Square, New York 3, New York.
C. H. McCloy, University of Iowa, Iowa City, Iowa.
Lynn W. McCraw, University of Texas, Austin, Texas.
Ernest D. Michael, Santa Barbara College, Santa Bar-
bara, California.
Henry J. Montoye, Michigan State University, East
Lansing, Michigan.
Dr. A. Bidon, Lyon. France.
G. Lawrence Rarick, University of Wisconsin, Madison
6, Wisconsin.
Dr. Ernst Jokl, Medical College, University of Kentucky,
Lexington, Kentucky.
Arthur H. Smith, Department of Biochemistry, Wayne
University College of Medicine, 1512 St. Antoine
Street, Detroit 26, Michigan.
Janet Wessel, College of Physical Education, Michigan
State University, East Lansing, Michigan.
Walter S. McClellan. Lecturer in Physiology. School of
Medicine, 406 Whitehead Circle, Chapel Hill, North
Carolina.
Wedell H. Griffith, Department of Physiological Chemis-
try, University of California Medical Center, Los An-
geles 24, California.
C. Etta Walters, Department of Physical Education for
Women, Florida State University, Tallahassee, Florida.
C. G. King, Nutrition Foundation, Inc., Chrysler Build-
ing, New York 17, New York.
J. Mayer, Nutrition Department, School of Public
Health, Harvard University, 695 Huntington Avenue,
Boston, Massachusetts.
E. W. McHenry, University of Toronto, Toronto, On-
tario, Canada.
L. B. Pett, National Health & Welfare Department,
Chief of Nutrition Division, Ottawa, Canada.
Margaret A. Ohlson, Department of Nutrition, State
University of Iowa, University Hospital, Iowa City,
Iowa.
Icie G. Macy, Consultant, Merrill Palmer School, De-
troit, Michigan.
Laurence Morehouse, University of California. 405 Hil-
gard Avenue, Los Angeles 24, California.
Howard A. Rusk, New York University-Bellevue Med-
ical Center, Institute of Physical Medicine and Re-
habilitation, 400 E. 34th Street, New York 16, New
York.
Michael M. Dacso, New York University-Bellevue Med-
ical Center, Institute of Physical Medicine and Re-
habilitation 400 E. 34th Street, New York 16, New
York.
610
JMSMS
The Changing Scene
Fredrick F. Yonkman, M.D.
Summit, New Jersey
HP HE Changing Scene has touched many areas
of our national life but none more so, it would
seem, than our professional activities as they relate
to our allied professions and all other areas of
American enterprise. To some of these changing
scenes I should like to direct attention.
During the last thirty or forty years medical
research has come of size, it has grown to true
stature, it is big business as a result of imagina-
tive, challenging and loyal co-operative team play.
As this is being dictated on the plastic ribbon I
am gazing at a small black and white, framed
picture of my little one-room laboratory at Boston
University. In it I see a small kymograph, a
tissue bath, a desk lamp to warm the fluid in the
bath, and a few bottles of reagents and solutions
of drugs on the shelf nearby. Below, I see a
bucket to catch the washings. Gazing at this
picture brings back hallowed memories, for in
this same little room it was my privilege as
student counselor to confer with medical students
and staff members alike. As I gaze now toward
the other wall I see a large framed document
with the gold typed title, “American Pharmaceu-
tical Manufacturers’ Association — Code of Ethics,”
and scintillating as after images I see now through
closed eyes the many wonderfully equipped re-
search laboratories of our industry, in our coun-
try and the world over, along with all those other
excellently equipped and utilized research labora-
tories in our medical schools and hospitals and
research institutes. The scene has changed for
all of us in terms of the simple, smoked kymo-
graph and its equivalent, to the electrocardiograph,
electroencephalograph, spectrograph, spectroscope,
infrared spectrophotometer, Geiger counter, cyclo-
tron and their respective equivalents according to
one’s special field of interest and research en-
deavors. Research is big business. Medical re-
search is big business and has achieved this
stature because of very intimate and loyal co-
operative team play. And during this changing
of the scene, you and I in our respective fields of
Presented at Michigan Clinical Institute, Detroit,
March, 1956.
May, 1957
interest have been most privileged to have taken
a small active part therein.
In this connection I read with real pleasure in
my weekly anticipated copy of the Detroit Medical
News, the editorial by Dr. F. P. Rhoades entitled
“Partners in Research.” I quote him directly:
“The highly trained technical personnel for research
comes from many fields; the chemist, the physicist,
the bio-chemist, (and may I also humbly include the
pharmacologist), the physiologist, the bacteriologist, the
pharmacist, the veterinarian, and the clinician. Each
is obligated to make his contribution before a new
therapeutic agent can be released for general use.
“This team work must, of necessity, include the
practicing physician. He plays an important part be he
internist, surgeon, pediatrician, obstetrician, or generalist.
His careful clinical evaluation of the new agent dis-
closes any untoward effects. These should be reported
in writing. Clinical trials also discover additional and
unsuspected uses for the new agent. It should be
obvious that the product of the original research should
be used to the exclusion of substitutes which, rest as-
sured, will spring up as soon as the value of the new
agent becomes apparent.
“While the majority of practicing physicians cannot
find the time to conduct carefully controlled clinical
tests, they can contribute to research by making new
funds available through prescribing the products of re-
search. They should not yield to the temptation to
use ‘something just as good’ in the mistaken belief that
they are doing their patients a service.
“The research houses” says Dr. Rhoades, “are con-
stantly striving to bring forth ever-increasingly effective
therapeutic agents for the alleviation of the multitudi-
nous ills of mankind. We, the practicing physicians,
owe them all the support within our power. Let us
be part of the research team through the use of new-
found therapeutic agents which bear the authoritative
stamp of ethical investigators of the research pharmaceu-
tical firms.”
How could one have said it better?
The scene has changed in reference to medical
publicity or medical writing as evidenced by this
occasion when you are honoring members of
the press, members of the radio and television
media of distribution. This is as it should be.
An educated citizen is the strength of our country.
Many of you will recall the first and foremost
of popular medical writers, a citizen of our state
611
THE CHANGING SCENE— YONKMAN
and an honorary member of our Michigan State
Medical Society and of my local Ottawa County
Society, a man whom I am most pleased to con-
sider as one of my best friends, Paul DeKruif.
You will recall his Microbe Hunters, which to me
is still his best work and which I know was one
of the main influences in directing many a soul
into scientific and medical research and practice.
What a joy it must be for Dr. DeKruif to reread
on occasion his hundreds of letters telling him
just that, “Because of your Microbe Hunters I
am a physician today.” Paul was a pioneer and
a lonely one at that, even well beyond the ap-
pearance of his Aden Against Death, which I be-
lieve to be his second best. If only these two
works were his sole contributions to this im-
portant field of medical writing, his prodigious
efforts to the present moment notwithstanding,
they would suffice to endow him appropriately
with the title, “The Forerunner” or “The Pioneer”
in this very important field. In our American
system of free enterprise we need you medical
writers as a “good press,” as you need us to
press you.
Medical writing in scientific journals has ex-
perienced a changing scene but, unfortunately
and all too frequently, from a pleasant readable
style to that of most straight-laced, corseted and
confined routine telegraphic format. Would that
our editors would permit even a smattering or
smithering of the English style. Frankly, my first
choices of medical reading are the British journals.
In their writings the author’s personality is not
always subdued, his style is revealing and per-
sonalized. thus captivating the reader's attention
while he pleasantly encounters a solid pearl or
two.
In this very important educational medium,
we need a change of scenery, back to the delight-
ful, personalized style, certainly for those authors
who really have something to say.
The changing scene has affected medical educa-
tion. The old Materia-Medica has sublimed into
more specific therapy. The old course in pa-
thology has become functional. The diseased pa-
tient is now considered as one with aberrant or
disturbed physiologic mechanisms. He has been
altered biochemically. Anatomy is now being
taught as a functional discipline with pathologic
and surgical implications. The enthusiastic con-
scientious internist now frequently returns (or
even retreats!) to the laboratory to search further
into those fundamental concepts to which he was
originally exposed during his early years of medical
training but which at that time did not appear
to be of sufficient importance to demand whole-
hearted attention ; only now do these concepts
and principles become of great significance in
reference to a specific medical or surgical problem.
New facts added to old facts pile up to moun-
tains of information which at times seem to be
insurmountable, but if facts, important as they
are, could be minimized and more fancy be per-
mitted, that is, cogitation, imagination and good
old solid thinking which obviously implies that
adequate time must be allotted for it, would our
future physicians be even better equipped to
handle diagnostic problems as they present them-
selves in general practice? Several medical facul-
ties have initiated and others are now exploring
the so-called vertical system of education rather
than the horizontal approach, that is, an organ
such as the kidney for example is studied succes-
sively from the point of view of anatomy, physiol-
ogy, pathology and therapy; in other words, in
logical sequence from a structural, functional,
pathologic and treatment point of view, following
which another organ or system such as the lung
or respiratory system is sequentially studied in a
similar manner. This is being done in a laudable
attempt to have one see the forest as well as the
trees. These educational experiments will indeed
be interesting to examine during the next several
years.
The scene has shifted in terms of the medical
apprenticeship; whereas formerly the country doc-
tor was the devoted medical faculty in the old
horse-drawn buggy between calls, his place has
been very properly assigned chiefly to full time
teachers who make a career of their various
specialties. But is there still room for some sort
of modified apprenticeship? How much does the
average medical graduate know about setting up
medical housekeeping from a business or economic
point of view? What does he know about the
very many unanticipated duties and responsibili-
ties associated with general practice, be they social,
economic, religious or otherwise in nature? Could
even one month reasonably be spared from, or
added to, the present medical curriculum to
permit the future graduate to live in, or work with,
some busy practitioner in a sort of father-son rela-
tionship if for no other reason than to pick up
a few pearls of wisdom he never could learn in
612
JMSMS
THE CHANGING SCENE— YONKMAN
the classroom, the laboratory, or the hospital bed-
side? Should some form of apprenticeship return
to the medical scene? In our present position
of being so closely scrutinized by the general
public, would that very important personal ele-
ment change the current and all too often unde-
sirable connotation of the M.D. to that of the
true physician with all that this term implies?
The scene has shifted and will shift more
emphatically no doubt in the closely allied pro-
fession of pharmacy. Years ago the professional
pharmacist was heavily occupied with the com-
pounding of complex prescriptions, certain in-
gredients of which might have had some definite
beneficial effects, others of which perhaps had
little if any therapeutic value. Today the average
drug store, (please note that I did not say the
average pharmacy), is so cluttered up with beach-
balls, chewing gum, hair tonics and garden hoses
in many instances, that one is almost defied to
find the most important unit in the store, the
prescription counter. Why must one wade through
a maze of nonprofessional five-and-dime type of
material to obtain a prescription? The alert
pharmacist will soon place his prescription counter
in full view either from the sidewalk or im-
mediately upon entrance to his store. This is
his lifeblood as it is also that of his customer.
Why not make it the most important unit in his
shop in order to justify the name of pharmacy?
Many pharmacists will tell you that in order to
break even or to make a small profit they must car-
ry all these extra gadgets and appliances, but this is
highly doubted. Statistics definitely support that
pharmacist who has sworn off selling lawn mowers,
soup strainers, beachballs and straw hats in favor
of ethical pharmaceutical prescription items and
the trend today is definitely in the latter direc-
tion.* This scene is changing favorably. At several
recent meetings of our Board of Trustees of the
Columbia University College of Pharmacy, this
has been a topic of major interest. It is reasonable
to anticipate, I believe, on the basis of these and
other discussions, that the future pharmacist may
be trained along new lines, and this is where we
as physicians might definitely enhance this picture.
We have confidence in our better trained phar-
macist and we should encourage and support
the most professional atmosphere and curricular
disciplines possible in this closely allied important
profession.
In this respect the professional pharmacists have
been duly recognized en masse by the physicians
in this area in the form of an auxilliary group
known as The Pharmaceutical Associates of the
Wayne County Medical Society. This pioneering
effort undoubtedly will be duplicated across the
country during the next decade or two. This is
truly a favorable change in scenes.
We have come to the last act, in fact we are
changing to almost the last scene, that of the
newer media for distribution of medical informa-
tion, namely, radio and television. Last year you
honored the latter medium, namely television, by
inviting Mr. Leland I. Doan, President of the
Dow Chemical Company, to discuss with you the
topic : “And Then Came Medic.” Most of us have
seen “Medic” on one occasion or another and
no doubt with mixed feelings of genuine pleasure,
surprise, or great or mild satisfaction; seldom if
ever have I heard frank condemnation, but such
has been reported. The same no doubt can be
said of “Medical Horizons,” which has been spon-
sored for the last year and a half by the pharma-
ceutical company which I represent. Believe me,
when I say that such services as rendered by
Smith, Kline and French in their program, “The
March of Medicine,” by Dow Chemical Com-
pany’s having supported “Medic,” by Ciba’s spon-
soring “Medical Horizons,” and by the several
other companies which sponsor closed circuit tele-
vision geared primarily to the physicians assembled
in various auditoriums across the country, have
come into being only after a great deal of soul-
searching and deliberation. Each group, I am sure,
has this main theme in mind: we will do this
because it will be of more value than harm to
the greater number of people viewing our presen-
tation. In our own case, and I am sure it is
true of others, we say “The primary purpose of
‘Medical Horizons’ is to promote better under-
standing of the doctor as an individual and as a
member of the complex team (including allied
professions and industry) that protects the na-
tion's health.”
Mr. T. F. Davies Haines, our president, ampli-
fied this in last Monday night’s final telecast in
this current series as follows:
“It's teamwork that makes medical progress, many
heads, many hands working together. The physician,
the surgeon, your family doctor, has with him, the
*“The General Report of the Pharmaceutical Survey
1946-49” conducted by the American Council on Educa-
tion (page 93).
May, 1957
613
THE CHANGING SCENE— YONKMAN
pathologist, the radiologist, the laboratory technician.
Together, these men of science form what we might
call a medical army whose dedicated efforts are con-
quering diseases one after another.
“Ciba hopes that, through ‘Medical Horizons’ you
have gained even greater confidence in your doctor.
For today, armed with new techniques, new medical
knowledge, new drugs, your doctor can cure diseases
considered fatal just twenty years ago. And new
medical horizons are opening each day. Progress is
encouraging. The future of medicine looks bright. We
in the pharmaceutical industry are proud to have a
part in this progress being made toward better health.”
There is little doubt in my mind that television
will be utilized more in the future, for the old
physiologic dictum still holds true that “the eye
perceives fourteen times faster than the ear.”
In applying this physiologic principle, obviously
our individual and collective responsibilities are
great in the selection of the appropriate material
to be telecast either for professional, lay or mixed
audiences. It is one thing to alert and inform
a viewing audience but certainly this must be
done with great circumspection. Mr. John Public
wants to know, and if he does not find his answer
in published media, whether they be the daily
newspapers, weekly or monthly periodicals, he
will seek it on the radio or via television. This
happy circumstance offers all of us a great chal-
lenge in terms of mass education of the proper
type. Yes, the scene has shifted to include televi-
sion with the microscope.
And now for our last scene. One of the most
significant changes in scenery is associated with
recent developments in the field of mental health.
As you well know, fifty-one out of every one
hundred beds in our hospitals in this country
are occupied by patients with some degree of
mental illness, minor or major in nature. This
situation presents the greatest challenge ever of-
fered to any professional group with all due re-
spect to those fine Nobel prize winning medical
achievements of the past; the latter’s great, re-
spective values come into proper focus, however,
as one honestly visualizes today’s medical Public
Enemy No. 1, namely, mental illness. For what
profiteth it a man if he should gain a whole
and well body but be governed by an ill mind?
On the other hand, in direct contrast — what
marvelous accomplishments man is capable of
when one thinks of Milton (or Helen Keller) for
example — keenly endowed with all mental facul-
ties despite the curse of blindness, an imperfect
body. What is this world coming to when in-
creasing numbers are diagnosed as psychotics or
neurotics of one type or another? How important
it is to attack this problem from many points of
view, sociologic, spiritual and not the least, medi-
cal, and here we have at least some rays of
hope in the clinical reports of the last two years
concerning the new phrenotropic drugs. Let us
hope sincerely that in due course the line of
march to the mental hospital may be slowed down
while the line from that hospital is accelerated.
The challenge is great in the shifting of this
scene!
I sincerely hope that my brief words, despite
the changing scenes which inevitably lie ahead,
may help to solidify and strengthen the profes-
sional bonds that bind us with only one thought
in mind, to maintain and advance still further
the best standards and practice of medicine with
the assistance of the best therapeutic agents de-
veloped in the research laboratories of our great
private, state and industrial institutions, as per-
mitted by the finest system of free enterprise ever
designed, the American Way of Life.
ELEVENTH GENERAL ASSEMBLY, WORLD MEDICAL ASSOCIATION
One of the tangible privileges of membership in
the U. S. Committee of the World Medical Association
is the opportunity to attend its annual assemblies as an
official observer for the Committee. With the forth-
coming 11th General Assembly to be held in Istanbul,
Turkey — the world’s “oldest and newest city” — mem-
bers are confronted with a tempting opportunity to visit
all the world famous centers of medical lore and his-
torical interest between the Atlantic and the Bosporus.
The dates of the Assembly are September 29 to October
5, 1957. The pre-registration fee of $15 includes at-
tendance at the annual dinner and an excursion.
614
JMSMS
Chronic Disease — A Challenge
to the Medical Profession
/^''HRONIC disease has been described as “one
of the last frontiers of medicine.” Since
the power is not given us to see into the future,
I cannot speak for the “last.” Certainly, it is
a most important medical frontier of today —
and will be, for some time to come. The acute
illnesses have given way to chronic illness and
disability as the major health problem of the
nation in this mid-20th century. That the medical
profession of Michigan clearly recognizes this
transition is demonstrated by the prominence of
the subject on the program of your ninety-first
annual meeting.
The questions which we as physicians must
answer are “What more can we do about this
major health problem?” “What are we going to
do?” This is our challenge!
The Problem
First, I think, we must face the problem in its
full magnitude. It is one of staggering propor-
tions. In 1950, an estimated 28 million Ameri-
cans suffered from disabling and nondisabling
chronic disease or impairment. 5.3 million of
these people — almost twice the population of the
metropolitan area of Detroit — required a pro-
longed or continuous period of care : at least
thirty days in a general hospital or more than
three months in another institution or at home.
These are sobering statistics. To the physi-
cians of Michigan this means that well over a
million (1,176,000) persons in your state have
a chronic disease or other impairment, and that
long-term care is required for approximately one-
quarter million. These statistics also point out
the need for emphasizing the preventive as-
pects of chronic disease if we are to reduce — -
or even stabilize — this burden for the future.
It has been estimated that chronic disease re-
sults in one-half to three-fourths of a billion man-
Presented before the Second Assembly of the 91st
Annual Meeting of the Michigan State Medical Society,
Detroit, Michigan, September 26, 1956.
Dr. Anderson is Assistant Surgeon General, United
States Public Health Service.
By Otis L. Anderson, M.D.
Washington, D. C.
days lost from production each year. Chronic
disease accounts for public expeditures of $1.5
billion a year for medical and hospital services,
and for an equal amount each year for payment
of cash benefits. To the individual, the cost of
chronic illness is an even greater catastrophe.
In 1952, some half-million families spent between
50 and 100 per cent of the total family income
on medical care, of which the largest part was
due to chronic disease. Another half-million
iamilies were burdened with medical expenses
exceeding their income.
These figures will continue an upward trend
unless we as physicians accept personal respon-
sibility in pushing back the frontier of chronic
disease.
Relationship of Chronic Disease to Aging
Since more people are living to the ages at
which the chronic diseases occur most frequently,
it is natural to associate chronic illness with the
aging process. However, we must not be misled
into thinking of chronic disease as an exclusive
problem of old age. Over one-half of the chron-
ically ill are under age forty-five; more than
three-fourths of them are between fifteen and
sixty-four. In the ages over ten, more than 60
per cent of the days of disability are due to
chronic disease. This proportion rises with in-
creasing age, of course.
During the past fifty years, we have made
great advances in the reduction of mortality in
the early age groups; but mortality rates among
persons forty-five years of age and over, particu-
larly among males, have been reduced relatively
little. It is in this group that the greatest waste
of human life occurs today . . . waste in years of
life lost through premature death . . . waste in
years of production through premature disability.
Currently, well over 25 per cent of the entire
population has reached or passed forty-five years
of age. As the numbers of our aged population
continue to grow, the impact of the chronic
May, 1957
615
CHRONIC DISEASE— ANDERSON
diseases becomes ever more significant — medical-
ly, economically, and sociologically.
A New Attitude Toward Chronic Disease
The size of the task might prove overwhelming
rather than challenging if it were not now pos-
sible to look upon chronic disease with a spirit
of reasonable optimism. The defeatist attitude
which has prevailed in the past has no place
in modern medicine. Physicians who accept their
chronic disease patients with resignation and lack
of interest, regarding them as nuisances “for whom
nothing can be done anyway” are oriented to
medical practice of several decades ago. There
is continuously being developed new knowledge
which makes it possible to render effective re-
lief— if not to provide a cure — for a host of
chronic conditions.
Homburger2 supports the realism of this posi-
tive, constructive attitude in his striking illustra-
tions of progress made in recent years toward
mitigating the effects of chronic disease. Among
others, he cites such things as new knowledge
concerning the rehabilitation of hemiplegics,
means for alleviating the distress of advanced
cancer, dietary measures for overcoming the poor
nutritional status of many aged and chronically
ill patients, and modern methods of treating
arthritis and osteoporosis.
Unfortunately, many practitioners who en-
counter these problems daily do not apply or
are not in a position to utilize this new scientific
knowledge at the bedside, in the office, or the
clinic. Although some time-lag between scientific
discoveries and their full application is to be
expected, we cannot afford to widen this gap by
medical apathy.
A Sound Approach to the Chronic Disease
Problem
In man’s fight against disease, prevention has
always been his most desired goal. The pro-
gress we have made with respect to acute ill-
nesses is due largely to the tremendous strides
made during the past half century in improved
surgical procedures, medical techniques, and pre-
ventive health practices of both a clinical and
public health nature. The knowledge and ex-
perience we have already acquired holds rich
promise for the reduction of premature disability
and premature death from the chronic diseases.
It is my firm belief that the chronic disease
616
challenge can best be met through prevention —
in its broadest sense. To the extent possible, by
preventing the occurrence of disease; beyond
that, by preventing the progression of disease and
of associated disability.
Positive Action Against Chronic Disease
There have been proposed at least four dis-
tinct lines of preventive action, which I, in turn,
should like to suggest to you:
We can prevent the inception of certain diseases.
We can prevent the progress of certain diseases by
early detection and early therapy.
We can prevent or delay the onset of premature
death or premature disability due to known or exist-
ing disease through timely diagnosis, treatment, and
rehabilitation.
We can join the effort to prevent the destructive
social and economic effects of chronic disease on
the patient, on his family, and on the community.
You will agree, I think, that the practicing
physician has a real responsibility and a golden
opportunity in each area. Reparative medicine
alone is far from adequate.
We now know that through judicious use of
oxygen therapy for premature infants, retrolental
fibroplasia can be prevented and that use of my-
driatics is to be avoided in the eye examinations
of older persons for glaucoma.
The incidence of rheumatic fever can be re-
duced by instituting early and vigorous penicillin
therapy in streptococcic throat infections.
Some neoplasms can be prevented by proper
treatment of precancerous conditions or lesions.
Others can be prevented by making patients more
aware of cancer-inducing agents which might be
modified or removed. For example, they should
know that excessive exposure to sunlight should
be avoided and that industrial exposures to such
substances as tar, pitch, creosote, arsenic, radio-
active substances, soot, et cetera, should be re-
duced insofar as possible in order to prevent skin
cancels. Likewise, that proper control measures
for reduction of air contaminants are significant
in the prevention of lung cancer.
Many home accidents — which frequently in-
volve long-term or permanent disability — could
be reduced, if physicians, among other profession-
al persons, when visiting patients at home ob-
served and called the family’s attention to hazards
there which could lead to accidents.
Early detection and early therapy depend upon
TMSMS
CHRONIC DISEASE— ANDERSON
development of “a high index of suspicion” for
discovery of hidden cases of disease among pre-
sumably well patients. All practicing physicians
perform varying types of diagnostic procedures.
Many are narrow — confined to a given specialty —
and do not provide for the discovery of other
physical and mental deviations. There are over
200,000 practicing physicians in the United States.
Until a majority of them emphasize diagnostic
procedures on a broader base of screening — to
detect abnormal conditions both among patients
who present themselves because of illness and
among those who appear for routine or other
examinations — little real progress will be made
toward prevention and control of chronic disease.
There is available at least one simple blood
sugar screening test for diabetes that can be
performed in any physician’s office in less than
five minutes. Relatives of diabetic patients, over-
weight patients and parents of babies of large
birth weight, in particular, should be checked
periodically for diabetes.
The aspiration method of making a vaginal
smear is quick and simple. It is an invaluable
tool in the early diagnosis of unsuspected cancer.
Kurlander1 2 3 4 5 6 7 8 9 10 11 has listed a number of tests and
procedures which yield a high return in the dis-
covery of unsuspected disease — simple procedures
which can be performed every day in the physi-
cian’s office or by using diagnostic facilities gen-
erally available within the community. If we
care to indulge in the popular pastime of the
season, we might conduct a poll of this audience
to see how many of these tests each of you per-
form routinely in your practice. The Kurlander
list includes:
1. Chest x-ray examinations for tuberculosis, cancer,
and heart disease
2. Annual cervical cytologic examination on all
women twenty years of age and over
3. Breast examinations of all female patients
4. Blood tests for syphilis and diabetes
5. Intraocular pressure examination of all persons
forty-five years of age and over for the detection
of glaucoma
6. Anorectal examinations — particularly on male
patients
7. Urine testing for sugar and albumin
8. EKG tests for men and women forty-five years
of age and over
9. Hearing tests to detect incipient deafness
10. Blood pressure testing
11. Oral examinations to detect dental defects which
would have a deleterious effect on health.
As you see, although there is still much we do
not know about specific etiology of chronic disease
prevention, there is much we do know. Our work
is only partially done — our obligation to society
only partially fulfilled — -if all present knowledge
regarding the detection and diagnosis of disease
is not fully used.
Equally important is the prevention of com-
plications of disease — through modern treatment
and rehabilitation. The physician who practices
surgery must be aware of the postoperative com-
plications that may follow particular surgical pro-
cedures and use every means to prevent them.
The orthopedist and rheumatologist must know
how to prevent deformities; the cardiologist, how
to offset the recurrence of rheumatic fever, and
so on through the many specialized fields.
As a cause of death in diabetics, acute infection
ranks high. Here, the keystone of prevention, of
course, is adequate control of the disease, proper
nutrition, and meticulous cleanliness.
We now know that osteoporosis is a disease to
be expected in the aged and chronically ill.
Through maintenance of a reasonable degree of
physical activity, proper dietary measures, and
androgen or estrogen therapy, control of this
disease can be facilitated. Too often, its existence
is completely ignored or merely accepted as being
inevitable.
In the not-too-distant past, it was generally
thought that a patient with hemiplegia — particu-
larly an aged person — was doomed to spend the
rest of his life-span in bed, perhaps in complete
immobility. Modern methods of management and
rehabilitation have opened the door to restora-
tion of self-sufficiency and sometimes a reasonably
normal family and social life for many hemiplegic
patients. Yet neither the medical profession nor
the lay public seems to be entirely cognizant of
how much disability can be prevented by prompt
and appropriate treatment. Looking to the ulti-
mate plan of placing the patient in his home
environment, full understanding and co-opera-
tion of the family is essential. In varying degree,
depending upon the extent of disability, it is now
possible through several months of intensive re-
habilitation to: (1) Prevent deformities or to
treat them as they occur; (2) retrain the patient
for ambulation and daily activities; (3) develop
substitution skills in the unaffected extremities;
(4) treat and rehabilitate the affected arm and
May, 1957
617
CHRONIC DISEASE— ANDERSON
hand; and (5) treat loss of speech when this is
present.
Even those conditions which at one time
seemed most hopeless are now responding to pa-
tient, intelligent, and imaginative rehabilitation
efforts.
Many Resources Needed for Prevention and
Control of Chronic Disease
In the field of chronic disease, the division be-
tween preventive, curative, and restorative services
is less sharply defined than in the area of the
communicable diseases. The doctor-patient re-
lationship is not as simple as in the treatment
of an acute illness. Indeed, the whole situation
is more complex. Frequently, it is complicated
by serious financial, social, economic and psy-
chologic implications — not only for the patient,
but also for his family, and often for the com-
munity as well. The problems are too numerous
and involved to be handled by the physician
alone.
The significance of this fact — particularly
among the aging — was referred to by the out-
going president of the American Medical Associa-
tion in his address to the House of Delegates in
June, 1956. Dr. Hess1 suggested that a commit-
tee representing the medical profession might be
used as a nucleus to join with other agencies
(both medical and nonmedical) for a complete
socio-economic and medical approach to the prob-
lem.
First, and possibly most important, among
those from whom the physician must have the
highest possible degree of co-operation is the pa-
tient. The physician may prescribe thoroughly
effective drugs, diet, rest, or exercise — but the
patient must cany out the prescribed treatment.
An entire battery of diagnostic tests may be a
routine part of every examination a physician per-
forms, but if the patient visits his physician only
when he is ill, and fails to present himself period-
ically for a general physical examination to de-
termine the status of his health, little benefit will
be drived from these good case-finding techniques.
It is part of the physician’s responsibility to urge
his patients — particularly those in the age groups
most susceptible to chronic illness — to have period-
ic examinations as a means of preventing or
arresting the development of disease and dis-
ability. The attitude of his patients and the ex-
tent of their co-operation depend largely on their
general understanding of the nature of disease,
its probable effects, and the importance of fol-
lowing their physician’s advice. Their behavior
is strongly influenced by the confidence they feel
in their physician — that he will help them find
answers to their health problems, including those
of a related socio-economic nature.
A wide range of talents and competencies is
needed for broad-gauged prevention and case-
finding and for proper long-term care of chroni-
cally ill patients. Many professional skills must be
carefully co-ordinated and welded into a smooth-
ly functioning team for continuity of service to
the patient. A variety of physical facilities and
up-to-date equipment will be needed: hospitals,
nursing and convalescent homes, rehabilitation
centers; x-ray, electrocardiographs, and other spe-
cialized equipment. One could go on. Individu-
al and family financial reserves are frequently in-
adequate to meet the heavy expense of long-term
treatment and care, coupled with the associated
loss of income. For such cases, it will be neces-
sary to seek the aid of voluntary and official
agencies. Major reorientation in the field of
community planning and action is essential to
meet the total needs.
The health department has an important role
in providing assistance in the development of
resources to provide the services needed. It may
supply a number of them directly, such as x-ray,
laboratory tests, home nursing instruction (and
sometimes care), nutritional aid. medical social
service, and physical therapy.
Mutual co-operation among the patient, the
physician, other health professions, the health de-
partment, and voluntary health agencies of the
community is essential if we are to achieve true
prevention and control of chronic disease on a
community-wide basis. Occasional, episodic co-
operation is not enough. Organized community
planning and co-ordination of effort, directed to
complete use of existing resources and the develop-
ment of other necessary services which are lacking,
is a basic requirement of a total health program —
one which will bring to the people all that
modern science has to offer in preventing,
minimizing, and controlling chronic disease. Con-
tinuing support of such a program by the prac-
ticing physician is a challenge to the medical
profession, for the physician holds the key to its
success or failure. Our traditional practice of
(Continued, on Page 639)
618
JMSMS
Chronic Disease — A Challenge
to Public Health
By Otis L. Anderson, M.D.
Washington, D. C.
HPHE PUBLIC health movement in this coun-
try has always responded to challenges. At
the turn of the century, pioneer health workers re-
sponded to the problems of those days — yellow
fever, smallpox, typhoid, and the rest — and proved
that these diseases could be prevented.
Chronic disease today presents us with the same
type of challenge that faced our precursors, who
literally developed the public health profession
through their triumphs over these major health
hazards.
In a nation which, within the past decade, has
recognized chronic illness as the paramount health
problem, one need no longer plead for accept-
ance of chronic disease as a legitimate public
health concern; it remains rather to identify the
manner in which public health workers are al-
ready attacking the problem, and to suggest how
much more can and will be done in the future.
Admittedly, much research is needed to further
the progress of community application of chronic
disease control practices. However, within the
limits of our present knowledge, there is still much
that can be done.
Impact of Current Public Health Programs
on Chronic Disease
Through its present programs, public health
exerts its influence in two ways: (1) on the
individual directly, and (2) on the individual
indirectly, through his environment. Many ac-
tivities serve both ends. Efforts to prevent or
to minimize the effects of chronic illness must be
undertaken at every stage of man’s whole life-
span. Public health is an operation that extends
over the full seventy-year cycle of man’s current
anticipated lifetime.
To start at the beginning, even before birth,
Presented before the Section on Public Health and
Preventive Medicine of the Michigan State Medical
Society at the 91st Annual Meeting, Detroit, Michigan,
September 26, 1956.
Dr. Anderson is Assistant Surgeon General, United
States Public Health Service.
research is now being conducted which would
alter the carbohydrate metabolism of pregnant
women with an elevated blood sugar, and thus
alter the uterine environment of the fetus, with
the aim of preventing diabetes in later life through
preventing early damage to the fetal pancreas.
Next in chronological order would come the
whole field of maternal and child health services.
These services have been strengthened greatly in
recent years, and contribute undeniably to the
prevention of adult disease.
The fluoridation of public water supplies, which
affects the individual from the day of birth,
should help to form future communities where
it will no longer be true, as it is today, that 56
per cent of all people over sixty years of age are
edentulous.
In fact, all phases of protection of the purity
of the water supply, and of the food supply, are
traditional public health methods of contributing
to the safety of the environment, and thus, indi-
rectly, to the health of the individual.
Still dealing with youth, mental health pro-
grams designed for children and young people are
doing much, and can do more in the future, to
prevent mental illness in adults. And mental
illness is one of the major chronic diseases of our
day.
Health education comes to mind at this junc-
ture as a traditional public health procedure which
contributes to the prevention of chronic illness
through the inculcation of good personal health
practices. Each year, as we gain experience, we
recognize more clearly the role that health educa-
tion plays in chronic disease prevention.
Vaccination against poliomyelitis is an example
of a method designed to prevent acute illness and
the crippling effects that individuals would other-
wise carry with them through life. This is also
an excellent example of how, here in America
where team-work is a universal ideal, the public
health profession and private physicians have co-
operated in the interests of the nation’s health.
May, 1957
619
CHRONIC DISEASE— ANDERSON
Public Health Programs on the Horizon
No public health program at the present time
gives more promise of effective primary preven-
tion in the chronic disease field than does rheu-
matic fever prophylaxis. By preventing the occur-
rence, recurrence of rheumatic fever in children,
through penicillin prophylaxis, the incidence of
rheumatic heart disease can be steadily reduced.
Already physicians in private practice and public
health clinics are conducting programs for this
purpose in many parts of the country.
The prevention of disability and death caused
by accidents is a relatively new public health
goal. Now that accidents have come to rank
fourth among the leading causes of death in the
United States (1954) the problem is indeed an
urgent one. The newly-created Accident Preven-
tion Program in the Public Health Service is
one response to this challenge. At the state and
local levels, much effective work is also being done
in this field through studies and programs relating
to home accidents, human factors in highway
accidents, and accidental poisoning.
The attack on community air pollution, which
in the last year has been strengthened through
Federal legislation (P.L. 159 — 84th Congress) and
substantial authorization of state and local funds,
typifies an environmental problem of acknowl-
edged significance to the individual. Research is
now being actively undertaken to explore the pos-
sible relationship between community air pollu-
tion and various types of chronic illness.
As atomic energy develops into a common
source of power for peacetime use, the problems
of radiation protection will increase correspond-
ingly, and public health must keep pace. Already
important research and planning are going for-
ward in this field.
To conclude this selective listing of current and
incipient public health programs that are designed
to meet the challenge of chronic disease, I should
like to mention the work which for so long has
been carried forward in the field of nutrition.
Public health is especially concerned with the re-
lationship between diet and the development of
chronic disease.
A Look to the Future
The challenge of chronic disease is a challenge
to public health because it must be met by our
communities, as well as by individuals. It is at
the community level that an organized attack
against chronic disease must have its beginning.
Implementation must then be carried forward
through community cooperation. Preventive,
curative, and restorative chronic disease programs
are all part of one great unity. Our communities
must learn to mobilize and integrate all their re-
sources— both public and private — to be success-
ful in their efforts.
In frankly facing the problem of chronic dis-
ease, a community, like an individual, can choose
between various alternatives in determining the
pattern to follow.
I should like to suggest four different ways of
viewing this problem:
1. The individual may reject his health problem
and hope it will disappear. Communities may
react in the same way, elect to “stay in a rut”
and do nothing about chronic disease. This is
the easiest way, but, of course, it doesn’t solve
anything.
2. The individual may take the defeatist atti-
tude: accept his health problem in a spirit of
hopelessness. The community may make a similar
choice, deciding that this major health problem
is simply too big a job to be tackled.
3. The individual, anxious and disturbed about
his condition, may turn to self-medication or pur-
veyors of “miracle medicines” for help. This
course can be paralleled at the community level
by seeking a “short-cut” solution, without serious
evaluation of resources and needs, instead of de-
veloping a program which will truly solve the
community’s problem.
4. The individual may accept his health prob-
lem in a mature fashion and react in a positive
manner. It is to be hoped that all communities
will ultimately adopt this alternative, and grapple
with chronic disease in an organized and efficient
manner.
Before we can, as a nation, move forward into
large-scale prevention of chronic disease, com-
munity planning must be oriented to the problem.
Planning, followed by action, must be partici-
pated in by responsible members of the health
professions, health agencies, and individual citi-
zens. The team approach is essential. Health
departments should provide leadership in devel-
oping and mobilizing community resources.
Merely to list the kinds of health services re-
quired illustrates the need for cooperative effort.
The following services must, in one way or an-
other, be made available: detection, diagnosis,
620
JMSMS
CHRONIC DISEASE— ANDERSON
therapy, care for both physical and mental con-
ditions, nursing, restorative services, medical so-
cial services, and health education — public, profes-
sional, and patient.
Not only should these services be made avail-
able, but they must be carefully coordinated for
maximum restoration of health and self-depend-
ence to the chronically ill patient. Medical super-
vision frequently must be continued over long
periods of time — usually without requiring the
constant attendance of the physician. Home care
of the hospitalized patient needs to be planned
while he is still in the hospital; home nursing serv-
ice while the hospital nurse is still on duty. In
many instances, there will be need for a social
worker, a physical therapist, an employment coun-
sellor, or occupational therapist. Diet restrictions
or nutritional problems may require consultation
and instruction for the patient and the home-
maker. It may be necessary to arrange for em-
ployment of a housekeeping aide. Plans for these
and other follow-up measures should be part and
parcel of the plans for medical service.
Health services must be increased many fold,
broadened, and have community-wide support if
persons with disabling and handicapping condi-
tions, their families, the community, and the gen-
eral economy as well, are to be benefited.
Success of the team approach will depend,
primarily, upon acceptance of the concept of
unity, and recognition of the urgency of finding
ways to work together. In a recent talk to the
American College of Chest Physicians, the Sur-
geon General of the Public Health Service*
strongly emphasized this point in a way that seems
to me most appropriate:
“Group planning and action calls, first of all, for
a certain attitude of mind toward the changes that
have occurred and the contribution others can make —
a tolerance of ways and thoughts which are not nec-
essarily ours; an open mind in the free spirit of
science; a ready acceptance of the best from any
and every source; an attitude of rational receptiveness
rather than antagonism to new ideas.-’
The “Team Approach” at Work
How does a community proceed in putting the
“team approach” to work? What are the spe-
cific steps involved in achieving desired “unity of
*Burney, Leroy E.: What Can Public Health Con-
tribute to the Private Practice of Medicine? Louis Mark
Memorial Lecture, delivered to American College of
Chest Physicians. Chicago, Illinois, June 7, 1956.
May, 1957
action?” I should like to propose six fairly dis-
tinct steps — though they will not necessarily be
taken in consecutive order, for there is much in-
terweaving among them.
Defining the Problem — First, the problem must
be defined. The community plan for positive ac-
tion will give priority to meeting those needs
which have wide local recognition and which of-
fer opportunity and promise for improvement
within available resources. This means that one
or several segments of the total chronic disease
problem will be selected for action. The phase
of the problem chosen will be defined as care-
fully and specifically as possible.
Current Status of Problem. — Once defined, it
is important to determine what the community
is presently doing to meet the problem — to sound
out the interest and concern of community lead-
ers, health workers, and those most immediately
concerned, the chronic disease patients themselves
and their families. What health services not now
available are needed? What resources are avail-
able to provide them?
Assessment of Resources. — Concurrently, an-
other planning activity may be going on — the
assessment of resources. Past failure to provide
needed services for the chronically ill or disabled
may have been due to lack of resources. On
the other hand, too limited a view of the com-
munity’s potential ability to meet the needs may
have been the cause. Skilled health workers with
imagination and ingenuity can often uncover
sources of assistance, which have previously been
overlooked.
Defining Objectives. — -In light of these findings,
the program goals will be established. With the
objectives determined, actual procedures to be
taken to reach them can be planned. For ex-
ample, in developing a chronic disease program,
the first step decided on may involve case find-
ing. It has been well established that, in addi-
tion to the many people in a community who are
known to be chronically ill or disabled, there are
others who have the same diseases without being
aware of it. What sort of screening or diagnostic
program could practically be carried out in order
to identify these unknown persons? How can they
be brought under medical supervision? What
additional services can be provided to help them
621
CHRONIC DISEASE— ANDERSON
toward recovery, or to stem the progress of the
disease?
Pla?i of Operation. — Step by step, a plan for
action is worked out — one which is within com-
munity resources, for which interest and support
can be enlisted, and which will move toward the
objectives set.
Evaluation. — Continually, as the program de-
velops, there is a careful review of what is being
accomplished, the methods of operation, the use
of resources — to determine whether other ways
are more promising, or better procedures are
available. The community must be kept informed
of progress, the plan must have the participation
and interest of every individual and organization
that can aid in reaching its objectives.
In this connection, public health can benefit, I
believe, by making more use of the skills of social
scientists. In solving the problems of the con-
tagious diseases and sanitation, the scientific epide-
miological approach has been eminently success-
ful. There is need today to apply this same kind
of thinking in solving the problems of chronic
illness. Here, however, the emphasis must shift
from primary concern with environmental factors
to concern with man himself and the individual
physiological changes which affect the state of his
health. It is necessary to understand how he acts
in matters that concern his health — what moti-
vates him to act as he does. Such information
provides the means for bringing about improve-
ment in his health behavior. His active under-
standing and participation are essential to in-
volving him in the chronic disease program to
the extent that medical diagnostic procedures may
reflect the need for further services. An adequate
scientific approach to solution of the chronic ill-
ness problem requires the use of skills, concepts,
and technicjues of behavioral scientists — psycholo-
gists, anthropologists, and sociologists — who apply
epidemiological methods to the study of man’s be-
havior.
The Health Department as a Member of the
Community Team
As a member of the community team, the pub-
lic health agency is in a position to give leadership
through the initiation of co-operative community
planning as previously described. I have reviewed
some of the current public health activities which
are contributing to the prevention and control
of chronic disease. In developing more compre-
hensive programs, as may be needed, these ac-
tivities would become a part of the planned
community action.
The health department has an important role
in providing guidance and leadership for the de-
velopment of resources to provide the services
needed. It may supply a number of them directly,
such as x-ray, laboratory tests, home nursing in-
struction— and sometimes care, nutritional aid,
medical social service, physical therapy, et cetera.
It can also arrange to obtain some collateral
services from other sources. The ready avail-
ability of these community services is particularly
important to the physician when coping with
chronic illness in the middle and lower income
brackets. Through its broad educational activi-
ties, the health department can also supplement
the efforts of private physicians in promoting ac-
tion which individuals must take to protect and
improve their own health. Health department
nurses through their regular home-visiting pro-
grams can smooth the chronic disease patient’s
difficult transition from the period of intensive
hospital treatment to the phase of long-term home
care.
In a discussion of the changing health picture
in North Carolina,* the state health officer’s con-
cept of the role of the health department was
summed up in this fashion:
“I again express the belief that we (the public health
profession) can work out a program in the control of
health problems in the non-communicable field, that
will be ethical, acceptable and effective, encroaching
upon the prerogatives of none. All public health pro-
grams directed against these problems will have but one
objective, that is, to promote early private medical
care for the patient, and to insure the success of that
care, by providing to every physician, where needed,
the services of trained personnel, in case-finding, fol-
low-up, and rehabilitation.”
It is a sound position, forthrightly expressed, I
think. To it, I would add that in carrying out
those programs which have long been regarded
as more exclusively the health department’s re-
sponsibility, greater attention should be given to
the prevention of conditions which may become
chronic.
( Continued on Page 639)
*Richardson, William H., The Changing Health Pic-
ture in North Carolina. The Health Bulletin of the
North Carolina State Board of Health. Vol. 71, No. 7,
July, 1956.
622
JMSMS
Evidence on Aging
The modern concept regarding the problems usually as-
sociated with the aging process and aged persons has under-
gone considerable revision since large numbers of physicians
have become interested in gerontology and more versatile in
geriatrics. Gerontology is the study of the aging process it-
self and geriatrics is the application of gerontological knowl-
edge to those aging persons who may come under their ob-
servation, management and treatment.
Aging is inevitable. Perhaps this is iterating a very old
observation but it refers to the passage of time which no
one can escape. Many other deterrents to a more desirable
aging process can be escaped so that it approaches the normal
state. With judicious guidance, more persons than ever be-
fore may hope to attain comparatively healthy and vigorous
later years. They may hope to avoid some of the mistakes
made by older persons in other times and some of the pit-
falls along the way to purposeful and healthful mental and
physical later life. To be without a purpose in life is to have
lost one of the most important reasons for living. To be
without health makes all else seem purposeless.
The loss of elasticity which is nearly always a concomitant
of the aging process can be forestalled somewhat by keeping
active; therefore, complete retirement at any age should be
discouraged. The chronological age of sixty-five years at
which so many persons retired either voluntarily or in-
voluntarily is not a good criterion for terminating useful work
of some kind. It has been outmoded by all the evidence at
hand.
The loss of some physical strength should be recognized
and adjustments made in the physical work or activity.
Putting forth more energy to accomplish the things once
done with relative ease is not a rational solution. Work
should be changed to conform to the worker’s strength.
Older housewives or those with heart ailments who should
conserve their energy may have their kitchens rearranged
so as to save themselves noticeable toil, exertion and extra
steps.
The loss of rapid recuperation after exertion is more or
less normal among older persons. They tire more quickly and
the return to normal following activity is somewhat delayed;
therefore, long duty and monotonous work should not be
continuous but should be interrupted by rest periods, holi-
days and vacations.
On the other hand, complete idleness is not a desirable
manner in which to promote good health among the aging,
and those who choose to do nothing soon become decrepit.
President, Michigan State Medical Society
President J
e
May, 1957
623
Editorial
GERIATRIC MEDICINE
Geriatric medicine occupies each year a great-
er part of the physician’s time. As more people
live to be sixty to ninety years of age, the greater
is the incidence of those illnesses most common
to our later years. More time than ever before
must be given to the clinical problems of aging
individuals, and the doctor must prepare himself
for this change in his practice.
During the past few years, we have read in
these pages, as well as in almost every other medi-
cal journal, articles having to do with the treat-
ment of illnesses in the older person. Except for
the pediatrician and obstetrician, all specialties
must be concerned. The general practitioner,
however, will continue to see more people at this
age than any other group of physicians and it
is for them in particular that state medical jour-
nals should provide authoritative as well as prac-
tical articles for their reading.
Your Geriatric Committee has felt that any-
thing we could do preventive-wise would be of
infinitely more value than treatment after illness
had already developed. Three years ago, a whole
issue of The Journal MSMS was devoted to
a discussion of a wide variety of subjects having to
do with preventive geriatrics. It was presented in
the form of a panel discussion in which a large
number of individuals took part. It served as an
introduction to the issues which were planned
for the future.
This year, Dr. Fred Swartz, our vice chairman,
has again accumulated a great deal of material on
nutrition and exercise as it affects health later in
life. It is our belief that if health can be main-
tained, at an optimum level, through the appli-
cation of good preventive measures, the develop-
ment of many of the illnesses of the older person
could be prevented.
In a subsequent issue, it is planned to present
another discussion with particular emphasis; this
time, upon the psychosomatic, emotional and psy-
chiatric factors affecting the lives of older people.
We believe with Anton J. Carlson, there is rea-
son to hope that with continuing study and bet-
ter application of what knowledge does exist not
only can the life span be extended further but
624
also the period of usefulness to the community
may be prolonged. Longevity without continued
health and usefulness is not a blessing.
A. Hazen Price, M.D.
JUNE IS MULTIPLE SCLEROSIS MONTH
Despondency and despair have always been
associated with multiple sclerosis, due mainly to
ignorance or misinformation of the true facts.
Even in places of good repute, the patient in his
search for a “cure” is invariably told that nothing
can be done for him, thus robbing him of all
hope. This hopeless attitude, adopted by the
patient, is the challenge taken up by the Michi-
gan Multiple Sclerosis Center. Here a ray of
hope is given to him; not a promise of a cure,
but a treatment which enables a better way to
maintain a relationship with his environment than
he had before.
This Center is unique in that it devotes all its
time and energies to multiple sclerosis alone. The
best of facilities for medical diagnosis and treat-
ment are provided. Research is also continually
in progress in the field of multiple sclerosis. Bet-
ter public relations are being established by means
of distribution of literature, presentations of TV
programs, and lectures which point out that the
outlook is far from hopeless.
Because of the multiple disabilities associated
with this disease, a very efficient, sympathetic, and
well-trained staff is essential for treatment. In-
volvement may cause ataxia, spasticity, speech and
visual defects, incontinence, and other disabilities.
Another factor which makes it difficult to work
with this type of patient is that some have a great
fear of falling due to previous falls and will not be
co-operative when being treated. Others are
over-anxious to improve, so take foolish risks
when moving about and will not heed warnings.
Many ask a great number of questions concerning
their condition which require a good deal of
wisdom to answer. Those working with these
patients must not be too encouraging, thus raising
false hopes, or too discouraging, thus causing des-
pondency. A compromise must be made to give
comfort to the patient.
Gabriel Steiner, M.D.
JMSMS
EDITORIAL
BASIC BLUE SHIELD PRINCIPLES
The medical prepayment program of the whole
medical profession was based on a few funda-
mental principles. The concept became established
before a vast percentage of our present active
members ever finished medical school. Hope-
fully, they will never again see conditions like
those that confronted us then. There has prob-
ably never been a time in historic memory when
comprehensive or even adequate medical care
was available to all our suffering people. The
well-to-do and the securely employed persons
could and did have the services of the medical
practitioners with the best knowledge and facili-
ties available at that time.
The indigent have always been with us, and
in most instances there were charitable hospitals
to which they could go. In modern times, the
state has assumed responsibility and provided for
these same people through the social welfare de-
partments.
Long continued years of desperate want and
frustration proved that even the reasonably em-
ployed persons found that medical conditions call-
ing for hospitalization could become calamitous.
Michigan doctors (and others) evolved Blue
Shield and Blue Cross to ensure medical and
hospital care for all with foresight enough to
subscribe and contribute small payments in ad-
vance. Under-income-limit persons only were to
be accommodated. The very first group proved
there could be no prohibition to the ones just
over this arbitary income limit. In order to in-
sure and guarantee service to the really needy,
it was better that some others also be protected.
Unauthorized usage might develop, but the pro-
fession believed the great benefit to the most
worthy was our conscientious duty. The imme-
diate success of prepayment for services — not in-
surance— was adequate proof of the foresight and
dedication of medicine’s pioneers in an utterly
new field of service.
THE CHANGING TIMES
Nearly two decades have passed. Economic, so-
cial and political conditions are different. A new
generation is now enjoying almost unbelievable
advantages as compared to the times which
fathered the Blue Cross-Blue Shield economic
miracle. Practically anyone who wishes may have
a job, with reasonable hours of work and suffi-
cient pay to care for his family, especially if he
has moderate forethought. Medical care of the
highest quality is available when and if needed.
We also have a new generation of doctors who
never saw hard times. They finished school after
the great depression, never knew the tedium of
waiting in their offices for their first paying pa-
tient; never went through the rigors of trying to
collect for services gladly rendered but long after
the patient and his family had forgotten the
anguished pleas, “Doctor, spare no expense.” “In-
surability” of medical care was an established fact,
with large percentages of the population “in-
sured.”
Far too many doctors and far too many patients
are mistaking the advantages now available as
just a “rich insurance company” which can and
will pay even unauthorized, or unincluded
claims. They do not remember, or charitably do
not know, that the voluntary prepayment medical
care plans are not insurance companies but actual-
ly ourselves, our own medical societies selling our
own actual services to our own patients! Selling
these services in advance of need instead of the
age-old custom of caring for the patient and then
rendering a bill weeks or months later. In think-
ing of some physicians, due to the present pros-
perity, even the need of prepayment health insur-
ance plans has become obsolete. Recalling such
facts, and dedicating our efforts to the needful
care; being available when called; not using un-
necessary diagnosis or treatment factors will again
place our profession in the kindly affections of our
patients.
GOVERNMENT CARE
Government medicine is spreading all about us,
and the future doesn’t look to be much different.
A sizable portion of the old Wagner-Murray-
Dingell bills have been enacted piecemeal during
the years.
Besides the members of the armed forces and
other governmental quotas which are necessarily
given government medical care, many of the fam-
ilies are being included in the new Medicare. Of
our 22.5 million veterans, uncounted numbers are
eligible and are getting free care in the Veterans,
Hospitals. Each Congress presumes a number of
conditions to have been “service-connected.” Care
for older people is increasing. It now covers many
millions who have inadequate resources, some
May, 1957
625
EDITORIAL
are on Social Security and some on relief. It has
recently been proposed to give OASI persons up
to sixty days hospitalization per year which, in-
cluding Medicare, might add another 14 million
persons to the government medical care burden.
A new Dingell bill levying a percentage tax on
every employed person and his employer is in the
making. It sounds inoffensive. A new govern-
ment bureau in HEW will pay the bills for doctors
and hospitals. How long can that last before doc-
tors will be under coercion, working for the gov-
ernment, and reportable to the government? The
world has now reached another and different eco-
nomic socio-medical era which calls for a brand
new deal.
Some form of prepaid insurance has been pro-
posed by the HEW officials to care for the aging
and the marginal groups who just cannot provide
for or anticipate medical needs. “Coinsurance”
was suggested and abandoned. It is claimed that
existing insurance cannot cover this need without
help — that is true — but Blue Shield, which is
service and not insurance, has always provided
that any person in a group no matter what his
age may continue as an independent subscriber
when he retires from the group. A person over
sixty- five may not join as an individual, but may
in a group of employed persons.
Years ago, the Michigan State Medical Society
expressed the opinion that when government is
paying for medical care for its wards, they are no
longer indigent, and the medical care as well as
food, clothing, and shelter should be paid on an
acceptable rate, not cut in half as had been the
custom. The society, therefore, established a fee
schedule for government agencies.
Government could recognize the facts of life and
contract to use the available insurance principle
to care for its economically uninsurable.
FAULTS AND REMEDIES
The Governor’s Committee last year uncovered
widespread demand for more extensive care than
Michigan Medical Service is now giving and some
serious criticisms of the too frequent extra charges
being made. Labor has demanded certain office
and out-patient diagnosis and care, together with
a guarantee of full coverage under the contract.
Labor has started to organize its own service plan,
stressing groups and clinics with salaried doctors
and a prohibition of all extra charges.
A fast-growing complaint, possibly inspired, is
the difficulty of getting doctors to make calls after
hours or at night. This is serious, and some cities
are making efforts to have certain doctors on
special call every night.
All these complaints and criticisms point to an-
other “big look” on our part. Twenty years ago,
the profession was in trouble from several sources
and solved its problems then by united and con-
certed efforts as a cohesive body. Blue Shield and
its administration was the answer. Now we seem
to be in trouble again. Some farsighted members
are trying to show the road to light. They have
analyzed the situation, made repeated and exten-
sive studies and are now proposing a new evalua-
tion. We need not only leadership, but sacrifice
of personal and individualistic ideas and a united
front. The “enemy” is clearly outlined. The basic
contract of Blue Shield with some modifications is
still the primary anchor. “Comprehensive” or at
least well-extended services, office and out-patient
surgery, laboratory diagnosis, consultation, as-
sistants, diagnostic and therapeutic radiology must
be made available. The medical profession must
also reinstate itself in love and respect by always
being available for emergency calls. Someone
should be ready if the doctor called is busy. Our
most numerous competitors have seen this op-
portunity, grasped the chance and taken too
many of our patients.
Our first and foremost duty to our patients is
the very best medicine of which we or our con-
freres are capable. We have been taught all the
methods of diagnosis, how to interpret laboratory
and other intelligence and are freely using our
facilities. However, we were not generally told
how expensive all these tests are, or how little
money a family is likely to have after paying the
ordinary running expenses. We should all have
been taught — and should all remember — never to
order or inflict an unexpected and unnecessary
expense unless we are looking for a “new deal”
with some pressure group, or government, pulling
the strings. Our second duty is to the patient’s
economic ills. Response to that duty in the 1930’s
created Blue Shield.
VETERANS’ CARE
Care of veterans with service-connected dis-
abilities is to be continued. The Michigan Plan
was developed about ten years ago involving sim-
626
.TMSMS
EDITORIAL
plificd and short report forms. The program con-
tinued for years but finally there were only eight
states still active. The disabled veterans work in
other states is on direct contract between the doc-
tors, the patients and the government, mostly
being through Veterans’ Hospitals or Clinics.
About a year and a half ago, the director of Vet-
erans’ Affairs notified all the states involved, that
the program would be discontinued as of last July
first. Conferences in Chicago by the State Med-
ical Societies and Medical Service Plans involved
resulted in a visit to Washington, a hearing, and
a revocation of the termination notice. Recently,
a new order came from Washington again ter-
minating all service-connected veterans’ home-
town care through the Societies and Service Plans.
Another committee meeting in Chicago, this time
with the AMA having an observer, another visit
to Washington, various lay representatives from
several states, Michigan sending three doctors, and
South Carolina sending one, again met with suc-
cess. On March 13, word came of the complete
success of the committee and the adoption for all
areas of the Michigan Plan of Care. The veterans’
service-connected hometown medical care will con-
tinue.
The short, logical forms developed by John
Castallucci at the very first have proved adequate
and are being used and printed by the Federal
Government. In return, these eight states and
Hawaii have agreed to a uniform contract, which
really is a benefit to the Veterans Administration.
Note: Word from Washington April 17, 1957, indi-
cates uncertainty and the necessity for more conferences.
BLUE SHIELD COMMISSION
The annual conference of the Blue Shield Com-
mission was held in San Francisco, March 24 to
28, 1957. Robert L. Novy, M.D., of Detroit, pre-
sided as national President. The meetings were
attended by the Commission and by trustees, ad-
ministrators and staff members who seemed ob-
ligated or who could go for the semi-vacation. It
was an intensive program of the working variety.
The Blue Cross Commission held its conference
simultaneously. Present and taking part were R.
L. Novy, M.D., Jay C. Ketchum and C. D. Moll.
M. D., all of Detroit. There were twenty-seven
prepared speeches in Blue Shield and twenty-three
for Blue Cross by eminent men in their respective
fields — university professors, government officials,
plan directors and labor representatives.
Speeches, discussions and bull sessions developed
a few important facets of the voluntary medical
and hospital programs. We were told that in gen-
eral the voluntary programs are doing a good job,
not over-priced — rather the opposite, and with
some effort can be sold to a much more critical
public than in the past. There is danger that we
may make our plans so expensive that people in
the ordinary buying class, the workers, and em-
ployes who must live on their earnings will be
unable to buy. From all over the nation come
problems and questions of policy or procedure,
demands here, complaints there. Some facts are
outstanding:
1 . Labor is complaining bitterly that our plans
are not inclusive enough; that the doctors make
too many overcharges; that no prophylactic service
is offered; patients too often hospitalized for the
convenience of making several calls at one place;
or the difficulty of getting the doctor at night.
2. Most of the members thoroughly believe that
Blue Shield is not insurance run by an insurance
company with plenty of money and more if that is
not enough, but that it is our own medical society
operating in a different field, rendering just as im-
portant service to our patients and their needs.
We should never change that belief.
3. There is a tremendous necessity of educating
our members to the fact that since the medical
profession has demonstrated the feasibility of pre-
paid medical service, we must not now surrender
to the numerous handicaps and hindrances being
displayed, but must again demonstrate to our pub-
lic that the medical profession is ready and can
meet this present obligation.
4. The insurance counsellors, the State Com-
missioners of insurance, all believe our plans are
in fact insurance, for they are most of them ad-
ministered by the state insurance commissioners,
even if their enabling acts do classify them differ-
ently. We must all follow insurance practices, rules
and laws.
5. It is the universal belief that Blue Shield
and its counterpart, Blue Cross, in the early forties
did stop the firmly determined pressure toward
compulsory health insurance administered by the
Government and stopped socialized medicine.
This was done by concerted and determined ob-
jective action.
6. Many of our speakers expressed the convic-
tion that the independent practice of medicine in
May, 1957
627
EDITORIAL
the well-recognized American style is again in
utmost danger from several sources: pressure
groups, bureaucrats in the government, demands
by the lower income persons for more assurance
of full care; resentment against some very obvious
mispractices.
7. The pioneers of yesteryear who carried the
burden in the past score of years are just as en-
thusiastic and confident that the men of medicine
still have the vigor, the daring, the confidence, the
knowledge, the same dedication and genius to find
again the true path to preserve once again the
American way of life. They believe the public
will respond.
8. In the past experience, there were many
sacrifices of personalities and individualities ac-
cepting ultimate good as most necessary. More
sacrifices are needed and will be just as willingly
given.
Gleanings
Blue Shield’s basic philosophy is service to sub-
scribers, mainly aimed at lower income groups. It
is much better to endure a few abuses or misap-
plications in order to make sure the worthy and
needy will not fail to receive their just benefits.
HEART SPECTACULAR
Millions of people saw Jim Blodgett operate on
mitral stenosis as presented over WWJ-TV. For
weeks afterwards, this was the topic of conversa-
tion. In their own living rooms, people saw the
ultimate in surgical miracles. Drama of life and
death — life triumphant! What the public didn’t
see was the antecedent work, laborious research
that preceded the skillful presentation of operative
victory of the modern knight. He is the first to
acknowledge his obligation to his contemporaries
and those who have gone before. And the doctors
of Michigan are in the forefront of those who
unravel the mysteries and contribute to the un-
derstanding of the heart.
In 1896, George Dock, professor of medicine at
the University of Michigan, published the first
report in the English language of the clinical fea-
tures of coronary thrombosis and myocardial in-
farction, the second report in the world literature.
It was two generations later that this understand-
ing was diffused to the medical profession. We
never saw a clinical case of coronary thrombosis
at the University of Michigan when we were stu-
dents. The great Warthin showed them to us at
the autopsy table. What medicine owes to War-
thin!
Next at Michigan is Wilson. No further identi-
fication is necessary for physicians any place in the
world. He is the most famous throughout the
world of Michigan medical teachers. An authority
on the heart and teacher of electrocardiography,
he made available to physicians the understanding
and use of this instrument. In 1934, Wilson and
his associates reported the use of the central ter-
minal for obtaining so-called unipolar electro-
cardiographic leads, chiefly precordial leads. In
1929, a patient who required surgical drainage for
suppurative pericarditis afforded an opportunity
for Paul Barker of Wilson’s group to stimulate the
exposed ventricles electrically and record the re-
sponses electrically; these observations by Barker
led to a correction of the previous erroneous inter-
pretation of bundle branch block curves.
Wherever physicians treat the heart, they are
familiar with the great names of Wilson and
Barker.
In 1938, Wilson and F. D. Johnson were the
first to record vector cardiograms by means of
the cathode ray tube. Johnson succeeded Wilson
in the famous chair in cardiology at Ann Arbor.
Detroit workers have contributed with distinc-
tion in the understanding of the heart. Everyone
is familiar with the work of Gordon Myers as re-
searcher and teacher, professor of medicine at
Wayne State University Medical School. His lec-
tures on electrocardiography are a worthy suc-
cession to those of Wilson. Myers has published
books on the electrocardiogram and his papers on
correlation of the electrocardiogram and infarc-
tion are said by Prinzmetal to be the most sig-
nificant published. His post-graduate courses on
the heart draw attendance from all over the
United States and abroad.
With the development of modern anesthesia to
equal status with surgery, operations are routine
that were previously only dreamed about. With
modern anesthesia, pumps for shunting the blood
around the heart and oxygenating and returning
to the body can be used. In Detroit, Dodril, of
Harper Hospital, led the way in developing the
heart pump with which he was able to pioneer in
heart surgery'.
Any mention of heart at Harper Hospital brings
to mind the large series of Gene Osius in vascular
surgery. And always mentioned are the many
628
JMSMS
EDITORIAL
students and practitioners who are obligated to
Bob Novy for learning about the diagnosis and
treatment of coronary heart disease; he has the
diagnostic drive interest of youth, aggressively
learning, tempered with the maturity of judgment
that comes to those of great experience. A great
name, Novy.
At Ford Hospital, Szilagyi is doing impressive
work, removing diseased aorto-iliac and femoral
occlusions and replacements with homografts and
woven chemical substitutes! New aortas for old!
Also Ziegler, of Ford Hospital, has clarified the
subject of infant cardiology and the congenital
heart. He utilized cardiac catheterization, with-
out which the understanding and operations on
congenital heart lesions could not be undertaken.
He is the author of a textbook on pediatric cardi-
ology; pediatric electrocardiography. Janny
Smith brought Detroit to notice and prominence
in heart circles with his oft quoted work on anti-
coagulants and coronary thrombosis; he has been
the moving force in development of understand-
ing of heart disease at Ford Hospital.
In rheumatic heart disease in Michigan, there
are two outstanding men. Rosenzweig, of Chil-
dren’s Hospital and Detroit Receiving Hospital,
has a series of more than a thousand cases, and
his clinical teaching of rheumatic heart disease
and congenital heart disease has made common-
place what used to be an intricate puzzle. He
has given a lifetime to the care of sick rheumatic
children. Clarke, of Providence Hospital, has
focused on the understanding of rheumatic heart
disease and its treatment. He is very proud that
he has one of the few M.S. degrees in cardiology
presented under Wilson of Ann Arbor. He has
been working on the di-hydroxy and tri-hydroxy
homologues of salicylic acid in treatment of rheu-
matic fever. He is one of the first to note that
T-wave changes, resulting from severe blood loss
in intestinal hemorrhage could mimic coronary
heart disease in the electrocardiogram. He is now
doing work of promise with versine in atheroma-
tous vascular lesions in angina and cerebrovascular
strokes.
At Receiving Hospital, the teaching hospital of
Wayne State University, in addition to Gordon
Myers’ monumental work in medicine, there is
Harper Hellems who trained a whole group in
cardiac catheterization. As mentioned, it is work
like his that makes feasible a bold surgical ap-
proach and cure of the cardiac cripple. The sur-
geons, Jacobsen and Wible, at Receiving Hospital
under C. G. Johnson, have been busy in heart re-
search. Their latest achievement is the use of a
spring valve inserted in the heart to correct mitral
insufficiency.
Michigan has made history and is writing its
chapter on heart disease — its understanding, treat-
ment and cure. We thank Jim Blodgett for
dramatizing on television the achievement of all
these medical doctors.
Dave Sugar, M.D.
CORRECTION
In the March issue of The Journal, page 360, ap-
peared an editorial entitled “Deaths Balance Births,”
which should have read “Deaths Around Birth,” dealing
with the perinatal time. We have checked the galley
proofs which did read “Deaths Around Birth.” How
this change occurred we have no explanation, and we
had no knowledge of the change until our attention was
called to it by Dr. Goldie Corneliuson. We are making
this explanation so that our readers may mark this cor-
rection in their copies of The Journal.
Editor
MSMS ANNUAL MEETING
September 25-26-27, 1957
Civic Auditorium, Pantlind Hotel
Grand Rapids
— » Make your hotel reservation now
May, 1957
629
' ^\ \ \ i ;
Record Set!
Michigan Clinical Institute Success Story
I he excellence of the scientific program, the widespread advance publicity and
the extraordinarily favorable weather contributed to the outstanding success of
the 1957 Eleventh Annual Michigan Clinical Institute — a meeting which used to
be known as the “little session.”
Attendance at this year’s meeting, held traditionally in Detroit, surpassed 1956
totals by 766. Doctors of medicine registering during the three-day postgraduate
session numbered 1,654, an increase of 231 over 1956. Guest registrations soared
also to a total of 845, including dentists, veterinarians, nurses and medical students.
High point in the week’s events was the telecast to the general public of a live
mitral commisserotomy operation performed by James B. Blodgett, M.D., Detroit,
from the operating rooms of The Grace Hospital, on Tuesday, the eve of the MCI
opening. The hour-long program was carried by WWJ-TV in compatible color.
Lansing area viewers also watched the significant display of the techniques of
modern medicine by means of a network hookup. Subsequently a kinescope of
this program was used on several other Michigan TV stations.
The program marked the first time an actual operation had been broadcast
live to the public in Michigan and was the second such telecast in history.
Sponsors were the Michigan State Medical Society, Wayne County Medical
Society and the Michigan Heart Association, in co-operation with Smith, Kline
& French Laboratories, technical producers of the show.
Chairman of the MCI Television Committee was Dan W. Myers, M.D., of
Detroit. The Committee was also responsible for the closed circuit clinical TV
programs broadcast daily from the Grace Hospital to the main ballroom of the
Sheraton-Cadillac Hotel on Wednesday. Thursday, and Friday, through the courtesy
of Smith, Kline & French.
Also lending color and technical information was the American Cyanamid
Corporation exhibit featuring continuous colored motion pictures of clinical and
surgical procedures.
Because of a bulging program, presentation of papers by thirty leading medical
authorities began at 8:30 a.m. in order to accommodate speakers and the daily
clinical television programs.
Formal presentation of Michigan’s
Foremost Family Physician Award was
effected on Thursday noon at a special
Testimonial Luncheon honoring both
medical and lay persons for their accom-
plishments and contributions to health
and medicine. The luncheon was ar-
ranged by G. B. Saltonstall, M.D., who
served as toastmaster. Arch Walls, M.D.,
MSMS President, presented the awards
to the honorees.
1957 MCI Registration
Here is the final tabulation of
registrants at the Eleventh
Annual
Michigan Clinical Institute
at the
Sheraton-Cadillac Hotel,
Detroit,
March 13-14-15.
Doctors of Medicine
.1,654
Nurses
. 334
Guests (dentists, medical
students, veterinarians)...
. 845
Exhibitors
. 410
Total
.3,243
Ralph G. Cook, M.D., venerated Kala-
mazoo doctor, sportsman and Indian
Chief, received the Foremost Family Phy-
sician award following his selection by
the MSMS House of Delegates in September. An identical citation was awarded
posthumously to Joseph H. Sherk, M.D., of Midland, who passed away shortly
after his nomination. Mrs. Maurice Ittner accepted the scroll for Doctor Sherk’s
family, as a representative of the Woman’s Auxiliary to the Midland County
Medical Society.
Special tribute was paid to eight Michigan doctors of medicine who are currently
serving as presidents of national medical organizations. Those honored were:
J. S. DeTar, M.D., Milan, American Academy of General Practice; Ann Arbor
doctors, Cameron Haight, M.D., American Association for Thoracic Surgery;
Norman F. Miller, M.D., American Gynecological Society and William D. Robin-
son, M.D., American Rheumatism Association; and the following doctors from
Detroit, Charles G. Johnston, M.D., American Association for the Surgery of
Trauma; Rupert C. L. Markoe, M.D., American Academy of Tuberculosis Physi-
cians; Edgar E. Martmer, M.D., American Academy of Pediatrics; Robert L. Novy, 1
M.D., National Association of Blue Shield Medical Care Plans.
Distinguished Health Service awards were also presented at the luncheon to 1
non-members of the medical profession. Mr. Jay C. Ketchum received an illumi-
nated scroll from MSMS for his nationally recognized leadership in the field of
prepayment medical service. Five other awards went to: Labor Commissioner
John Reid for his many years of service as a Director of Michigan Medical
Service; Representative Arnell Engstrom, Senator Clarence F. Graebner, Senator
Perry W. Greene, and Senator Elmer R. Porter. The members of the Michigan I
legislature were recognized for their support of the finer principles of medical |
education and medical care as chairman, respectively, of the House Ways and
Means, The Senate State Affairs, Senate Public Health and Welfare and Senate
Appropriations Committees.
One Outstanding Health Service citation was awarded this year to Radio
Station WHAK, Rogers City, for two years broadcast of health information
programs. The scroll was accepted by the station’s president Harvey A. Klann.
The guests at the Testimonial luncheon heard an address by Wayne State Uni-
versity President Clarence F. Hilberry, Ph.D.
Several MCI speakers were honored at special luncheons on Wednesday and
Friday. L. Henry Garland, M.D., San Francisco, and Charles B. Huggins, M.D.,
Chicago, were presented with citations at a special luncheon Wednesday, sponsored
by the Michigan Division and the Southeastern Michigan Division of the American
Cancer Society. J. W. Hubly, M.D., of Battle Creek, served as chairman of
arrangements.
On Friday, March 15, the Michigan State Pharmaceutical Association honored
Mr. George P. Larrick, of Washington, D. C. Mr. Larrick is the Commissioner
of Food and Drugs of the U. S. Department of Health, Education and Welfare.
Howard B. Sprague, M.D., of Brookline, Mass., was the guest speaker at the
public Annual Meeting of the Michigan Heart Association in the Sheraton-Cadillac
Grand Ballroom. The subscription dinner was attended by more than 250 guests
who saw The Honorable Charles E. Wilson receive a scroll of appreciation for
his service to the organization as Board Chairman.
In all, seventeen meetings of special societies, alumni and ancillary groups were
held in conjunction with the MCI.
An important sidelight of the MCI was the Wednesday night Panel on Tran-
quilizing Drugs held in the Grand Ballroom and featuring a panel of doctors
from the University of Michigan: R. W. Waggoner, M.D., R. W. Gerard, M.D.,
and J. G. Miller, M.D.
News interest in the week’s scientific activities was unprecedented. Stories on
1. Julius Bauer, M.D., Los Angeles, fi.
Guest Essayist. 7
2. Fredrick C. Swartz, M.D., Lan-
sing.
3. A. Hazen Price, M.D., Detroit. 8.
4. Howard B. Sprague, M.D.,
Brookline, Mass., Guest Essayist.
5. Wm. M. LeFevre, M.D., Mus- 9.
kegon, Guest Essayist and Pro-
gram Chairman, MCI.
General view close-up.
Sen. Clarence F. Graebner, Sagi-
naw, Distinguished Health Serv-
ice Awardee.
Sen. Perry W. Greene, Grand
Rapids, Distinguished Health
Service Awardee.
Sen. Elmer R. Porter, Blissfield,
Distinguished Health Service
Awardee.
Ralph G. Cook, M.D., Kalama-
zoo, Michigan’s Foremost Family
Physician.
Rep. Arnell Engstrom, Traverse
City, Distinguished Health Serv-
ice Awardee.
Jay C. Ketchum, Detroit Execu-
tive Vice President, Michigan
Medical Service, Distinguished
Health Service Awardee.
13. Gilbert B. Saltonstall, M.D.,
Charlevoix, Chairman, MCI Tes-
timonial Luncheon.
14. Claude L. Weston, M.D., Owos-
so, Member, MCI Press Com-
mittee.
15. A. B. Gwinn, M.D., Hastings,
Chairman, MCl Press Commit-
tee.
16. Otto O. Beck, M.D., Birming-
ham, General Chairman, MCL
17. L. Fernald Foster, M.D., Bay
City, Secretary, MSMS.
18. Ralph W. Shook, M.D., Kala-
mazoo, Chairman, MSMS Fi-
nance Committee.
19. Arch Walls, M.D., Detroit, Pres-
ident, MSMS.
20. Cancer Exhibit — B. E. Luck,
D.D.S., Lansing.
21. Maternal Health Exhibi t —
Charles A. Behney, M.D., Mich-
igan Department of Health, Lan-
sing.
22. Lester P. Dodd, Detroit, MSMS
Legal Counsel.
23. Wilfrid Haughey, M.D., Battle
Creek, Editor, Journal, MSMS.
*See preceding pages for illustrations numbered 1-14 and 22-23.
the MCI, and particularly in the live heart operation,
began appearing a week in advance in papers all over
the state. Individual stories on the scientific papers
were still running in Detroit newspapers on Saturday.
And reports on the “heart” patient’s recovery appeared
as late as two weeks after the meeting.
Assisting the various news media in obtaining infor-
mation and arranging interviews was the Press Rela-
tions Committee; A. B. Gwinn, M.D., Hastings, Chair-
man; H. F. Dibble, M.D., Detroit; L. R. Leader, M.D.,
Detroit; J. J. Lightbody, M.D., Detroit; Ralph W.
Shook, M.D., Kalamazoo; and C. L. Weston, M.D.,
Owosso. 1
Co-sponsoring organizations, who played an impor-
tant part in the success of the 1957 MCI include:
Michigan State Medical Society, the medical schools at
University of Michigan and Wayne State University,
Michigan Cancer Co-ordinating Committee, Wayne
County Medical Society, Michigan Heart Association,
Michigan Foundation for Medical and Health Educa-
tion, Michigan Chapter — American College of Sur-
geons, Michigan Regional Committee on Trauma- —
American College of Surgeons, Michigan Department
of Health and Michigan Public Health Officers Asso-
ciation.
REPORT OF KNOSTMAN & SMITH, CPA— 1956
The Council, Michigan State Medical Society:
Pursuant to your request, we have examined the
Statement of Financial Condition of the MICHIGAN
STATE MEDICAL SOCIETY, Lansing, Michigan, as
at December 24, 1956, and the related statements of
income and expense and fund transactions for the year
then ended. Our examination was made in accordance
with generally accepted auditing standards, and ac-
cordingly included such tests of the accounting records
and such other auditing procedures as we considered
necessary in the circumstances.
In our opinion, the accompanying Statement of Finan-
cial Condition and related statements of income and
expense and fund transactions, present fairly the position
of the MICHIGAN STATE MEDICAL SOCIETY as
at December 24, 1956, and the results of its operations
for the year then ended, in conformity with generally
accepted accounting principles applied on a basis con-
sistent with that of the preceding year.
Knostman & Smith
Certified Public Accountants
Lansing, Michigan
January 7, 1957
The following comments are submitted relative to
our examination of the MICHIGAN STATE MEDI-
CAL SOCIETY, Lansing, Michigan, for the year ended
December 24, 1956.
HISTORY
The MICHIGAN STATE MEDICAL SOCIETY
was organized on September 17, 1910, under the laws
of the State of Michigan, as a non-profit corporation.
The charter has been extended for a period of thirty
years from September 17, 1940. The Society is affiliated
with the American Medical Association, and it charters
county medical societies within the State of Michigan.
The purposes of the Society are the promotion of science
and art of medicine, the protection of the public health,
and the betterment of the medical profession. In the
furtherance of these purposes, the Society publishes
“The Journal of the Michigan State Medical Society.”
COMMENTS
The regular society bank account maintained at the
Michigan National Bank, Lansing, Michigan, was con-
firmed by direct correspondence with the bank as at
December 24, 1956. and the balance thus obtained was
reconciled to your books of account.
The balance in the Treasurer’s account is in accord-
ance with a letter from the Michigan National Bank,
Grand Rapids, Michigan, dated December 28, 1956,
addressed to Mr. Robert Roney.
Cash in the Lansing office, in an amount of $36.61,
was counted by our representative. Detroit petty cash
of $50.00 was not verified.
Confirmation of Accounts Receivable have been
mailed. A very small number of replies have been re-
ceived due to the early date of this report. Any nega-
tive replies will be reported to your office. An aging
analysis of the accounts by the month of charge is as
follows:
October, November. December $22,265.52
July, August, September 528^20
Over Six Months 1 19^99
Totat .$22,913.71
Insurance premiums due from employees are reim-
bursed to the Society via a payroll checkoff.
634
A summary of the 1956
premium
cost is as
follows :
Total
Society
Share
Employee
Share
Premium — 1 year
,..$19,718.84
... 1,437.11
$10,640.21
849.60
$9,078.63
587.51
Net
...$18,281.73
$ 9,790.61
$8,491.12
Collections from Employees
... 7,878.73
7,878.73
10,403.00
Due from Employees in January
1956 612.39
612.39
612.39
Net Society Cost
..$ 9,790.61
$ 9,790.61
$
Investments as set forth in Schedule 10 were con-
firmed in a letter to Mr. Roney from the Michigan
National Bank, Grand Rapids, Michigan, dated Decem-
ber 28. 1956. We did not count these securities, nor
was a confirmation letter sent to us directly from the
bank.
Property and equipment are set forth in schedule 11.
Office equipment is charged to expense when pur-
chased and hence is not set forth as an asset of the
society.
The distribution of such general expense items as
office supplies, printing, telephone, repairs and equip-
ment to the various society functions is very burden-
some and time consuming to your accounting depart-
ment. We suggest that Mr. Roney be authorized to
charge these minor items to their respective expense
category without attempting to distribute them to each
small function.
Membership dues for the period were reconciled to
paying members of 5,541. Of the 6,053 cards used we
were able to account for 6,051.
The Annual Session and the Michigan Clinical Insti-
tute booth space income was verified by us and a spot
check of Journal Advertising was in agreement with
your books of account.
Prior years 1% unallocated collection items due
county societies were closed to miscellaneous income in
an amount of $1,398.35 upon our suggestion.
Net gain for all society functions for the year ended
December 24, 1956, was $40,060.31 as combined in
Exhibit “C” of this report.
Respectfully submitted,
Knostman & Smith
Certified Public Accountants
STATEMENT OF FINANCIAL CONDITION
December 24, 1956
ASSETS
CASH ON HAND AND IN BANKS
Michigan National Bank
Lansing, Michigan $21,013.69
Grand Rapids, Michigan
(Treasurer’s Account) 8,713.01
Office Cash (Lansing and
Detroit, Michigan) 86 61
$ 29,813.31
ACCOUNTS RECEIVABLE
Advertising, Allowances and Other Items... $22, 913. 71
Collection Expense 15.50
Due from Employees-Insurance Premiums.... 612.39
Employee Advances 562.65
LESS Allowance for Doubtful
$24,104.25
Accounts 126.30
INVESTMENTS (Schedule 10)
(Market or Redemption Value— $223,813.13)
23,977.95
229,795.25
.TMSMS
REPORT OF KNOSTMAN & SMITH, CPA
PROPERTY AND EQUIPMENT
(Schedule 11)
Land • $10,000.00
Office Building $34,500.00
Lot Adjoining Office Building ... 6,000.00
Building Improvements 5,664.06
Building Equipment 3,836.09
Parking Lot 1,913.60
51,913.75
$61,913.75
LESS Depreciation Allowance 8,634.55
53,279.20
OTHER ASSETS
Prepaid Expenses 231.66
TOTAL ASSETS $337.097.37
LIABILITIES
ACCOUNTS PAYABLE
Federal Unemployment Tax $ 206.42
Michigan Unemployment Tax 48.35
Unpaid Invoices 14,512.95
Payroll Taxes — Payable 1,524.72
$ 16,292.44
DEFERRED INCOME
1957 MCI Booth Sales $13,650.00
1957 Membership Dues 2,160.00
15,810.00
TOTAL LIABILITIES $ 32,102.44
SOCIETY EQUITIES
RESERVED FOR SPECIAL PURPOSES
Public Education Reserve $57,245.00
Public Education Program.... 73,891.87
$131,136.87
Public Sendee Account 3,675.16
Prolessional Relations Account 4,897.50
Rheumatic Fever Control Program... 7,675.56
Contingent Fund 53,614.34
Building Fund 14,124.94
TOTAL RESERVED $215,124.37
General Society Equity
12-24-55 77,593.98
Net Gain for Period
(Exhibit “B”) 12,276.58
89,870.56
TOTAL EQUITIES (Exhibit “C”) $304,994.93
TOTAL LIABILITIES AND EQUITIES $337,097.37
STATEMENT OF INCOME AND EXPENSE
December 24, 1955, to December 24, 1956
INCOME
Membership Dues $156,346.76
Miscellaneous 1,456.35
Interest Income (Schedule 10) 4,241.03
Amortization (Schedule 10) 660.04
$162,704.18
OTHER INCOME
Annual Session (Schedule 2) (2,468.88)
Michigan Clinical Institute
(Schedule 3) (73.38)
“The Journal” (Schedule 4) 1,096.70
(1.445.56)
TOTAL INCOME $161,258.62
EXPENSES
Administrative and General
(Schedule 1) $85,160.42
Society Activity (Schedule 1) 40.603.79
Committee Expenses (Schedule 1) 23,217.83
148,982.04
NET GAIN $ 12,276,58
EXPENSES
December 24, 1955, to December 24, 1956
ADMINISTRATIVE AND GENERAL
Printing, Mailing and Postage $13,464.35
Office Supplies...^ 3,574.33
Insurance and Fidelity Bonds 4,813.05
Auditing 750.00
Salaries — Administrative and Office 34.157.58
General Counsel Retainer and Expense 6,856.53
Equipment and Repairs 2,145.16
Telephone and Telegraph 5,046.92
Payroll Taxes 1,963.15
Miscellaneous Expense 2,598.74
Employee’s Retirement Trust 9,790.61
TOTAL ADMINISTRATIVE AND
GENERAL EXPENSES $85,160.42
SOCIETY ACTIVITIES
Council Expense $15,599.98
Delegates and Alternates to AMA 7,011.68
General Society Travel and Entertainment 7,501.61
Officers’ Travel 5.558.78
Secretary’s Letters 1,273.43
Woman’s Auxiliary 600.00
Dues Collection Expense 3,058.31
TOTAL SOCIETY ACTIVITIES
EXPENSES $40,603.79
COMMITTEE EXPENSE
Legislative $ 1,020.08
Postgraduate Medical Education 2,712.09
Preventive Medicine 102.11
Cancer Co-ordinating Committee 1,000.00
Child Welfare 431.71
Geriatrics „ 244.86
Industrial Health 90.93
Maternal Health 570.39
Civil Defense 204.50
Mental Health 507.85
Scientific Radio..— 724.00
Venereal Disease 38.49
Tuberculosis Control 50.49
Michigan Health Cbuncil 10,000.00
Rural Medical Service 211.24
Highway Accident Committee 460.70
Beaumont Memorial Restoration (Note 1) 2,353.56
Permanent Conference Committee 31.27
Sundry Committee Expense 2,463.56
TOTAL COMMITTEE EXPENSES $23,217.83
TOTAL EXPENSES (Exhibit “B”) $148,982.04
Note 1:
This item is the net expense, after deducting $6,920.00 of contri-
butions received.
INCOME AND EXPENSE SUMMARY
December 24, 1955,
to December 24,
1956
Income
Expenses
Net
Balance
for the
for the
Gain or
12-24-55
Period
Period
(Loss)
$162,704.18
$148,982.04
$13,722.14
Equity — General Fund 5
23,757.50
26.226.38
(2,468.88)
Annual Session l.
$ 77,593.98
Michigan Clinical Institute (
13,360.00
13,433.38
(73.38)
The Journal J
94,400.27
93,303.57
1,096.70
Contingent Fund
37,267.34
16,347.00
16,347.00
Building Fund
13,788.46
10,898.00
10,561.52
336.48
Public Education Reserve
30,000.00
27,245.00
27,245.00
Public Education Program
76.494.02
34,217.21
36.819.36
(2,602.15)
Public Service
281.28
19.071.51
15.677.63
3.393.88
Professional Relations
6,805.30
28,607.23
30,515.03
(1,907.80)
Rheumatic Fever Control Program
22,704.24
10,000.00
25,028.68
(15,028.68)
TOTAL
$264,934.62
$440,607.90
$400,547.59
$40,060.31
Balance
12-24-56
$89,870.56
53,614.34
14,124.94
57.245.00
73,891.87
3,675.16
4,897.50
7,675.56
$304,994.93
May, 1957
635
REPORT OF KNOSTMAN & SMITH. CPA
INCOME AND EXPENSE OF THE ANNUAL
SESSION
INCOME AND EXPENSE OF THE PUBLIC
EDUCATION PROGRAM
December 24, 1955, to December 24, 1956
December 24, 1955, to December 24, 1956
INCOME
Booth Sales — (99 spaces)
.$23,757.50
EXPENSES
Scientific Meeting
Registration and Hotel Expense
Exhibit Expense
State Society and Officers Night ; ...
Promotion — Printing, Mailing, Postage and Scientific
Work Committee
Press Expense...-
Salaries
House of Delegates
Miscellaneous and Travel
4,199.77
985.14
3,804.27
3,253.73
3,840.85
2,652.95
4,999.92
1,365.66
1,124.09
TOTAL EXPENSES
.$26,226.38
LOSS ON ANNUAL SESSION.
,$(2,468.88)
INCOME AND EXPENSE OF THE MICHIGAN
CLINICAL INSTITUTE
December 24, 1955, to December 24, 1956
INCOME
Booth Sales — (75 spaces) $13,360.00
EXPENSES
Scientific Meeting 2,146.77
Registration and Hotel 768.33
Exhibit Expense 3,535.48
Promotion — Printing, Mailing, Postage and Committee
Meetings 3,654.05
Press Expense 1,692.92
Salaries - - . 1,399.92
Residents and Interns Conference 39.76
Miscellaneous 196.15
TOTAL EXPENSES $13,433.38
(LOSS) ON MCI $ (73.38)
“THE JOURNAL OF THE MICHIGAN STATE
MEDICAL SOCIETY”
December 24, 1955, to December 24, 1956
INCOME
Allocation from Dues $ 8,173.49
Subscriptions of Others 821.48
Advertising Sales 80,812.64
Reprint and Cut Sales 4,592.66
TOTAL INCOME $94,400.27
EXPENSES
Editors Expense $ 3,000.00
Printing, Mailing and Postage 54,431.14
Reprint and Cut 3,508.22
Salaries 12,699.9 6
Discounts and Commissions 19,551.75
Miscellaneous 112.50
TOTAL EXPENSES $93,303.57
GAIN ON The Journal $ 1.096.70
INCOME AND EXPENSE OF THE BUILDING
MAINTENANCE FUND
December 24, 1955, to December 24, 1956
INCOME
Allocation from 1956 Dues
EXPENSES
Maintenance — Utilities, Decorating,
Work, etc
Janitor — Salary
Taxes, Property
Insurance
Depreciation
Reception Room Furnishings
Parking Area
Remodeling
.$10,898.00
Supplies, Yard
2,789.71
1,814.99
815.65
541.88
1,756.79
111.72
658.48
2,072.30
TOTAL EXPENSES $10,561.52
GAIN ON BUILDING MAINTENANCE FUND $ 336.48
INCOME
Allocation from Dues.. $34,056.26
Miscellaneous (Commissions) 160.95
TOTAL INCOME (Note 1) $34,217.21
EXPENSES
Committee Meetings 149.11
Equipment and Repairs 1,442.74
Printing, Mailing and Postage 3,796.46
Office Supplies 969.81
Salaries — 14,554.50
Telephone and Telegraph 1,367.50
Travel and Entertainment 6,410.41
Publications, Pamphlets and Clippings 2,279.32
Radio, Television and Cinema 3,632.08
Miscellaneous 595.65
Exhibit Expense ...» 1,621.78
TOTAL EXPENSES $36,819.36
LOSS DURING PERIOD $(2,602.15)
Note 1
This does not include $27,245 allocation of dues specifically set
aside for the Public Education Reserve.
INCOME AND EXPENSE OF THE PUBLIC
SERVICE ACCOUNT
December 24, 1955, to December 24, 1956
INCOME
Allocation from Dues $19,071.51
EXPENSES
Salaries $12,285.10
Telephone and Telegraph 171.75
Rural Health Conference 258.72
Travel and Entertainment 2,962.06
TOTAL EXPENSES $15,677.63
GAIN DURING PERIOD .$ 3,393.88
INCOME AND EXPENSE OF THE RHEUMATIC
FEVER CONTROL PROGRAM
December 24, 1955, to December 24, 1956
INCOME
Grant from Michigan Heart Association $10,000.00
EXPENSES ( Central Office)
Committee meetings .; 244.14
Equipment and Repairs
Payroll Taxes 332.90
Printing, Mailing and Postage 1,826.02
Office Supplies
Salaries — Administrative and Office 11,600.07
Travel 900.30
Fellowships 2,875.00
Laboratory Aid Plan
Telephone and Telegraph
TOTAL CENTRAL OFFICE EXPENSES $17,778.43
CONTROL CENTERS
Alpena $ 200.00
Ann Arbor 357.50
Bay City 780.00
Benton Harbor 165.00
Detroit 500.00
Grand Rapids and Muskegon 3,200.00
Jackson
Kalamazoo 1,142.75
Lansing
Petosky
Pontiac and Royal Oak 37.00
Saginaw
Sault Ste. Marie
Traverse City 868.00
TOTAL CONTROL CENTERS $ 7,250.25
TOTAL EXPENSES $25,028.68
LOSS DURING PERIOD
636
.$(15,028.68)
JMSMS
REPORT OF KNOSTMAN & SMITH, CPA
INCOME AND EXPENSE OF THE PROFESSIONAL
RELATIONS ACCOUNT
December 24, 1955, to December 24, 1956
INCOME
Allocation from Dues $28,607.23
EXPENSES
Rent to Wayne County Medical Society $ 480.00
Salaries 14,824.59
Telephone and Telegraph 764.22
Travel and Entertainment 5,710.87
National Meeting Expense 1,263.47
Public Relations — County Secretarys’ Conference 6,225.04
County Society and Field Secretarys’ Meetings 306.68
Woman’s Auxiliary 940.16
TOTAL EXPENSES $30,515.03
LOSS DURING PERIOD $(1,907.80)
MSMS ANNUAL MEETING
September 25-26-27, 1957
Civic Auditorium, Pantlind Hotel
Grand Rapids
—* Make your hotel reservation now.
SECURITIES OWNED
December 24, 1956
UNITED STATES GOVERN-
MENT SECURITIES
Savings Bonds — Series “G”
Savings Bonds — Series <CG”
Treasury Bond — Series “B” 2 3A%
Savings Bonds — Series “K” 2.76%
Savings Bonds — Series “K” 2.76%
Treasury Bond — 2%%
Treasury Bond — 2I//2%
Treasury Bond — 2XA%
Treasury Bond — 2I/2%
Time Certificate — Michigan
National Bank, 2I/2%,
Dated 3-16-55
Time Certificate — Michigan
National Bank, 2!/2%,
Dated 3-18-55
BONDS HELD FOR PUBLIC
EDUCATION PROGRAM
Savings Bonds — Series “G”
Interest
Received
Cost
Redemption
Purchases Amortization
Cost
Interest
to Last
Maturity
Face
12-24-55
Prices
during
Debit or
12-24-56
Paid on
Interest
Date
Value
(Book Value)
12-24-56
Period
(Credit) (Book Value) Purchase
Date
5-1-58
$ 5,000.00
$ 5,000.00
$ 4,910.00
$
$ $
5,000.00
$
$ 125.00
3-1-60
5,000.00
5,000.00
4,850.00
5,000.00
125.00
4-1-80/75
8,000.00
8,169.58
8,000.00
(8.92)
8,160.66
220.00
6-1-66
45,000.00
45,000.00
43,875.00
45,000.00
1,242.00
7-1-66
4,000.00
4,000.00
3,880.00
4,000.00
110.40
6-15-62/59
25,000.00
23,265.63
24,375.00
208.33
24,583.33
107.58
562.50
3-15-70/65
10,000.00
9,760.94
8,812.50
26.56
9.787.50
250.00
11-15-61
25,000.00
23,687.50
24,164.06
167.19
24.331.25
276.44
625.00
11-15-61
Six months
Notice Subject
35,000.00
33,162.50
33,665.63
266.88
33,932.51
197.35
437.50
to Renewal
25,000.00
25,000.00
25,000.00
25,000.00
Six months
Notice Subject
to Renewal 15,000.00
15,000.00
15,000.00
15,000.00
375.00
8-1-58 30,000.00
30,000.00
29,370.00
30,000.00
750.00
$232,000.00
$146,930.52
$223,813.13 $82,204.69
$660.04 $229,795.25 $581.37
$4,822.40
PROPERTY AND DEPRECIATION ALLOWANCE
December 24, 1956
Date
Acquired
Land 1951
Building 1951
BUILDING IMPROVEMENTS
New Building Entrance
Remodel Basement and Storeroom
BUILDING EQUIPMENT 1952
Lighting 1952
Boiler
PARKING LOT 1953
LOT ADJOINING OFFICE BUILDING 1952
This is part of the report of The Council MSMS. See
pages 364-376 in the March, 1957 number.
May, 1957
Depreciation
Estimated
Depreciation Depreciation
Allowance
Life
Expense
Allowance
Cost
Prior Years
(Years)
1956
12-24-56
$10,000.00
$
$
$
34,500.00
5,050.00
30
1,150.00
6,200.00
44,500.00
5,050.00
1,150.00
6,200.00
3,917.85
326.50
30
130.60
457.10
1,746.21
30 (6 mos. )
29.10
29.10
$ 5.664.06
$ 326.50
$ 159.70
$ 486.20
$ 2,121.50
$ 565.72
15
$ 141.43
$ 707.15
1,714.59
457.14
15
114.30
571.44
3,836.09
1,022.86
255.73
1,278.59
1,913.60
478.40
10
191.36
669.76
6,000.00
$61,913.75
$6,877.76
$1,756.79
$8,634.55
637
Michigan Foundation for Medical and Health Education
PRESIDENT S ANNUAL REPORT
By Earl Ingram Carr, M.D.
Lansing, Michigan
Some added satisfaction can be conveyed by this
twelfth annual report to the Members and Trustees
of the Michigan Foundation for Medical and Health
Education, Inc. Monetary advancement has occurred
as will be indicated here and by later reports.
The Trustees are most happy to announce acceptance
of appointment to the board by Mr. Howard C. Bald-
win to fill the vacancy left by the death of our valued
Trustee, Mr. C. Stewart Baxter. Mr. Baldwin is a dis-
tinguished lawyer, Trustee of the Kresge Foundation
and director of various corporations and financial insti-
tutions. You will remember the part he played in the
magnificent contribution of the Medical Research and
Library Structure to the University of Michigan by
the Kresge Foundation. Many of us attended the
impressive ceremonies at the dedication.
The various activities and sponsorships, from year to
year enumerated and reported, have been assumed
through 1956. The business of the corporation has
been faithfully conducted throughout the year and the
officers and committees responded to needs and requests
as they arose.
In The Journal of the Michigan State Medical
Society entitled “As the Physician Serves His Patient,
So His Society Serves the Public,” the story of the
Foundation is told on pages 1326 and 1327 under the
title “Organized Aid to Medical and Health Education."
Reprints of this article are available at the secretary’s
office.
The Michigan Foundation Annual Lecture was de-
livered at the Clinical Institute in Detroit on March
7, 1956, by Doctor Alton Oschner of New Orleans on
the subject of “What's New in Lung Cancer.” The
Biddle Annual Lecture was delivered in September by
Lawrence A. Hafstad, Ph.D., of General Motors Cor-
poration. His subject was “The Future of Atomic En-
ergy and Medicine.” Both lectures are financial re-
sponsibilities of the Foundation.
Processed, granted and advanced loans under the
Revolving Fund Plan have aggregated to date $15,-
263.00 to nine individuals. One loan in 1951 and a
second loan to another student in 1953 have already
been repaid in full making a return of $3,100.00 In
another instance $1,500.00 remains not yet advanced.
The outstanding loans at the moment rest at $10,663.12.
The Rural Health Conference for 1956 was held last
week on January 16, 17, and 18, at the Kellogg Center
on the campus of Michigan State University. This
three-day affair was generally regarded as one of the
most successful with an attendance of at least 300.
168 attended the banquet and 24 presidents of vari-
ous Michigan health organizations were present. Over
40 speakers and resource people participated. The
program was divided by days, the first, Professional
Day, the second, Rural Health Day, and the third,
Community Health Day. The Michigan Foundation
was credited as being the financial sponsor and there
were 104 listed co-sponsors.
Gifts during 1956 exceeded $11,000.00. $2,313.12
was drawn upon the allocated $6,000.00 for the Student
Loan Fund by the Ingham County Medical Society.
The balance of this allocation earned $72.19 in interest
making the total balance $3,759.07 to be utilized under
the terms of the gift. Setting an example for other
county medical societies, the Barry County Medical
Society donated and delivered $5,000.00 this year.
They stipulate that it be used for residents of their
county who need supplemental financial aid as medical
students under the Foundation Student Aid Revolving
Fund Plan. No applicants under this gift have yet
appeared. Appreciation of this generosity has been ex-
pressed by the trustees by special communication and
by editorial in The Journal of the State Society.
Contributions of $1,000.00 each have been received from
the Women’s Auxiliary of the Wayne County Medical
Society and from the estate of the late Henry A. Luce,
M.D. Other contributions under the LeFevre Birth-
day Plan and otherwise, aggregate for the year $2,360.00.
Our investment portfolio yielded for the year $3,543.84
in interest and dividends.
The auditors show total reserves of $127,332.90 be-
sides redemption value increase of $5,431.11 and the
balance of allocation by Ingham County Medical So-
ciety of $3,759.07 makes a total of $136,523.08 as a
net worth of the Foundation on the audit date.
Increase of diversity and number of activities by the
Foundation depends upon money. General acceptance
of the LeFevre Birthday Plan would make regular an-
nual income. Remember the Foundation on your birth-
day, just before or just after your health audit.
January 23, 1957.
REPORT OF THE SECRETARY
By Wm. J. Burns, LL.B.
Lansing, Michigan
The Secretary has executed the duties of his office Board of Trustees and with the helpful guidance of
according to the By-Laws and as provided in Roberts President Carr.
Rules of Order, pursuant to the instructions of the On January 24, 1956, the Woman’s Auxiliary to the
638 JMSMS
MICHIGAN FOUNDATION FOR MEDICAL AND HEALTH EDUCATION
Wayne County Medical Society contributed $1,000.00
to the Student Loan Revolving Fund, with certain
specifications attached to the gift which were noted
by the Foundation’s Board of Trustees, January 25,
1956.
On February 4, 1956, the late Henry A. Luce, M.D.,
devised $1,000.00 to the Foundation, the gift contain-
ing a special earmarking purpose: for research into
physical causes of mental illness.
On November 1, 1956, the Barry County Medical
Society contributed $5,000.00 to the Foundation, ear-
marked for purpose of loans to medical students, resi-
dents of Barry County.
The Michigan Foundation for Medical and Health
Education Lecture, to be given at the 1957 Michigan
Clinical Institute — with the speakers’ expenses to be
paid out of the Biddle Fund to the Foundation — will
be presented March 13 by Charles B. Huggins, M.D.,
of Chicago who will speak on the “Control of Human
Cancers by Endocrinologic Methods.”
The Student Loan Fund has been utilized to aid the
medical education of the following medical students:
Robert E. Pearson Wayne State University
Robert O. Webster University of Michigan
A1 Edmond Eary, Jr University of Michigan
Benjamin J. Koepke Wayne State University
Donald P. Jackson Wayne State University
John C. Shelton University of Michigan
Russell F. Smith University of Michigan
Paul C. Linnell University of Michigan
Richard Morin University of Michigan
January 23, 1957
CHRONIC DISEASE— A CHALLENGE
TO THE MEDICAL PROFESSION
(Continued, from Page 618)
each specialist working more or less independ-
ently needs objective scrutiny — and such modifica-
tion as may be necessary.
Conclusion
A number of hardy pioneers have already at-
tacked the medical frontier of chronic disease.
Each day brings further progress. All segments
of American medicine are called upon to push
forward in developing new scientific knowledge
and to fully utilize existing knowledge in meeting
today’s chronic disease problems. Many of these
can be prevented. The effect of others can be
minimized, or the condition arrested.
In moving toward these goals, it would profit
us well, I think, to consider Dr. Franklin
Murphy’s4 good advice. He reminds us that:
“These problems have many facets, scientific,
economic, and social, and will tax our greatest
combined efforts. They will require imagination
and objectivity for their solution. New paths
must be blazed (as indeed is the case in many
other aspects of our culture today) . Their effec-
tive resolution will be hastened as we blend public
and private effort on the basis of logic and need.”
References
1. Hess, Elmer, M.D.: Address of president before
the house of delegates at the annual meeting of
the American Medical Association in Chicago, Il-
linois, June 11, 1956. J.A.M.A., 161:734-738
(June 23) 1956.
2. Homburger, F. : The medical care of the aged and
chronically ill. Boston: Little, Brown and Com-
pany, 1955.
3. Kurlander, A. B.: Preventive aspects of chronic
disease. J. Nat. M. A., 48: March, 1956.
4. Murphy, F. D.: Health — Public or Private? Am.
J. Pub. Health, 46:15-18 (January) 1956.
CHRONIC DISEASE— A CHALLENGE
TO PUBLIC HEALTH
(Continued from Page 622)
Conclusion
Many health departments have not yet faced
up to their unmistakable responsibility or con-
centrated their full potential in the chronic disease
field. In public health, as in any other important
activity, we must address our efforts to problems
as they are- — not as we should like to see them.
This leaves us no choice. The chronic illness
problem is of such magnitude and complexity that
no one group, no one profession can hope to solve
it alone. We must assure a co-ordinated effort
of the necessary groups and disciplines if we are
to achieve success.
The ideal response to this challenge has been
described as “unity of services.” Preventive, cura-
tive, and restorative programs — both public and
private — must be combined to accomplish that
“unity.”
We have, as a nation, concentrated our re-
sources in a commendable fashion on the prob-
lems of youth and youth’s environment. The
job ahead in the health field is to effect a com-
parable concentration on the problems that gen-
erally manifest themselves in adult life.
May, 1957
639
Michigan’s Department of Health
Albert EL Heustis, M.D., Commissioner
NEW BIRTH, DEATH RECORDS SET
Provisional vital statistics for 1956. compiled in the
state health department, show six new records set in
Michigan.
The state’s birth rate reached an all-time high of
27.4, slightly over the previous record rate of 27.3
established in 1954. Births totaled 205,650, exceeding
the 200,000 mark for the first time in the state’s
history. The 100,000 mark was passed in 1941.
The death rate of 8.5 in 1956 was an all-time low,
though only a slight gain over the 8.6 of 1954.
The vital index, the birth-death ratio, reached 320
in 1956. The previous high was 316, recorded in 1954.
The infant death rate stood at 24.6, an all-time low.
This was a slight gain over the 24.8 recorded in 1955
but still high for a state like Michigan.
The state’s population totaled 7,516,000 in 1956,
a gain of 1,144,234, or 18 per cent over the 1950
figure. This makes Michigan the fastest growing state
in the Midwest.
Provisional 1956 figures for the United States include:
birth rate, 29.9; death rate, 9.4; vital index, 266; and
infant death rate, 26.1.
NEW HOSPITAL MANUAL IN PREPARATION
First draft of a manual to be used as a companion
to the Michigan Department of Health publication,
“Rules and Minimum Standards for Hospitals,” has
recently been completed by staff members. It is designed
to clarify some of the rules and to suggest acceptable
procedures for patient care, especially in the maternity
department.
The preliminary draft of the manual is being re-
viewed by a number of physicians, nurses and hospital
administrators and the detailed and thoughtful sugges-
tions that are coming to the Commissioner from this
busy group are greatly appreciated. It is the same type
of helpful advice that was given the department when
it was developing rules and standards after being given
responsibility in hospital licensing in 1951.
It will be several months before the manual is ready
for distribution.
OCCUPATIONAL HEALTH ENGINEERS
AID INVESTIGATION
Department occupational health engineers, working
with plant engineers and representatives of management
and labor, took an active part in investigating the recent
paint solvent explosion in the frame painting building
of an automobile manufacturing plant. In the explosion,
some twenty-two workmen were injured and four have
died.
Immediate plans for rebuilding the frame painting
area were drawn up by plant engineers. These plans
were discussed in detail at several conferences and new
safety features proposed were examined thoroughly
by department engineers. As one checking procedure
a pilot production run was made to determine whether
design specifications were being met. On the basis of
results, additional improvements were suggested and
put into effect.
At a meeting between department and plant engi-
neers, state and municipal officials and company and
union representatives, results were reviewed and addi-
tional investigative procedures outlined.
At a final meeting, department engineers reported
that it was their opinion that the company had installed
a greatly improved system so far as safety was con-
cerned and that within the limits of the present method
of frame painting, everything within reason and good
practice had been installed. It was emphasized that
there is no industrial painting operation of a similar
nature that is 100 per cent explosion proof and that
this makes of first importance the installation and
maintenance of measures and precautions that prevent
injury to the workers in the event of an explosion.
DEPARTMENT MOVES INTO NEW ADDITION
The division of engineering and two sections of the
division of disease control, records and statistics are
now occupying their new quarters in the department’s
recently completed addition. The new two-story build-
ing adjoins the Administration Building on the south.
BABY SITTER HANDBOOK AVAILABLE
A recent publication that is much in demand from
the department is a 30-page booklet entitled “Baby
Sitting.” The material was prepared by a sub-committee
of the Interdepartmental Staff on Children and Youth.
The booklet emphasizes the responsibilities of the sitter
to the family and the family to the sitter, discussing
safety precautions, understanding the behavior and needs
of children at different age levels, and ways to help
children to play happily. The content is sufficiently de-
tailed to serve the needs of the many courses that are
now being given in junior and senior high schools for
the training of boys and girls in baby sitting.
Copies of the booklet are available upon request.
In orbital tumors, a presumptive diagnosis can be
made on the basis of six millimeters or more of unilateral
exophthalmos. All other symptoms are secondary and
offer only inconclusive hints to the physician.
* * *
Malignant melanoma and retinoblastoma are the
most common malignant tumors of the eye.
640
TMSMS
CONFIRMED THERAPEUTIC UTILITY
Pro-Banthine!..
A Primary Drug in Peptic Ulcer
Among the many clinical indications for
Pro-Banthine (brand of propantheline bro-
mide), peptic ulcer is foremost. During
treatment, Pro-Banthine has been shown
repeatedly to be a singularly valuable agent
when used in conjunction with diet, antacids,
sedation and psychotherapy as required.
Lichstein and his associates* report that
Pro-Banthine “proved almost invariably
effective in the relief of ulcer pain, in de-
pressing gastric secretory volume and in
inhibiting gastrointestinal motility. The
incidence of side effects was minimal. . .
The therapeutic utility and effectiveness of
Pro-Banthine in the treatment of peptic ulcer
are repeatedly confirmed in the medical lit-
erature. Dosage: One tablet with each meal
and two tablets at bedtime. G. D. Searle &
Co., Chicago 80, Illinois, Research in the
Service of Medicine.
*Lichstein, J.; Morehouse, M. G., and Osmon, K. L.: Pro-
BanthTne in the Treatment of Peptic Ulcer. A Clinical
Evaluation with Gastric Secretory, Motility and Gastro-
scopic Studies. Report of 60 cases. Am. J. M. Sc. 232; 156
(Aug.) 1956.
May, 1957
Say you saw it in the Journal of the Michigan State Medical Society
641
ACETYLCARBROMAl TABLETS
• Proved safe and effective by 6 years’
clinical use.
• Soothes the central nervous system,
produces calmness without hypnosis.
• Non-toxic, non-cumulative, non-addict-
ing, no known contraindications.
• Does not impair mental or physical
function.
• Orally effective within 30 minutes for
sustained action up to 6 hours.
• Economical.
Indications: Tension, nervousness,
anxiety and muscular spasm.
Supplied: White round tablets
Acetylcarbromal 5 gr. in bottles
of 100, 1000.
Write for samples and literature
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3021 WABASH, DETROIT 16, MICHIGAN
In Memoriam
Eugene V. Gourley, M.D., forty-four, Detroit prac-
titioner for eleven years and staff physician at Mt.
Carmel Mercy Hospital. Bom in Mexico, he was a
graduate of the University of Detroit and Wayne State
University College of Medicine, and had interned at
Grace Hospital. Dr. Gourley served in the Army
Medical Corps during World War II, attaining the
rank of lieutenant colonel. He was a member of the
Wayne County Medical Society. He died suddenly in
his office March 8, 1957, of a heart attack.
* * *
James W. MacMeekin, M.D., forty-nine, prominent
Saginaw surgeon and chief of staff of Saginaw General
Hospital. A native of Saginaw and son of a Saginaw
doctor, he graduated from the University of Michigan
Medical School. During World War II he served as a
Navy doctor with the rank of lieutenant commander.
Doctor MacMeekin was an amateur pilot of about 15
years’ experience. He was a member of the Saginaw
County Medical Society. He died March 16, 1957,
when his private plane crashed.
* * *
Sylvester J. O’Connor, M.D., thirty-nine, Ann Arbor
surgeon and Associate Professor of Surgery at the Uni-
versity of Michigan Medical School. Born in Burbank,
South Dakota, he received his Bachelor of Science de-
gree from Trinity College, Sioux City, Iowa, and was
graduated from the University of Michigan Medical
School in 1942. During World War II, he was associ-
ated with the Army Medical Corps, stationed at Uni-
versity Hospital. He was a member of the Washtenaw
County Medical Society. He died suddenly March 10,
1957. ’
* * *
David H. O’Donnell, M.D., eighty-seven, Detroit
practitioner for sixty-six years and physician to many
prominent Detroit families. Born in Wardsville, Ontario,
he graduated from the Detroit College of Medicine in
1891. During his career, Doctor O’Donnell delivered
more than 7,000 babies, among them the late Edsel
B. Ford. Organizer of Providence Hospital in 1908,
he later was chief of staff of the hospital for thirteen
years. He was also medical director of St. Joseph’s
Retreat, Dearborn, for thirty years. He was a member
of the Wayne County Medical Society and an Emeritus
Member of the Michigan State Medical Society. He
died March 18, 1957.
* •* *
Frederick W. Palmer, M.D., fifty, superintendent of
the Mt. Pleasant State Home and Training School since
1949. Born in Yale, Michigan, he received his M.D. de-
gree from the University of Michigan. He was a mem-
ber of the Gratiot-Isabelle-Clare County Medical Society.
He died suddenly March 23, 1957.
* * *
Melvin D. Roberts, M.D., seventy-seven, Hancock
general practitioner for fifty-three years. Born in Char-
(Continued on Page 644)
642
Say you saw it in the Journal of the Michigan State Medical Society
.TMSMS
come to
M a HAPPY HOLIDAY
There are many things to see and do when you
come to Dearborn. Here, nearby The Dearborn Inn,
you can enjoy the amazing collection of Americana
in the Henry Ford Museum, the early workshops
and actual homes of great Americans in Greenfield
Village and the fabulous Ford Rotunda, gateway to
the huge Ford Rouge Plant. While in Dearborn or
the Detroit area, you’ll like the friendly atmosphere
and pleasant lodgings at the Inn.
enjoy
THE INN’S HOSPITALITY
There’s every modern
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Free parking.
For further details or accommodations,
write or call The Dearborn Inn.
visit
HENRY FORD MUSEUM
GREENFIELD VILLAGE
FORD ROTUNDA
ROUGE PLANT
The Dearborn Inn • Oakwood Boulevard • Dearborn, Mich. • LOgan 5-3000 • Richard D. McLain, Manager
Qastmlme
the creamy antacid
WORKS IN SECONDS
PROTECTS FOR HOURS
Superior Buffering Capacity
Gastralme stands out in comparison with other
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acid within 5 minutes and a pH of 6.4-7. 1 was main-
tained for 120 minutes. After 150 minutes, the
s
Gastralme mixture continued to show a pH of 5.2, and
it was 180 minutes before the pH dropped to 2.9.
For treatment of
Peptic Ulcer
and control of
Gastric
Hyperacidity
Literature and
clinical samples
available on request .
MEYER & COMPANY
16361 Mack Avenue • Detroit 24, Michigan
May, 1957
Say you saw it in the Journal of the Michigan State Medical Society
643
IN MEMORIAM
ANNOUNCING
A Completely New and Timely Addition
to the Year Book Series
The Year Book Of
CANCER
Edited by Randolph Lee Clark, Jr., M.D., and
Russell W. Cumley, Ph.D., University of Texas
M.D. Anderson Hospital and T umor Institute. With
the assistance of an editorial board of 27 and 93
consulting editor-authorities.
The Year Book of Cancer brings together under one
cover, and for the first time in any language, detailed
abstracts (with illustrations and editorial comments)
of the best international journal articles on all aspects
of the cancer problem. Presented in the concise, terse
style for which the Year Book Series is so widely used
and appreciated, the truly significant work in research
and clinical management now becomes available in a
compact, convenient quick-reference format never
before obtainable. Ready June. Approx. 475 pages,
190 illustrations. Price, $7.50.
FIELDS & SEED’S
Clinical Use of RADIOISOTOPES
Just Ready — A simplified, working manual — not a
tome intended exclusively for those with specialized
interests.
Principal emphasis is on established applications of
isotopes in diagnosis and treatment — Thyroid Evalu-
ation, Treatment of Toxic Goiter, Therapy of Blood
Diseases, Cancer and Cardiac Therapy, etc.
Additional discussions deal with the radioisotope
laboratory, materials, apparatus, radiation safety, glos-
sary of terms, signs, symbols, etc.
By 17 Authorities. Edited by Theodore Fields , ALS.,
Assistant Director Radioisotope Laboratory , V A Hospital,
Hines, Illinois, and Lindon Seed, M.D., Clinical Associate
Professor of Surgery, College of Medicine, University o J
Illinois. 384 pages; illustrated. $9.50.
THE YEAR BOOK PUBLISHERS, INC.
200 E. Illinois St.f Chicago 11, III.
Please send for 1 0 days’ examination.
YearBook
PUBLISHERS
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□ Year Book of Cancer. $7.50
I I Clinical Use of Radioisotopes 9.50
Name
Street
Zone State
Melvin D. Roberts, M.D.
(Continued from Page 642 )
lotte, Michigan, he graduated from the University of
Michigan Department of Medicine and Surgery in 1903.
He did military service in both World War I and
World War II, retiring to civilian life in 1945 with
the rank of Commander. He was a member of the
Houghton-Baraga-Keweenaw County Medical Society
and a Life Member of the Michigan State Medical
Society. He died March 8, 1957, after a long illness.
* * *
George W. Robinson, seventy-nine, Detroit obstetrician
for fifty years. Born in Bradford, Ontario, he was
graduated from the Detroit College of Medicine in
1905. He had been a consultant staff member at Detroit
Memorial Hospital before his retirement in 1948. He
was a member of the Wayne County Medical Society,
and a Life Member of the Michigan State Medical
Society. He died March 10, 1957.
* * *
Joseph Burgess Whinery, M.D., ninety, of Winter
Park, Florida, former Grand Rapids practitioner for
fifty-seven years and father of State Representative
Thomas J. Whinery. Born in Wilmington, Ohio, he
graduated from the University of Michigan Medical
School in 1892. During World War I, he served as a
major in the Army Medical Corps. He was a member
of the Kent County Medical Society and an Emeritus
Member of the Michigan State Medical Society. He
died March 21, 1957.
S AMMON D PLEASANT LODGE
Offers to the elderly and chronically ill
Peace and quiet. Freedom oi a large and richly
iumished home and acres oi lawns and wooded
rolling grounds, scientifically prepared tasty
meals, congenial companionship. A real
"Home away from Home''
Approved by the American Medical Association
and Michigan State Department of Social Wel-
fare— Highly recommended by members of the
Medical Profession who have had patients at
the Lodge.
For further information write toi
SAMMOND PLEASANT LODGE
124 West Gates Street
Romeo. Michigan
City
644
Say you saw it in the Journal of the Michigan State Medical Society
.TMSMS
F/tec the anemic
FROM
IRON INTOLERANCE
high
hemoglobin
response
excellent tolerance
FERGON
BRAND OF FERROUS GLUCONATE
FOR ALL SIMPLE IRON DEFICIENCY ANEMIAS
SUPPLIED: Fergon tablets of 5 grains, bottles of 100 and 500.
Fergon tablets of 2Vi grains, bottles of 100.
Fergon elixir 6% (5 grains per teaspoonful),
bottles of 16 fl. oz.
May, 1957
Say you saw it in the Journal of the Michigan State Medical Society
645
NEWS MEDICAL
MICHIGAN AUTHORS
M. K. Newman, M.D., Detroit, is the author of an
article, entitled “Diagnosis, Management, and Prob-
lems of Muscular Dystrophy,” published in the Detroit
District of the Michigan State Nurses Association
Journal, March, 1957.
Charles S. Stevenson, MJD., Harold A. Ott, M.D.,
Palmer E. Sutton, M.D., and Mary Lou Bard, M.D.,
Detroit, are the authors of an article, entitled “Maternal
Deaths from Obstertic Anesthesia and Analgesia: Can
They Be Eliminated?” published in Obstertics and
Gynecology and condensed in American Practitioner and
Digest of Treatment, February, 1957.
Carl T. Javert, M.D., New York, is the author of an
article, entitled “Program of Therapy for Repeated
Abortion Patients,” published in The Journal of the
Michigan State Medical Society, July, 1955, and con-
densed in the American Practitioner and Digest of
Treatment, February, 1957.
Leon S. McGoogan, M.D., Omaha, is the author of
an article, entitled “Endometriosis,” published in The
Journal of the Michigan State Medical Society, July,
1955, and condensed in American Practitioner and
Digest of Treatment, February, 1957.
Robert E. L. Berry, M.D., F.A.C.S., and William
Rottschafer, M.D., Ann Arbor, are the authors of an
article, entitled “The Lymphatic Spread of Cancer of
the Stomach Observed in Operative Specimens Removed
by Radical Surgery Including Total Pancreatectomy.”
published in the Journal of Surgery, Gynecology and
Obstetrics, March, 1957.
Seward E. Miller, M.D., Ann Arbor, is the author
of an article, entitled “Medical Aspects of Radiological
Health,” presented in part at the Ninth Health Confer-
ence for Business and Industry in Houston, September,
1956, and published in Industrial Medicine and Surgery,
March, 1957.
Mathew Alpem, Ph.D., Ann Arbor, is the author of
an article, entitled “The Position of the Eyes During
Prism Vergence,” published in A.M.A. Archives of Oph-
thalmology, March, 1957.
J. Reimer Wolter, M.D., Robert L. Goldsmith, M.D.,
Ann Arbor, and Roland L. Phillips, M.D., Eloise, are
the authors of an article, entitled “Histopathology of
the Star-Figure of the Macular Area in Diabetic and
Angiospastic Retinopathy,” published in A.M.A. ^4r-
chives of Ophthalmology , March, 1957.
Irving Shapiro, M.D., Minneapolis, Clifford W. Gur-
ney, M.D., and Arthur J. Solari, M.S., Ann Arbor, are
the authors of an article, entitled “Radioiodine Content
of Aqueous, Vitreous, and Lens,” published in A.M.A.
Archives of Ophthalmology, March, 1957.
Carl F. List, M.D., Grand Rapids, is the author of
an article, entitled “Disturbances of Eye Movements as
a Neurologic Problem,” published in the New England
Journal of Medicine, March 8, 1956, and reprinted in
Guildcraft, February, 1957.
R. S. Knighton, M.D., and J. D. Fox, M.D., Detroit,
are authors of an original article, “Diagnosis and Treat-
ment of Eosphinophilic Granuloma of Skull,” which ap-
peared in JAMA December 1, 1956, page 1294.
J. P. Ferguson, M.D., V. Z. Linn, M.D., J. A. Sheets,
Jr., M.D., and M. M. Nickels, M.D., Traverse City,
are authors of an original article, “Methyplenidate
(Ritalin) Hydrochloride Parenteral Solution,” which ap-
peared in JAMA of December 1, 1956, page 1303.
* * *
Three new employees have been added to the AMA
headquarters staff in Chicago. Two of them — John
Guy Miller of Louisville and Joseph Miller of Lexing-
ton, Kentucky — joined the staff of the Council on
Medical Service on April 1. They will be members
of what is commonly known at headquarters as a
“research task force” which will be established to handle
special projects for the Council’s eight different com-
mittees. It is planned to have three or four members
on this force, who will work on such specific assign-
ments as Hill-Burton, the new disability program under
Social Security, the relationship of private physicians to
physicians in public health, and other projects.
John Guy Miller has been serving as field repre-
sentative for the Kentucky State Medical Association
since 1952; prior to that job, he served in a similar
capacity with the Michigan State Medical Society.
* * -si-
Physical Medicine and Rehabilitation. — Highland
View Hospital, Cleveland, Ohio, in affiliation with
Western Reserve University, is offering a six-month
post-graduate Course in Physical Medicine and Rehabil-
itation. The Course will be from July 1 to December
31, 1957. Its purpose is to provide didactic and ap-
plicatory training in the principles and practices of
Physical Medicine and Rehabilitation, with particular
emphasis on chronic illness. The course is designed pri-
marily to enhance the proper practice of rehabilitation
methods by allied specialists. Fellowships are avail-
able for this course from the Office of Vocational Re-
habilitation, Department of Health, Education and
Welfare. Application should be made to Highland
View Hospital, Cleveland 22, Ohio.
(Continued on Page 648 )
646
TMSMS
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LOCALIZED ANTIBACTERIAL ACTIVITY
Sulfacetamide— eliminates mixed infections rapidly because of its unusual
solubility in acid urine common to bacterial invasion of the urinary tract. No
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—the dual activity of SULFID with the well-known antispasmodic effect of
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PHARMACAL COMPANY columbus 16, ohio
May, 1957
Say you saw it in the Journal of the Michigan State Medical Society
647
NEWS MEDICAL
BURDICK UT-4
ULTRASONIC UNIT
The acceptance of ultrasonic therapy as a standard
office procedure points up the need for an efficient
compact unit.
Combining light weight, effective radiating inten-
sity and automatic control features, the UT-4 sets
a new standard of economy and convenience in
ultrasonic treatment for every physician’s office.
Among the many features of the Burdick UT-4 are:
•Weight — 25 pounds
• Size — • 16 x 12x9 inches
• Radiating area — 6 cm2
• Effective intensity — 21/2 watts/cm2
• Automatic timer
• Meter — registers intensity and output
• Price — under $400
For a full appreciation of the many features of
the UT-4 see your Burdick dealer — or write us
for information.
THE BURDICK CORPORATION, MILTON, WISCONSIN
THE G. A. INGRAM COMPANY
4444 Woodward Avenue, Detroit 1, Michigan
(Continued from Page 646)
Harry M. Nelson, M.D., Detroit, Chairman of the
Michigan Cancer Coordinating Committee, was guest
speaker at the Cancer Forum sponsored by A. C. of S.,
Georgia Division, in Atlanta on March 15. Dr. Nel-
son’s topic was “Value of Routine Vaginal Smears
and Proctoscopies in Cancer Detection.”
■*■ * *
The Sixth Annual Symposium for General Practi-
tioners on Tuberculosis and Other Chronic Pulmonary
Diseases will be held at Saranac Lake, New York,
July 8-12, 1957. For information on this Symposium,
sponsored by the American Trudeau Society, et al.,
write Henry W. Leetch, M.D., General Chairman,
P.O. Box 11, Saranac Lake, New York.
* * *
Fear: “A Doctor does not know from one day to
the next whether or not he will be on the rounds at
the hospital or under the boot of the political police
in jail,” comments Laszlo Kovasci, M.D., a Hungarian
refugee in Ann Arbor. “Doctors can be fired in one
minute on the charge of being ‘against the state.’
This usually happens whenever a qualified, reliable
Communist Party member is available to replace him.”
Dr. Kovacsi says that medicine has suffered greatly
under Communist domination.
* * *
Undergraduate scholarships worth $50,000 have been
established by the Upjohn Company of Kalamazoo for
the 1957-58 school year, including six for students who
plan to major in pre-medicine, pharmacy, engineer-
ing, or any of the chemical or biological sciences. For
information, write the Upjohn Company.
* * *
Did you know that babies are being born at a rate
of 480 an hour — 11,520 a day — 4,205,000 a year?
Did you know that deaths are occurring at a rate
of 171 an hour, 4,104 a day, and 1,498,000 a year?
Did you know that the net population increase of
the United States (including immigration) is 336 an
hour, 8,064 a day or 2,900,000 a year.
Did you know that since 1950 our population has
increased by 17,627,000 — more than equivalent to the
population of Canada? Our U. S. population by 1975
(less than twenty years from now) will increase to
220,800,000 — an increase of 31.2 per cent.
* * *
Construction of a $1,500,000 College of Nursing
building at Wayne State University, Detroit, will begin
in September, 1957, and will be ready for occupancy
in early 1960.
* * *
Construction of a new Children’s Hospital within
the University of Michigan Medical Center will give
Michigan its first complete children’s center providing
total care, including psychiatric, for the child, accord-
ing to a University of Michigan release which indicated
that the new 200-bed hospital will be constructed ad-
jacent to the existing 75-bed Children’s Psychiatric
Unit opened in December, 1955.
648
Say you saw it in the Journal of the Michigan State Medical Society
JMSMS
NEWS MEDICAL
Current information on tuberculosis indicates that
here are somewhat less than 400,000 active tubercu-
osis cases in the United States at any one time, ap-
iroximately one-third of which are hospitalized for
uberculosis, one-third are known cases at home, and
me-third are undetected cases. — Robert J. Anderson,
tf.D., Public Health Reports, February, 1956.
* * *
Sidney Friedlaender, M.D., Detroit, Michigan, was
me of the participants in the Panel discussions on
‘Present Concept of Therapy in Allergy with Cortisone
,nd Allied Drugs” and “Drug Sensitivities,” sponsored
ty the Honolulu County Medical Society, at Honolulu,
iawaii, on February 15, 1957.
* * *
Upper Penisula Medical Society members and their
vives will convene on June 21 and 22 at Houghton, in
he heart of the Copper Country’s beautiful vacation
and. Committees have been appointed by T. P. Wick-
iffe, M.D., President of the Society, and plans are well
inder way to make this sixty-fourth session an out-
tanding success, both from the scientific and social
tandpoint.
The Copper Country offers some of the country’s
nost beautiful scenery and a wide variety of vacation
ictivities. Doctors of the Lower Peninsula are urged
o mark the dates, and are cordially invited to attend
he meeting and enjoy a vacation. Information may be
ecured by writing to Secretary F. W. Larson, M.D.,
doughton.
The Seventh American Congress on Maternal Care
(formerly known as the American Congress on Obstet-
rics and Gynecology) is scheduled for the Palmer
House, Chicago, July 8-12, 1957. The five-day Congress
will present topics dealing with the interprofessional
approach to maternal and infant care. For information,
write the American Committee on Maternal Welfare,
116 South Michigan Avenue, Chicago 3, Illinois.
* * *
The United States Atomic Energy Commission has
announced the awarding of forty-eight unclassified life
science research contracts in the fields of medicine,
biology, biophysics, and radiation instrumentation, as
part of the AEC’s continuing policy of assisting and
fostering research and development in the fields related
to atomic energy. Among these awards is one to the
University of Michigan for the “Clinical Evaluation of
Teletherapy,” the investigators being F. J. Hodges,
M.D., and Isadore Lampe, M.D.
* * *
Home Town Care Program. On March 12, 1957,
the Central Office of the Veterans Administration re-
versed its position in regard to the proposed cancella-
tion of the Home Town Care Program for veterans
utilizing such intermediaries as Blue Shield. The states
involved in this problem were North Carolina, Wis-
consin, South Dakota, Colorado, Oregon, Washington,
California, the Territory of Hawaii and Michigan.
Dr. William Bromme had been named as spokesman
for the group. Mr. L. Gordon Goodrich was present,
Battle Creek Sanitarium
91st Tear of
Continuous Service
Ideal for Executives. Rest combined with med-
ical supervision and a physical examination.
Diagnostic and therapeutic service. Special De-
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therapy, Radiotherapy and Massage.
Well suited for treatment of metabolic disorders,
hypertension, obesity, arthritis and degenerative
diseases generally. All Sanitarium care is under
the immediate guidance of qualified physicians.
For rates and further information,
address Box 40
THE BATTLE CREEK SANITARIUM
Battle Creek, Michigan
Not affiliated with any other Sanitarium
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May, 1957
Say you saw it in the Journal of the Michigan State Medical Society
649
NEWS MEDICAL
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Medical Arts Supply Company
233 Washington S. E. Phone GL 9-8274
Grand Rapids 2, Mich.
Medical Arts Pharmacy
20-24 Sheldon S.E. Phone GL 9-8274
Grand Rapids 2, Mich.
representing the intermediary used in Michigan.
It was agreed that the uniform contract developed by
the representatives of these medical areas, which is, in
effect, the program as it has operated in Michigan for
over a decade, would be the standard uniform agree-
ment for this type of program; and that the reporting
forms as presently used in Michigan, would become the
official reporting forms in this program. It was the
opinion of those present that when the Veterans Ad-
ministration initiates the long term program these same
forms might be easily adapted for the purposes of the
new program. Certain items of administrative expense,
which in the past have been borne by the intermediary,
such as Michigan State Medical Service, would now
be taken care of by Veterans Administration. An ex-
ample of this is the printing and distribution of the
forms involved, the cost of which the Veterans Admin-
istration is assuming. Detroit Medical News , March 25,
1957.
* * *
University of Michigan Regional Conference on Hy-
pertension will take place in Ann Arbor, Michigan,
June 7-8, 1957, in recognition of twenty-fifth anni-
versary of the first production of Experimental Renal
Hypertension by Dr. Harry Goldblatt. Reports will
be presented on the Basic Mechanisms of Renal Hyper-
tension, including adrenal, neurogenic and renoprival
aspects. Overseas participants will include, among
others. Dr. Eduardo Braun-Menendez from Argentina,
and Drs. Goldblatt, Helmer, Wakerlin, Skeggs, Kohl-
staedt, Page, Kejdi and McCubbin from the Michigan
regional area. Those desiring to attend are urged to
write well in advance for information and reservations
to Dr. John Sheldon, Director, Department of Post-
graduate Medicine, University of Michigan Medical
School, University Hospital, Ann Arbor, Michigan.
* * *
Malaria Control. — The solution of the international
public health problem of highest priority in the Ameri-
cas was advanced one step forward by a special con-
tribution of $1,500,000, made by the United States
Government to increase the special fund of the Pan
American Sanitary Organization for malaria eradica-
tion.
Each year, some 250,000,000 persons are afflicted
with this disease throughout the world, approximately
2,500,000 dying of it annually. Here in the Americas
there are still extensive malarious areas and there are
only a few countries where it is non-existent or has
been eradicated. Malaria has been eradicated from the
United States, for instance, in only the past three
years.
* * *
Civil Aeronautics. — A new order makes medical cer-
tification of private pilots a more exclusive procedure.
Until now, any physician, even at times a chiropractor
could give the examinations. The new rule requires
that examinations be given only by Civil Aeronautics
Administration designated examiners, of whom there
are 1,800 in the land. There has been some delay,
but the rule should be in effect when this appears.
650
Say you saw it in the Journal of the Michigan State Medical Society
JMSMS
NEWS MEDICAL
A new bill in the House of Representatives would
authorize Walter Reed Army Institute of Research to
award Master’s and Doctor’s degrees, but it is being
delayed because of objection that the government should
leave awarding of degrees to the authorized educational
institutions.
* * *
The National Fund for Medical Education, being a
federally Congressional organization, makes a yearly
financial report. Grants to medical schools in 1956
totaled $3,066,079, compared with $2,657,434 in 1955.
Administrative expenses were $469,412, of which $230,-
079 covered salaries.
* * *
The Hill-Burton hospital program is now in its
eleventh year. To date, 3,332 projects have been ap-
proved, at a total estimated cost of $2,712,512,871, with
754 under construction. The total is 146,947 hospital
beds and 818 health centers.
* * *
M. K. Newman, M.D., Detroit, spoke before the
Factfinders Club, Tuller Hotel, February 26, 1957, on
“The Total Concept of Rehabilitation.” For the Staff
of Physical Medicine and Rehabilitation, University of
Michigan, he presented a talk, entitled “Practical As-
pects of Physical Medicine and Rehabilitation.” On
March 8, he presented a paper at the annual meeting
of the Greater New York Chapter of the American
Physical Therapy Association at the New York Coli-
seum. His subject was “Physical Medicine and Re-
habilitation in Geriatrics.” On March 22, he gave a
medical talk to the staff of physical medicine and re-
habilitation at the University of Illinois College of
Medicine, entitled “Rehabilitation Techniques in the
Management of Muscular Atrophy.”
* * *
Lewis Cohen, M.D., presented a paper entitled “Elec-
trovasography in the Study of Peripheral Vascular Dy-
namics” at the National Biophysics Conference in Co-
lumbus, Ohio, on March 5, 1957.
* * *
The American College of Surgeons held a Sectional
Meeting at the Royal York Hotel, Toronto, Ontario, on
March 25, 26, and 27, 1957. Michigan men participat-
ing in the program were Laurence S. Fallis, M.D.,
F.A.C.S., and Conrad R. Lam, M.D., F.A.C.S., Detroit;
Richard H. Meade, M.D., F.A.C.S., Grand Rapids; F.
Bruce Fralick, M.D., F.A.C.S., Ann Arbor; Reed M.
Nesbit, M.D., F.A.C.S., Ann Arbor; D. Emerick Szilagyi,
M.D., F.A.C.S., Detroit. Serving on the Board of
Regents are Reed M. Nesbit, M.D., Ann Arbor, and
Grover Penberthy, M.D., Detroit. Frederick A. Coller,
M.D., Ann Arbor, serves on the Advisory Council.
* * *
Auto Makers Urged to Work for Safety. — Manufac-
turers are the only ones who can incorporate safety
measures into autos, and if they don’t do so Congress
should act to force them. This in essence was the
May, 1957
Say you saw it in the Journal of the Michigan State Medical Society
651
NEWS MEDICAL
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Sc., 226:172, 1953.
THE G. A. INGRAM COMPANY
4444 Woodward Avenue, Detroit I, Mich.
testimony of a representative of the Michigan State
Medical Society, appearing before the special safety
subcommittee of the House Interstate and Foreign Com-
merce Committee. John D. Rogers, M.D., Bellaire,
the Michigan witness, also cited a recommendation of
the A.M.A. House of Delegates, adopted December,
1955, which urged Congress to authorize a national
body to approve and regulate auto safety standards. —
AMA Washington Letter, March 29, 1957.
* * *
General hospital admission x-rays in
Michigan led to the discovery of 500
previously unknown active cases of tu-
berculosis in 1955, the latest year for
which figures are available.
Not quite half of the admissions for
the fifty-five general hospitals report-
ing routine chest x-ray programs were
screened. Less than one-third of all
general hospital admissions were x-rayed
in Michigan.
The 1955 record suggests that there may be 1,000 or
more unsuspected active cases of tuberculosis among the
unscreened portion of hospital admissions.
Michigan Tuberculosis Association
* * *
Wayne State University’s Board of Governors, at a
recent monthly meeting, reviewed gifts and grants
totaling $85,850 accepted by the University.
Major grants went to the instructional and research
programs of the College of Medicine, including $42,286
from the National Fund for Medical Education and
the American Medical Education Foundation.
Scholarship and fellowship contributions totaled $5,-
902. The Ford Motor Company gave $5,000 and Bur-
roughs Foundation $1,500 to the Materials Management
Center.
* * *
Army hospitals in this country and overseas will
welcome 164 graduates from seventy-one approved
medical schools as interns for the year beginning July
1. The interns represent all sections of the United
States and were selected by the Army Medical Service
in participation with the sixth National Intern Matching
Program. This is the largest number of medical in-
terns to be admitted at one time by the Army Medical
Service. Reflecting the national trend towards earlier
marriage and larger families, 73 per cent (121) of the
interns are married. Of this group, over half have chil-
dren: thirty-three having one child, twenty-one having
two children, four having three children and two having
four children. The remaining sixty married interns
have none.
* * *
Columbia University has announced the establish-
ment of two postgraduate-level, correspondence-type
courses for hospital executives in eastern Hospital As-
semblies. The courses will focus on the problems of
small and medium-sized hospitals and will aim at giving
652
Say you saw it in the Journal of the Michigan State Medical Society
JMSMS
NEWS MEDICAL
people active in the field an opportunity for systematic
study of hospital organization and management. Funds
for the program will be supplied by the Kellogg Founda-
tion. Harold Baumgarten, Jr., former manager of Hos-
pital Relations of the Blue Cross Commission, has been
appointed program director. — Hospitals, February, 1957.
* * *
Erythropoetin. — University of Chicago medical scien-
tists reported March 23, 1957, that they have estab-
lished the mechanism and site of production of a new
hormone which controls red blood cell formation. The
hormone is produced in response to the changing balance
between the oxygen demand and supply of the body.
The process is analogous to the mechanism by which
the level of blood sugar regulates the production of
insulin. Leon C. Jacobson, M.D., and three of his
research team made the announcement. The hormone,
erythropoetin, is produced by the kidneys and is found
in normal blood of human beings and animals. It stim-
ulates the bone marrow to make the red cells. Though
it has not yet been chemically isolated, it has been
concentrated in blood serum by 100 to 1000 times
its normal amount.
* * *
Social Security Extensions. — Health, Education, and
Welfare reports show that more than one-half of the
country’s clergymen have exercised their option and are
covered by social security. The deadline was April 15,
1957.
Members of Congress are still receiving letters and
petitions from individuals and groups requesting Social
Security for M.D.s.
* * *
Medical Budgets. — Congressional hearings just pub-
lished on the HEW Department’s budget, covering
1602 pages, gives the administration’s views of health
insurance; research in the 100-bed clinical center at
Bethesda, Md. ; comments on medical school subsidiza-
tion, Indian care, and U. S. Public Health Service. It
is an encyclopedia.
* * *
Hoxsey Counter-attack. — Much attention was given
at the hearing to the Hoxsey Cancer Clinic’s counter-
offensive against FDA. Since the latter had posters
warning the public against Hoxsey treatment placed
in 46,000 post offices and substations, the Texas pro-
moter came back with a petition write-in campaign
calling for Congressional investigation of FDA. Larrick
attributed the campaign to Gerald B. Winrod, of Wichi-
ta, Kansas, as “a paid propagandist for Harry M.
Hoxsey.”
On Friday evening, March 15, 1957, while driving
home, the Editor heard a radio program “Sound Off,”
on which several persons asked whether anyone could
give the address of the Hoxsey cancer treatment. There
were at least half a dozen answers.
* * *
Plans for construction of a two-story addition to the
Henry Ford Hospital have been announced by Benson
Ford, President of the Board. The contract is signed
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3502 Woodward Avenue TEmple 1-4588
Detroit 1. Michigan
May, 1957
Say you saw it in the Journal of the Michigan State Medical Society
653
NEWS MEDICAL
and construction will begin immediately. The addition
will be atop the present front of the building and will
become the fifth and sixth floors of the main building.
There will be about 100,000 square feet of floor space
and about 150 beds, raising the hospital's capacity to
950.
The original Ford Hospital was started in 1913, and
was opened to the public in 1915. The present front
was opened in 1920-1921, and the new clinic building
in February, 1955.
* * *
Social Security Deadline Extended. — Ranking mem-
bers of the House of Representative Ways and Means
Committee are sponsoring a bill (H.R. 6191) to extend
for one year the deadline for disabled workers to apply
for determination of disability preliminary to “freezing”
of their benefit rights, now June 30, 1957. HEW
believes this will make an additional 165,000 workers
eligible.
* * *
Hospitalization for the Aged. — There has been much
consideration of hospitalization for the aged for quite
some time, but the AFL-CIO Executive Council has
announced its support, and the measure is again re-
activated. The plan started in 1951 under our old
acquaintance, Oscar Ewing, and has been reintroduced
each term. The program is the same, to give up to sixty
days of each year of hospitalization for persons over
sixty-five on OASI. The government would pay the
costs out of the Old Age and Survivors Trust Fund.
The worker’s dependents over sixty-five would also be
eligible.
* * *
Army Medical Officers. — Elsewhere in this issue the
assignment of 160 new medical interns and residents to
army hospitals is reported. Occasionally announcements
of opportunities for younger men to apply for Army
Service have also been published. There are about
five applications for each vacancy. We have always
been of the opinion high ranking officers were few in
the Army Medical Corps, but upon inquiry find there
are eleven Major Generals, and twenty-one Brigadier
Generals. There have never been any Lieutenant
Generals, and we believe there should be — at least to
carry an equal rank with many installations. The
Senate, on March 25, 1957, approved three new Briga-
dier Generals.
* * *
The total membership in Blue Cross Plans as of De-
cember 31, 1956, was 53,914,355 and consisted of
21,769,699 subscribers and 32,144,756 dependents . . .
an average of 2.48 members per subscriber contract.
The national per cent of the population enrolled by
Blue Cross Plans rose to 30.14. Enrollment in six
states has exceeded 50 per cent of the state population
— Rhode Island, Delaware, New York, Pennsylvania,
Ohio, and District of Columbia.
Comparable Michigan Hospital Service figures as of
654
Say you saw it in the Journal of the Michigan State Medical Society
TMSMS
NEWS MEDICAL
December 31, 1956: Enrollment, 3,621,746 consisting
of subscribers, 1,343,002 and 2.278,744 dependents . . .
an average of 2.7 per subscriber contract. MHS at
that date had enrolled 47.49 per cent of the state
population. Michigan Medical Service for 1956: En-
rollment, 3,613,263, consisting of subscribers, 316,066
and 2,297,197 dependents ... an average of 2.7 per
contract.
* * *
MEDICAL TELEVISION SHOWS
Produced by Michigan Health Council
WJBK-TV, Detroit
March 3 — Subject: Attitudes and Alcoholism — Guests:
Melvin Selzer, M.D., of Ypsilanti, and George Nim-
mo of Lansing.
March 10 — Subject: Postgraduate Medical Education
(M.C.I.) — Guests: Cecil W. Lepard, M.D., Detroit,
and Otto O. Beck, M.D., Birmingham.
March 17 — Subject: Vision — (Films — Eyes for Tomor-
row and Light Is What You Make It).
March 24 — Subject: Medical Technologists- — Guest:
Miss Dorothea Kanellos, Detroit. Also Film — Career
Medical Technologist.
March 31 — Subject: Orthodontics — Guests: Marvin
Davis, D.D.S., and Bernard W. Lyon, D.D.S., both
of Detroit.
WKAR, TV East Lansing
March 14 — Subject: Operation Stop Polio — Guests:
George A. Sherman, M.D., Fred S. Leeder, M.D.,
Jack C. Krause, and William Emery, all of Lansing.
March 28 — Subject: Medical Technology — -An Inter-
esting Career — Guests: Marion Bennett, M.T., Sue
Walters, M.T., and Margaret Smith, M.T., all of
Lansing, and Athalie Lundberg, M.D., and Mary
Baker, M.T., both of East Lansing.
* * *
Carbon Monoxide Danger — Automobile. — The Uni-
versity of Michigan and the City of Detroit are co-
operating in a project which may point the finger of
responsibility for many automobile accidents on an
unavoidable by-product of our motorized age — carbon
monoxide fumes.
The study is financed by a grant of $44,000 from
the U. S. Public Health Service.
Although there is no direct evidence so far that odor-
less carbon monoxide gases released in automobile ex-
haust have anything to do with the causation of acci-
dents, it is known that certain physiological responses
are affected by excessive inhalation of this gas, says
Warren A. Cook of the U-M School of Public Health
and Institute of Industrial Health, director of the study.
It is not necessarily the carbon monoxide itself which
causes loss of visual sharpness, and increases drowsiness
or headaches. These responses result from the chemical
reaction which occurs when gas meets blood. Carbon
monoxide has 200 times the affinity for combining with
hemoglobin as does oxygen. This deprives the hemo-
globin of its capacity for a normal oxygen content in
the blood.
Field work for the investigation is being done on the
streets of Detroit with the co-operation and assistance
of the Detroit Health Department and its Bureau of
Industrial Flygiene, the Detroit Police Department, the
Department of Streets and Traffic, the Detroit Street
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5645
May, 1957
Say you saw it in the Journal of the Michigan State Medical Society
655
NEWS MEDICAL
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Railway and the Detroit Edison Company. The School
of Public Health administers the study.
Initial studies recording the amount of carbon mon-
oxide in the air throughout the day and night have
shown a lower number of parts per million of carbon
monoxide in the air on the depressed express highways
than on surface streets.
The U-M investigators are also interested in this
study from its possible implications in various phases
of occupational health. Although no information is
available yet, scientists will be interested in professional
drivers, truckers, cab drivers, delivery men. policemen,
and others who are exposed to the possible harmful
effects of carbon monoxide for as much as eight hours
a day.
In order to keep the industry fully informed and to
also have the advantage of its experience, a member
of the Automobile Manufacturers Association has been
invited to join the Project Advisory Committee. Target
date for completion of the field work is fall, 1957.
* * *
The International Academy of Proctology announces
the establishment of a Teaching and Research Fellow-
ship in Proctology under the direction of Dr. Marcus
D. Kogel, Dean of the Albert Einstein College of Medi-
cine, New York. The Academy has voted a $1,000
annual grant for each of three years to assist in the
development of research and educational projects in
proctology at the University.
The 1957 grant was accepted for the College by Dr.
Abraham White, Associate Dean and Professor and
Chairman of the Department of Biochemistry, at the
Ninth Annual Teaching Seminar of the International
Academy of Proctology, April 29-May 2, 1957, at the
Plaza, New York City.
One of the projects developed under this grant has
been a tissue slide “library” for teaching purposes under
the direction of Dr. Alfred Angrist, Professor of Pathol-
ogy.
As emphasized by the founder and secretary of the
International Academy of Proctology, Dr. Alfred J.
Cantor, Flushing. New York, at the time of the Eighth
Annual Teaching Seminar of the Academy in Chicago,
the major function of the Academy is educational. All
Academy funds are to be used for research and teaching
projects in proctology so that earlier diagnosis and
better treatment of patients with diseases of the colon
and rectum may be made universally available.
* * *
Trans-Ocean Joint Meeting. — On Wednesday, June
5, the Harvey Tercentenary Congress will meet in
London in the Great Hall of the Royal College of
Surgeons to discuss “The Results of Cardiac Surgery.”
This meeting will commemorate the 300th anniversary
of the death of William Harvey, the English physiologist
who first described the circulation of' the blood.
At the same time, the American Medical Associa-
tion will meet in Carnegie Hall in New York City at
10:15 a.m. (EDT) where the Symposium on the Re-
sults of Cardiac Surgery will be carried to New York
through the courtesy of Smith, Kline & French Labora-
tories. The two groups will be in direct communication
with conversations carried by telephone and amplified
in both places.
Plaihttell
Sanitarium
PLAINWELL, MICHIGAN
Member American Hospital Association
EDWIN M. WILLIAMSON, M.D.
Psychiatrist-in-Chief
Professional care for the nervous
and mentally ill.
Telephone MUrray 5-8441
Restful Six-acre Estate Overlooking the Kalamazoo River
656
Say you saw it in the Journal of the Michigan State Medical Society
TMSMS
NEWS MEDICAL
ST. JOSEPH’S RETREAT
Member: American Hospital Association
Catholic Hospital Association
National Association of Private
Mental Hospitals
The Central Neuro-Psychiatric
Hospital Association
Under fhe direction of the
Daughters of Charity of St. Vincent de Paul
Serving Metropolitan Detroit
and Michigan almost a century
Martin H. Hoffmann, M.D.
Medical Director
23200 West Michigan Avenue
Dearborn
Logan 1-1400
WOMAN’S AUXILIARY TO THE AMERICAN
MEDICAL ASSOCIATION
Thirty-fourth Annual Meeting
New York State is honored by serving as host to
the American Medical Association and its Woman’s
Auxiliary, the latter, the parent body of all State and
County Auxiliaries.
Mrs. Harry F. Pohlmann of Middletown, New York,
a past President of the Woman’s Auxiliary to the Medi-
cal Society of the State of New York and past chair-
man of several committees of the AMA Auxiliary, has
been named Convention Chairman for this meeting by
the national President, Mrs. Robert Flanders, of Man-
chester, New Hampshire.
Headquarters for the Auxiliary’s meeting will be the
Hotel Roosevelt at Madison Avenue and 45th Street.
New York, from June 3 to 7, 1957. The Roosevelt is
within walking distance of the Waldorf-Astoria Hotel,
where the AMA House of Delegates meet, and proxim-
ity to Fifth Avenue and Madison Avenue shops, theatres
and innumerable points of interest, make the location
of headquarters ideal.
Registration will open on Sunday, June 2, at 11:30
a.m. and will continue through Thursday. On Monday,
June 3, and Wednesday afternoon, June 5, there will
be round table discussions of interest and educational
value to all physicians’ wives. Members and guests are
cordially invited. The general meeting will be held Tues-
day, Wednesday, and Thursday until noon, and a Board
of Directors’ meeting at one o’clock on Thursday. A
post-convention Workshop for State Presidents. Presi-
dents-Elect and National Committee Chairmen will con-
vene Friday, June 7.
Social activities include:
Monday, June 3 — Tea, honoring President and Presi-
dent-Elect.
Tuesday, June 4 — Luncheon in honor of the Na-
tional Past Presidents, at which Dr. Howard Rusk, Di-
rector of the Institute of Physical Medicine and Re-
habilitation of the New York University Bellevue Med-
ical Center, will be the guest speaker. Dr. Rusk needs
no introduction — he is internationally known and is a
fine speaker.
Wednesday, June 5 — Luncheon in honor of the Na-
tional President and President-Elect. Dr. Dwight H.
Murray, President of the American Medical Association,
will be the guest speaker.
Thursday, June 6 — Annual Dinner for Auxiliary
members, husbands and guests, at which the guest
speaker will be Professor Allen Richard Foley of Dart-
mouth College.
It is hoped that each State and County Auxiliary and
the territorial Auxiliaries will be well represented. A
warm welcome awaits everyone, and a profitable meeting
and many hours of pleasure will make your visit a
memorable one.
Mrs. Ezra A. Wolff
Convention Publicity Chairman
657
May, 1957
Say you saw it in the Journal of the Michigan State Medical Society
NEWS MEDICAL
125 N. BIRCH RD., FORT LAUDERDALE, FLORIDA
GERIATRICS (care of the aging)
REHABILITATION . . . CONVALESCENT CARE
A private hospital especially planned tor the medical care and rehabilitation of the
CHRONICALLY ILL, the AGED, and the HANDICAPPED.
Departments of Medicine, Radiology, Laboratory, Dietary, Dentistry, Rehabilitation,
Occupational and Physiotherapy.
Patients accepted for long or short term care under direction of private physician.
MEDICAL RESIDENT STAFF
FOR information write to
Louis L. Amato, M.D., Medical Director Kenneth A. Dahl, Administrator
SIXTY-FOURTH ANNUAL MEETING OF THE
UPPER PENINSULA MEDICAL SOCIETY
Houghton, Michigan, June 21-22, 1957
Thursday, June 20
A.M.
9:00 Executive Committee of The Council of MSMS
will meet all day at the Miscowaubik Club, in
Calumet. Dr. and Mrs. T. P. Wickliffe will be
hosts. All MSMS members are invited to the
session to see how The Council functions.
P.M.
6:00 Cocktails and buffet supper for the exhibitors at
the Onigaming Yatch Club in Houghton.
Houghton-Baraga-Keweenaw Society will be
host. All visitors are invited on a “Dutch-Treat”
basis.
Friday, June 21
A.M.
9:00 Registration and View Exhibits — MCMT Union
Ballroom.
9:45 Welcome — T. P. Wickliffe, President, Upper
Peninsula Medical Society.
All Scientific Meetings at the Union.
Moderator — Simon Levin, M.D.
10:00 R. J. Rogers, M.D “Application of Smear
Technique in the Diagnosis of Cancer”
10:30 Arnold Jackson, M.D “Regional Enteritis”
11:00 Francis Murphy, M.D “Diagnosis and
Treatment of Acute Coronary Conditions”
11:30 Moses Cooperstock, M.D “Present-Day
Trends in Infant Feeding”
M.
12:00 Luncheon at Union (Tickets to be purchased at
Registration)
Moderator — A. M. Roche, M.D.
P.M.
2:00 Joseph Gale, M.D “Mediastinal Tumors”
2:30 Harrison McLaughlin, M.D “General
Principles in the Management of Fractures”
3:00 Carl Moyer, M.D “Present Ideas of
Treatment of Varicose Veins and LTlcers”
3:30 Recess to View Exhibits
Moderator — Percy Murphy, M.D.
4:00 Harold Falls, M.D “Constitutional Disease”
4:30 G. J. Curry, M.D “The Fractured Wrist”
5:00 A. C. Curtis, M.D “Some Recent Studies on
the Abnormalities of Pigmentation”
5:30 L. F. Foster, M.D., Secretary MSMS
Tom Paton, Michigan Medical Service Repre-
sentative
6:30 Cocktails and Dinner — Douglass House, Hough-
ton. (Tickets to be purchased at Registration)
8:30 Introduction — T. P. Wickliffe, M.D., President
Upper Peninsula Medical Society
Public Address at Auditorium, Houghton High
School
Arch Walls, M.D., President, MSMS
Saturday, June 22
Mode rat or^A'LFRED LaBine, M.D.
A.M.
9:00 R. O. Bergan, M.D “Antibiotic Therapy in
Pediatrics, Recent Developments”
9:30 Harrison McLaughlin, M.D., Rahn, M.D.,
Lyttle, M.D., G. J. Curry, M.D Panel on
“Trauma”
10:30 View Exhibits
11:00 Harold Walder, M.D “Antibiotics in Urinary
Tract Infections”
11:30 Meyer Davies, M.D (to be announced)
M.
12:00 End of Scientific Meeting
P.M.
6:00 Cocktails, Michigan Medical Service, Host.
Cocktails, Dinner and Dance at Onigaming
Yacht Club. (Tickets to be purchased at Regis-
tration.)
BLUE SHIELD LEAVES
LOW- VAULTED PAST
( Continued from Page 572)
$25 for a consultation, $15 per hour or fraction
thereof for “prolonged detention with patient in
critical condition,” and also such increased surg-
ical fees as $500 for the excision of an interver-
tebral disk with spinal fusion, for cardiorrhaphy or
for total gastrectomy instead of the current $300.
Furthermore, the Blue Shield Fee Committee is
presently working on the difficult problems of
preparing a table of relative values for various pro-
cedures. Once this is done, it will be possible to
consider a simultaneous percentage increase in
fees “across the board” to correspond with in-
creasing income levels, whenever such an increase
is needed. — Editorial, New England Journal of
Medicine, Feb. 28, 1957.
658
Say you saw it in the Journal of the Michigan State Medical Society
JMSMS
CORRESPONDENCE
Correspondence
>ear Dr. Haughey:
I was very much amazed at the very wide circulation
f The Journal. Requests for reprints of “Arabian
Medicine in the Post-Koranic Period” came from all
ver the country and even from Europe and the Middle
last.
With warm personal regards, I am.
Sincerely yours,
Benjamin L. Gordon
fentnor, New Jersey
March 5, 1957
* * *
Dear Doctor Haughey:
I hope sometime soon you will see fit to editorialize
this society in transition and what effort the physiatrist
is trying to exert to prevent our public health group,
non-official more than official, from dislocating the pri-
I uate practice of medicine in this fantastically hysterical
endorsement of rehabilitation centers.
The word itself has so much semantic magic that en-
tire communities, including members of our own pro-
fession, are seduced without ever applying objective
reasoning before whole-hearted endorsement.
Even the Father of Rehabilitation himself, H. A.
Rusk, M.D., has repudiated the idea of the Rehabilita-
tion Institute and now has wholeheartedly entered into
the chronic illness field guided by the sound grasp of the
situation held by Dean W. Roberts, M.D., M.P.H.:
“The Overall Picture of Long Term Illness.” ( Journal
of Chronic Diseases, Vol. 1, Pages 149-159, Feb. 1955.)
Official, quasi-official and non-official public health
people have continued, by inertia and perhaps pride, in
the original direction proposed by Dr. Rusk. You will
find all over this state, from Detroit to Battle Creek, a
few busy beavers coming into a community, selling the
community a real bill of goods ; namely, this — “Now
your community needs a few extra dollars. We have
it. You have a curative workshop. Let us, with your
facilities and our money, team up and get a Rehabilita-
tion Center going.” This sounds good (to everybody).
Meantime, before even the Community Council, which
has the overall planning of the community’s needs in
mind, has been informed, a Board is set up and incor-
porated as a non-profit agency. Generally, such a board
consists of the most prominent and influential citizens
of the community and they do have the interest of the
community at heart — this is the sad thing. A few ex-
pedient individuals can sew up an entire community in
its desire to do good — and we then have Rehabilitation
Center ad infinitum with very often a doctor fronting
for this non-profit corporation, as an administrator.
Dr. Haughey, I do not want social workers, voca-
tional counsellors, and the Federal Government dictating
for me or for any other physician, my relationship to my
patient. Yet this is the thing we ask as physicians, every
time we invite (having also been seduced) a rehabilita-
tion center into our home community.
Sincerely,
K. McMorrow, M.D.
Detroit , Michigan
March 11, 1957
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Say you saw it in the Journal of the Michigan State Medical Society
659
THE DOCTOR’S LIBRARY
THE DOCTOR’S LIBRARY
Acknowledgment of all books received will be made in this column,
and this will be deemed by us as full compensation to those
sending them. A selection will be made for review, as expedient.
BOOKS RECEIVED
HOME HEALTH EMERGENCIES. A Guide to Home
Nursing and First Aid in Family Health Emergencies.
Part One, Home Nursing; Part Two, First Aid. New
York: Medical Department, The Equitable Life As-
surance Society of the United States.
LITERATURE REVIEW. CIBA. Produced by the
Medical Information Service For Internal Circulation.
Vol. 1, No. 12 (Dec.) 1956. Basle, 1956.
THE ROCKEFELLER FOUNDATION ANNUAL RE-
PORT, 1955. New York, 1956.
CLINICAL ORTHOPAEDICS. Anthony F. DePalma,
Editor-In-Chief, with the assistance of the Associate
Editors, the Board of Advisory Editors, The Board of
Corresponding Editors. Number Seven. Philadelphia
and Montreal. J. B. Lippincott Company. Price
$7.50.
TUBERCULOSIS IN OBSTETRICS AND GYNE-
COLOGY. By George Schaefer, M.D., F.A.C.S.,
F.I.C.S., Assistant Professor of Clinical Obstetrics and
Gynecology, Cornell LTniversity Medical College; At-
tending Obstetrician and Gynecologist, Triboro Hos-
pital; Diplomate American Board of Obstetrics and
Gynecology; Fellow American Academy of Obstetrics
and Gynecology; Fellow American Trudeau Society.
With 58 halftone illustrations. Boston-Toronto: Little,
Brown and Company, 1957. Price $8.75.
THE YEARBOOK OF MODERN NURSING, 1956. A
Source Book of Nursing. Editor, M. Cordelia Cowan,
Nursing Educator, Author, Editor. Foreword by Mary
M. Roberts, Editor Emeritus, American Journal of
Nursing. New York: G. P. Putnam’s Sons, 1957.
A PSYCHIATRIC GLOSSARY. The Meaning of
Words Most Frequently Used in Psychiatry. By the
Committee on Public Information, American Psy-
chiatric Association. New York: American Psychiatric
Association, 1957.
COMPETITIVE PRESSURE AND DEMOCRATIC
CONSENT. By Morris Janowitz and Dwaine Mar-
vick. University of Michigan, Michigan Governmental
Studies, No. 32. An Interpretation of the 1952 Presi-
dential Election. Morris Janowitz is Associate Professoi
of Sociology and Research Associate, Institute of Pub-
lic Administration, University of Michigan, and
Dwaine Marvick is Assistant Professor of Political
Science, University of California (Los Angeles). Ann
Arbor: Bureau of Government, Institute of Public
Administration, University of Michigan, 1956. Price
$2.75.
CLINICAL ORTHOPAEDICS. Anthony F. DePalma,
Editor-in-Chief, with the assistance of the Associate
Editors, The Board of Advisory Editors, The Board
of Corresponding Editors. Number Eight. Fall, 1956.
Philadelphia and Montreal: J. B. Lippincott Com-
pany, 1956. Price $7.50.
Volume 8, like its predecessors, continues the sym-
posium form of presentation, which this time deals with
chronic hereditary diseases and developmental anomalies.
In addition, there is a special section dealing with mo-
torist injuries and motorist safety.
The current volume continues to be quite readable,
both in the manner of material presentation and typo-
graphical layout. As a single unit, this book is of pri-
mary interest to the orthopedist and not to the casual
passer-by, however, the series as a whole would be a
valuable addition to any physician’s library.
The lead section, dealing with chronic hereditary dis-
eases and developmental anomalies, does not attempt
to cover the field in the space available, but does con-
centrate primarily on defects and diseases of the skeleton
with a particularly excellent review of the genetics of
joint diseases.
The second section, concerning general orthopaedics,
presents a discussion of several orthopedic diseases, not
particularly related to one another or to the lead sec-
tion, and has a discussion of problems related to the use
of prostheses in children, which is a wonderful review
of the etiologic and psychobiologic factors involved.
This particular article does not deal with the technical
factors involved, but with all the “patient-as-a-whole”
factors with which any physician might find himself in-
volved.
The third section, dealing with motorist injuries and
motorist safety, is often technical, but from an engineer-
ing view would be of great interest to the motoring buff.
The historical development of auto crash injury re-
search is presented too, along with a good paper on the
engineering aspects of fractures.
R.H.A.
The HAVEN SANITARIUM,
Rochester, Michigan
Inc.
In operation since 1932
M. O. Wolfe, M.D. Ralph S. Green, M.D.
Director of Psychotherapy Clinical Director
Graham Shinnick
Manager
A private psychiatric hospital for the intensive treatment
of mental and emotional illnesses.
Telephone: OLive 1-9441
6f>0 JMSMS
Say you saw it m the Journal of the Michigan State Medical Society
THE DOCTOR’S LIBRARY
ENERAL UROLOGY. By Donald R. Smith, M.D.,
Clinical Professor of Urology and Chairman of the
Department of Urology, University of California
School of Medicine, San Francisco; Consulting
Urologist, San Francisco Hospital, and Consulting
Surgeon (Urology), Veteran’s Hospital, San Fran-
cisco; Chief of the Department of Urology, St. Luke’s
Hospital, San Francisco. Illustrated by Ralph Sweet.
Los Altos, California: Lange Medical Publications,
1957. Price $4.50.
Doctor Smith has treated the subjects in his book in
very comprehensive simplified manner which really
nveys to the reader the essence of the topic without a
: of surplus reading. It is an excellent reference work
' the busy urologist who desires the synopsis of a sub-
:t written in an easily understood capsule form. I am
re there is a ready need for a book such as this, and
feel it is a most outstanding book of its kind.
W. R. C.
kRCINOMA OF THE BREAST: The Study and
Treatment of the Patient. By Andrew G. Jessiman,
F.R.C.S., M.D., Henry E. Warren, Fellow and As-
sistant in Surgery, Harvard Medical School: Junior
Associate in Surgery and Cancer Co-ordinator, Peter
Bent Brigham Hospital, and Francis D. Moore, M.D.,
Moseley Professor of Surgery. Harvard Medical School ;
Surgeon in Chief. Peter Bent Brigham Hospital. 115
pages. Illus. Boston and Toronto: Little, Brown and
Company, 1956.
Fhis book is part of the New England Journal of
tdicine Medical Progress Series, and is an expansion of
ee very fine articles on this topic which appeared in
it journal. Charts, pictures of gross and microscopic
icimens of carcinoma of the breast and many illustra-
ns have been added which did not appear in the orig-
1 articles.
Many of the controversial aspects of the treatment of
s field of cancer are presented fully by the authors
0 present their own conclusions after thorough dis-
sion, giving the readers the fruits of their experience
ed on the premise: “In the light of the present evi-
lce, what is best for the patient?” The current
icWhirter controversy” with its local treatment is
sented; when to use irradiation; androgen or estrogen
rapy; cortisone; when to use castration (x-ray versus
ihorectomy) ; adrenalectomy; hypophysectomy are all
ughtfully discussed.
’articularly good treatment is given the various stages
the disease in Chapter VIII as the authors divide
ast cancer patients into eight different clinical types
1 present a suggested outline of treatment for each
e (the “young and early,” — “the old and early” —
>w, no bones” etc. This particular classification is
ried out with a completeness rarely found in other
rographs. The summary suggests: “Accurate surgery,
urate endocrinology and accurate radiology are equal-
issential in achieving the curative or palliative results
ie available to the patient by recent advances in
ical science.”
’his is an excellent reference for the surgeon in par-
lar, and would interest every physician whose pa-
ts fall in this field.
S. B. W.
Protection against loss of income from
accident and sickness as well as hospital
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Detroit 21, Michigan
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MANITOWANING LODGE
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"Just 28 S miles north from Detroit"
y, 1957
Say you saw it in the Journal of the Michigan State Medical Society
661
Classified Advertising
$2.50 per insertion of fifty words or less, with an
additional five cents per word in excess of fifty.
OFFICE SPACE: Rent or lease. Newly remodeled,
excellent location with established dentist near new
state office building. Available at once. Contact:
O. S. McElmurry, D.D.S., 607 W. Ottawa Street,
Lansing, Michigan. Telephone IVanhoe 4-0829.
PRINTING: GUMMED LABELS ON THE ROLL
Printed to Your Order. Handy Dispenser included.
Now you can save safely through quantity buying — -
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needed. Money back guarantee. Postcard brings
sample labels and pill envelopes. Boyd’s Printery,
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WANTED: Young Protestant, Christian, ambitious gen-
eral practitioner, for a private partnership practice
with middle aged established general practitioner in
center of progressive farming communities. Excellent
opportunities and hospital facilities. Reply Box No. 1,
606 Townsend Street, Lansing, Michigan.
PUBLIC HEALTH EPIDEMIOLOGIST— Salary,
$12,945 to $15,158. Within the Michigan Department
of Health. Provides medical services associated with
cancer, cardiovascular, diabetes and arthritis. Also
All important laboratory exam-
inations; including —
Tissue Diagnosis
The Wassermann and Kahn Tests
Blood Chemistry
Bacteriology and Clinical Pathology
Basal Metabolism
Aschheim-Zondek Pregnancy Test
Intravenous Therapy with rest rooms foe
Patients
Electrocardiograms
Central Laboratory
Oliver W. Lohr, M.D., Director
537 Millard St.
Saginaw
Phone. Dial 2-4100 — 2-4109
The pathologist in direction is recognized
by the Council on Medical Education
and Hospitals of the A.M.A.
acts as medical consultant to the professional staff of
the Michigan Office of Vocational Rehabilitation. Re-
quires eligibility for licensure to practice medicine in
Michigan and four years’ experience in public health.
Write for further job details to Michigan Department
of Health, Lansing, or Michigan Civil Service, Lan-
sing 13, Michigan.
INTERNIST-GASTROENTEROLOGIST: Certified in
both. Six years’ training, including Mayo Clinic and
faculty University gastroenterology section. Qualified
bone marrow interpretation, gastroscopy, other tech-
niques. Societies, publications. Desires group or indi-
vidual association. Reply Box No. 2, 606 Townsend
Street, Lansing, Michigan.
FOR SALE: Medical Practice of Dr. A. R. Hayton
(deceased) of Shelby, Michigan. Established 50 years.
Includes a fully furnished office and home on two
lots. May be purchased by low monthly payments.
Can be seen during the month of June. For further
details, address Stanley West, 1315 S. Main Street,
Corona, California.
FOR SALE: Well-established medical practice with
equipped office, including all case histories available.
Excellent location. Phone LI 2-6483, LI 7-1400, or
write 1772 Edgewood, Berkley, Michigan.
LOCUM TENENS wanted for month of July. Have
had previous locum tenens experience in Michigan.
Graduate Michigan 1955, internship Butterworth
1956, now ENT Resident. Chris Helmus, M.D., 1159
Sells Ave., Columbus, Ohio.
AVAILABLE July 1, 1957, because of illness, a second
generation General and Traumatic practice, with
fully equipped, newly decorated office space, excellent
location, good hospital facilities. Easy terms. Write:
J. Winslow Holcomb, M.D., 1315 Grand Rapids
National Bank Bldg., Grand Rapids, Michigan.
PITTSBURGH, PENNSYLVANIA, practice of a Gen-
eral Surgeon in downtown section can be obtained
by qualified young surgeon for less than the cost of
equipment. This includes radium, history charts for
past 30 years, and introduction by nurse who has
been in office 25 years. For further information,
contact W. C. Behen, M.D., McAllister Hotel, Miami,
Florida.
DOCTOR NEEDED in Marine City, Michigan. City
of 6,000; fifty miles from Detroit. Office available:
Contact T. M. Tucker, Algonac, Michigan, 4087
M-29 Highway, Phone SWift 4-3681.
CALIFORNIA CAREER OPPORTUNITIES
FOR PHYSICIANS AND PSYCHIATRISTS
Employment available as a result of interview
only. Assignments in State hospitals, juvenile
and adult correctional facilities, or a veterans
home. Three salary groups: 10,860-12,000; $11,-
400- 12,600; 12,600-13,800. Salary increases being
considered effective July 1957. Citizenship, pos-
session of, or eligibility for California license
required. Write Medical Recruitment Unit, Box
A, State Personnel Board, 801 Capitol Avenue,
Sacramento 14, California.
662
Say you saw it in the Journal of the Michigan State Medical Society
TMSMf
TIIE JOURNAL
of the Michigan State Medical Society
OLUME 56 JUNE, 1957
NUMBER 6
Table of Contents
Contributors to This Issue
L. Fernald Foster,
M.D.
George W. Slagle,
M.D.
THE COVER refers to Michigan Medical
Service to which this number of The Journal is
dedicated. The Blue Shield Plan of Michigan has
travelled far in serving our people’s health needs.
Now it has reached a crossroads. It’s future
progress depends on decisions that must be made
by Michigan’s medical men NOW.
Michigan Blue Shield Report
H"w We Got Where We Are
L. Fernald Foster, M.D 713
Current Attempts to Solve the Problem
Arch Walls, M.D., Donald Thorup, M.D., and
Max L. Lichter , M.D 716
Where Do We Go with Prepayment?
Jay C. Ketchum 720
What Road Shall We Follow?
George W. Slagle, M.D 724
Michigan Medical Service Payments to Doctors
of Medicine 727
A Method of Closing the Cataract Incision
W. C. Be hen, M.D 728
Spring Valve Mitral Prosthesis
James H. Wible, M.D., Lyle F. Jacobson, M.D.,
Prescott Jordan, Jr., M.D., Charles G. Johnston,
M.D., and Harper K. Hellems. M.D. 731
Detroit Surgical Association
Meeting of November 26, 1956 734
Meeting of January 28, 1957 734
Meeting of February 25, 1957 735
President’s Message
Philosophy and Facts 737
Editorial
Year of Destiny 738
Advance of Civilization 739
A Year of Trial 739
A Changed World 740
Doctor, Was That Order Necessary? 741
Hospital Beds and Costs 741
Who Owns America? 742
Michigan State Medical Society
Ninety Second Annual Session
Official Call 743
Outline of Speakers 744
Information 745
House of Delegates — Order of Business 746
Delegates and Alternates 748
Reference Committees; Credential Committee.... 751
MSMS House of Delegates, Special Session, April 27,
1957 753
Michigan’s Department of Health 778
News Medical 780
The Doctor’s Library 799
Correspondence 801
Wayne University Clinic Days and Alumni Reunion.. 670
AMA Washington Letter 676
AMA News Notes 678
PR Report 682
AMEF 690
You and Your Business 692
© 1957 by Michigan State Medical Society
ne, 1957
667
THE JOURNAL
of the Michigan State Medical Society
=' VOLUME 56 JUNE, 1957 NUMBER 6 =
PUBLICATION COMMITTEE
G. B. SALTONSTALL, M.D., Chairman Charlevoix
WILLIAM BROMME, M.D Detroit
B. M. HARRIS, M.D Ypsilanti
O. B. McGILLICUDDY, M.D Lansing
W. S. STINSON, M.D Bay City
T. P. WICKLIFFE, M.D Calumet
Office of Publication
2642 University Avenue
Saint Paul 14, Minnesota
Editor
WILFRID HAUGHEY, M.D.
610 Post Bldg., Battle Creek, Michigan
Secretary and Business Manager of THE JOURNAL
L. FERNALD FOSTER, M.D.
441 E. Jefferson.
Detroit, Michigan
Executive Director
WM. J. BURNS, LL.B.
606 Townsend Street, Lansing 15, Michigan
All communications relative to exchanges, books for review, manu-
scripts, should be addressed to Wilfrid Haughey, M.D., 610 Post
Bldg,, Battle Creek, Michigan.
All communications regarding advertising and subscription should
be addressed to Wm. J. Burns, 2642 University Avenue, Saint
Paul 14, Minnesota, or 606 Townsend Street, Lansing 15, Michigan.
Telephone Ivanhoe 57125.
© 1957, by Michigan State Medical Society.
Published monthly by the Michigan State Medical Society as its
official journal at 2642 University Avenue, Saint Paul 14, Minnesota.
Entered at the post office at Saint Paul, Minnesota, as second
class matter. May 7, 1930, under the Act of March 3, 1879.
Acceptance for mailing at special rate of postage provided for
in Section 1103 Act of October 3, 1917, authorized August 7, 1918.
Yearly subscription rate, $6.00; single copies, 60 cents. Additional
postage; Canada, $1.00 per year; Pan-American Union, $2.50 per
year; Foreign, $2.50 per year.
PRINTED IN U.S.A.
OFFICERS OF THE SOCIETY
1956-1957
President ARCH WALLS, M.D Detroit
President-Elect G. W. SLAGLE M.D Battle Creek
Secretary L. FERNALD FOSTER, M.D Detroit
Treasurer W. A. HYLAND, M.D Grand Rapids
Speaker K. H. JOHNSON, M.D Lansing
Vice Speaker J. J. LIGHTBODY, M.D Detroit
Editor WILFRID HAUGHEY, M.D Battle Creek
THE COUNCIL
D. BRUCE WILEY, M.D., Chairman, Utica
W. B. HARM, M.D., Vice Chairman, Detroit
L. FERNALD FOSTER, M.D., Secretary, Bay City
T erm
District Expires
A. E. SCHILLER, M.D 1st Detroit 1961
O. B. McGILLICUDDY, M.D 2nd Lansing 1960
H. J. MEIER, M.D 3rd Coldwater 1960
RALPH W. SHOOK, M.D 4th Kalamazoo 1961
C. ALLEN PAYNE, M.D 5th Grand Rapids 1961
H. H. HISCOCK, M.D 6th Flint 1961
H. B. ZEMMER, M.D 7th Lapeer 1957
L. C. HARVIE, M.D 8th Saginaw 1957
G. B. SALTONSTALL, M.D 9th Charlevoix 1957
W. S. STINSON, M.D 10th Bay City 1957
W. M. LeFEVRE, M.D 11th Muskegon 1958
B. T. MONTGOMERY, M.D 12th Sault Ste. Marie....l958
r. P. WICKLIFFE, M.D 13th Calumet 1959
B. M. HARRIS, M.D 14th Ypsilanti 1959
D. BRUCE WILEY, M.D 15th Utica 1960
G. THOMAS McKEAN. M.D 16th Detroit 1960
W. B. HARM, M.D 17th Detroit 1958
WILLIAM BROMME, M.D 18th Detroit 1959
ARCH WALLS, M.D President Detroit
G. W. SLAGLE, M.D President-Elect Battle Creek
K. H. JOHNSON, M.D Speaker Lansing
J. J. LIGHTBODY, M.D Vice Speaker Detroit
L. FERNALD FOSTER, M.D Secretary Detroit
W. A. HYLAND, M.D Treasurer Grand Rapids
W. S. JONES, M.D Past President Menominee
EXECUTIVE COMMITTEE OF THE COUNCIL
D. BRUCE WILEY, M.D Chairman
W. B. HARM, M.D „ Vice Chairman
W. M. LeFEVRE, M.D Chairman, County Societies Committee
G. B. SALTONSTALL, M.D Chairman, Publication Committee
RALPH W. SHOOK, M.D Chairman, Finance Committee
K. H. JOHNSON, M.D Speaker, House of Delegates
J. J. LIGHTBODY, M.D Vice Speaker, House of Delegates
ARCH WALLS, M.D President
G. W. SLAGLE, M.D President-Elect
L. FERNALD FOSTER, M.D Secretary
>V. A HYI.AND, M.D Treasurer
Dermatology and Syphilology
Wm. T. Kruse, M.D Grand Rapids
Chairman
Coleman Mopper, M.D Detroit
Secretary
Gastroenterology and Proctology
N. D. Nigro, M.D Detroit 1
Chairman
R. J. Tallant, M.D Detroit
Secretary
General Practice
F. P. Rhoades, M.D Detroit 2
Chairman
¥. C. Brace, M.D Grand Rapids
Secretary
Gynecology and Obstetrics
J. H. Beaton, M.D Grand Rapids
Chairman
R. W. McClure, M.D Detroit 26
Secretary
Medicine
J. M. Kaufman, M.D Detroit 26
Chairman
J. W. Hall, M.D Traverse City
Secretary
SECTION OFFICERS
Nervous and Mental Diseases
W. R. Slenger, M.D Ann Arbor
Chairman
S. C. Mason, M.D \nn Arbor
Secretary
Occupational Health
O. T. Johnson, M.D Bay City
Chairman
P. B. Rastello, M.D Detroit 9
Secretary
Ophthalmology and Otolaryngology
B. C. Wildgen, M.D Muskegon
Chairman (Ophth.)
W. K. Locklin, M.D Kalamazoo
Co-Chairman ( Oto.)
H. A. Dunlap, M.D Detroit 14
Secretary (Ophth.)
H. L. LeVett, M.D. Lansing
Co-Secretary (Oto.)
Pediatrics
C. E. Booher, M.D Grand Rapids
Chairman
A. M. Hill, M.D Grand Rapids
Secretary
DELEGATES TO A. M. A.
Public Health and Preventive
Medicine
J. D. Monroe, M.D Pontiac
Chairman
J. K. Altland, M.D Lansing 4
Secretary
Radiology, Pathology, Anesthesiology
R. B. Sweet. M.D Ann Arbor
Chairman ( Anes ,)
E. R. Jennings, M.D Detroit
Vice-Chairman (Path.)
E. O. Pearson, M.D Kalamazoo
Secretary (Rad.)
Surgery
E. T. Thieme, M.D Ann Arbor
Chairman
H. M. Bishop, M.D Saginaw
Secretary
Urology
R. P. Lytle, M.D Detroit 1
Chairman
J. F. Harrold, M.D Lansing
Secretary
Alternates
Delegates
W. A. Hyland, M.D., Grand Rapids, Chairman
J. S. DeTar, M.D., Milan
C. I. Owen, M.D., Detroit
W. D. Barrett, M.D., Detroit
W. H. Huron, M.D., Iron Mountain
R. L. Novy, M.D., Detroit
Section
G. C. Penberthy, M.D. (Surgical
W. W. Babcock, M.D.. Detroit 1957
E. F. Sladek, M.D., Traverse City 1957
O. J. Johnson, M.D.. Bay City 1957
William Bromme, M.D., Detroit 1958
J. R. Rodger, M.D., Bellaire 1958
G. W. Slagle, M.D., Battle Creek 1958
Delegate
Section) Detroit
1957
1957
1957
1958
1958
1958
668
JMSMS
everything
changes..
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ADDRESS-
CITY —
STATE-
Say you saw it in the journal of the Michigan State Medical Society
669
Wayne University Clinic Days and
Alumni Reunion
Wayne Clinic Days, held at Wayne University,
April 30 and May 1, 1957, attracted more than
700 physicians from across the nation. This was
the 71st annual “Clinic Days” program designed
by the alumni association to help physicians keep
abreast of the rapid progress being made by
modern medical science.
Activities Tuesday included ward-rounds at
Receiving Hospital, discussion periods, clinical
demonstrations and classroom instruction by mem-
bers of Wayne’s medical faculty. Sessions also
were held at the University’s Medical Science
building, Lafayette Clinic and Kresge Eye In-
stitute.
Six top-ranking medical men who presented
papers on their respective fields during Wednes-
day’s program, included: Herman K. Hellerstein,
M.D., Cleveland, Ohio, “Returning the Cardiac
Patient to Work”; Clyde L. Randall, M.D,, Buf-
falo, N. Y., “Clinical Evidences of the Inadequate
Placenta”; Campbell M. Gardner, M.D., Mont-
real, Canada, “Diagnosis and Treatment of Vari-
ous Lesions of the Stomach”; Raymond W. Wag-
goner, M.D., Ann Arbor, “The Application of
Psychiatry in General Practice”; William L. Rik-
er, M.D., Chicago, 111., “Emergency Surgery in
the Newborn”; and Maurice A. Schnitker, M.D.,
Toledo, Ohio, “Low-Grade Infection of the Urin-
ary Tract.”
Another highlight on Wednesday’s agenda was
the annual Alumni Reunion Dinner celebrating
the fiftieth anniversary of the Class of 1907 along
with announcement of distinguished service cita-
tions and scholarship awards to outstanding needy
students.
The 1907 graduates who attended and received
golden diplomas were: Raymond C. Andries, De-
troit; Frank A. Boet, Grand Rapids; Robert H.
Carmichael, Tinley Park. Illinois; Fred J. Drolett,
Lansing; Raymond B. Glemet, Detroit; Arthur J.
Griffith. Detroit; George C. Hardy, Rochester,
Michigan; Ernest M. Ling, Hancock; Castro J.
Power, Harrison; Herman H. Runo, Reedley,
California.
Those unable to attend, but all of whom sent
greetings, were: Clifford B. Clark, Miami; Wil-
liam P. Johns, Long Beach, California; Samuel
M. Kaufman, New York; Nathan P. Levin, Los
Angeles; L. Leonard Meddaugh, Millbrae, Califor-
nia, and Montgomery A. Stuart, Roanoke, Vir-
ginia.
Alumni Awards were presented as follows : Med-
ical Alumni Sophomore Scholarship Award to
Robert J. Thompson, 1959; Medical Alumni
Senior Scholarship Award to Mvron H. Joyrich,
1957.
Distinguished Service Citations were presented
( Continued on Page 672)
Class of 1907 Golden Anniversary Class at 71st Annual Session, Clinical Program and
Alumni Reunion of the Wayne State University College of Medicine Alumni Association.
May 1, 1957, Hotel Fort Shelby, Detroit.
Reading left to right: (first row ) Raymond C. Andries, M.D., Herman H. Runo, M.D.,
Robert M. Carmichael, M.D., Castro J. Power, M.D.
(Second row) Raymond B. Glemet, M.D., Fred J. Drolett, M.D., Frank A. Boet, M.D.,
Arthur J. Griffith, M.D., Ernest M. Ling, M.D, George C. Hardy, M.D.
*670
JMSMS
optimal dosages for atarax,
based on thousands of case histories:
mg. ( t.i.d.)
actdt indications:
TENSION SENILE ANXIETY MENOPAUSAL SYNDROME ANXIETY PREMENSTRUAL TENSION
PHOBIA HYPOCHONDRIASIS TICS FUNCTIONAL G. I. DISORDERS PRE-OPERATIVE ANXIETY
HYSTERIA PRENATAL ANXIETY • AND ADJUNCTIVELY IN CEREBRAL ARTERIOSCLEROSIS
PEPTIC ULCER HYPERTENSION COLITIS NEUROSES DYSPNEA INSOMNIA
PRURITIS ASTHMA ALCOHOLISM DERMATITIS PARKINSONISM PSORIASIS
perhaps the safest ataraxic known
pe^ce OF MIND ATARAX
(BRAND Of MY0R0XY2ING) Mil. O
Lablets-byrup
Consider these 3 atarax advantages:
• 9 of every 10 patients get release from tension,
without mental fogging
• extremely safe— no major toxicity is reported
• flexible medication, with tablet and syrup form
Supplied:
In tiny 10 mg. (orange) and 25 mg. (green)
tablets, bottles of 100.
atarax Syrup, 10 mg. per tsp., in pint bottles.
Prescription only.
une, 1957
Say you saw it in the Journal of the Michigan State Medical Society
671
WAYNE UNIVERSITY CLINIC DAYS
(Continued from Page 670)
this year to: Daniel E. Halsey, M.D., 1934, for
years of services as advisor and professor in the
College; Clarence E. Umphrey, M.D., 1924, for
was a member of the medical profession: James
M. Robb, M.D., physician and professor of sur-
gery in Wayne State University’s College of Medi-
cine, who has earned a distinguished record.
Pictured at the 71st Annual Session, Clinical Program and Alumni Re-
union of The Wayne State University College of Medicine Alumni Asso-
ciation, April 30, 1957, are (left to right): Don W. McLean, M.D., presi-
dent of the Wayne State University College of Medicine Alumni Association;
William J. Stapleton, Jr., M.D., historian of the Wayne State University
College of Medicine Alumni Association: Gordon H. Scott, Dean, Wayne
State University College of Medicine; Castro J. Power, M.D., Class of
1907; Lawrence Pratt, M.D., president-elect, Wayne State University
College of Medicine Alumni Association.
James Milton Robb, M.D., ’08 (left) receiving his
Alumni Award from Dr. Clarence B. Hilberry (right),
president of Wayne State University, at the 89th Annual
Alumni Reunion on the evening of May 18, 1957.
Seated (right) is Gladys M. Wright, ’41, Chairman of
the 1957 Alumni Reunion.
extraordinary service as advisor, Councilor, Presi-
dent of MSMS, and continuing service.
On May 18, 1957, at a grand banquet for the
89th alumni reunion, at the Sheraton-Cadillac,
President Clarence B. Hilberry presented Honor-
ary Alumni Citations to five persons, of whom one
672
The citation reads as follows:
Dr. James Milton Robb, a graduate in Medicine in
1908, for more than forty years has been a teacher in
the College of Medicine and is now one of this country’s
most distinguished practitioners in the field of Ophthal-
mology and Otolaryngology.
Honored by the Distinguished Service Citation of the
Wayne University Medical Alumni Association, the
Michigan State Medical Society Citation, and the Selec-
tive Service Medal of the Congress of the United States,
he has served as President of the Detroit Academy of
Medicine, of the Wayne County Medical Society, of the
Michigan State Medical Society, of the American Acad-
emy of Ophthalmology and Otolaryngology, and as
Chairman of the Section for the American Medical Asso-
ciation and Member of the Board of Governors of the
American College of Surgeons.
As a citizen in this community he has been an active
leader in the work of the Community Fund, the Detroit
Symphony Society, Institute of Arts Founders Society,
Friends of the Public Library, and of the Cranbrook
Institute of Science.
The University recognizes with pride the brilliant
career in medicine and surgery and the fine contribution
to civic life of this distinguished Alumnus.
When at all practical, surgery is the treatment of
choice for thyroid cancer.
JMSMS
Comments on PATH I BAM ATE from clinical investigators
• “I find it easy to keep patients using the drug
continuously and faithfully. I feel sure this is due
to the desirable effect of the tranquilizing drug.”5
rerences: 1. Borrus, J. C.: M. Clin. North America,
ress, 1957. 2. Gillette, H. E. : Internal. Rec. Med. & G. P.
. 169:453, 1956. 3. Pennington, V. M.: J.A.M.A.,
ress, 1957. 4. Cayer, D.: Prolonged Anticholinergic
rapy of Duodenal Ulcer. Am. J. Dig. Dis. 1:301-309
>0 1956. 5. McGlone, E B.: Personal Communication to
jrle Laboratories. 6. Texter, E. C., Jr.: Personal
imunication to Lederle Laboratories. 7. Bauer, H. G.
McGavack, T. H.: Personal Communication
ederle Laboratories.
• “The results in several people who were pre-
viously on belladonna-phenobarbital prepara-
tions are particularly interesting. Several people
volunteered that they felt a great deal better on
the present medication and noted less of the
loginess associated with barbiturate administra-
tion.”6
• PATH I BAM ATE... “will favorably influence a
majority of subjects suffering from various forms
of gastrointestinal neurosis in which spasmodic
manifestations and nervous tension are major
clinical symptoms.”7
bplied : Bottles of 100 and 1000
ministration and Dosage: l tablet three times a day
lealtimes and 2 tablets at bedtime. Full
• “In the patients with functional disturbances of
the colon with a high emotional overlay, this has
been to date a most effective drug.”5
LEDERLE LABORATORIES DIVISION, AMERICAN CYANAMID COMPANY, PEARL RIVER, NEW YORK
AMA Washington Letter
THE MONTH IN WASHINGTON
Again the Jenkins-Keogh plan is up for con-
sideration in Congress. While there is no assur-
ance it will be passed, or even get out of the
House Ways and Means Committee, many spon-
sors of the legislation this year are united in one
organization and are making themselves felt on
Capitol Hill.
Briefly, this bill would allow any self-employed
person to put a limited portion of his income
into a retirement fund without paying income
taxes on the money. Taxes would be paid when
the money was received as pension or retirement.
Sponsors of the Jenkins-Keogh plan point out
that it very definitely is not legislation to give a
special tax advantage to one group of people. For
one thing, every self-employed person would be
eligible, from farmers to doctors and from opera
singers to architects. For another, corporations
since 1942 have been allowed to put money into
retirement funds for their employes without pay-
ment of federal taxes on the money; the self-
employed merely want the same consideration.
At various times the American Medical As-
sociation has led in the campaign for enactment
of legislation of this type. Two years ago the
House Ways and Means Committee voted to re-
port it out. as part of a broader tax bill, but the
committee never actually got around to sending
the combined bill to the House floor.
Now the lead is being taken by a newly formed
American Thrift Assembly, or officially the Ameri-
can Thrift Assembly for Ten Million Self-Em-
ployed. In addition to the AMA, the new group
has the support of American Dental Association,
American Bar Association, and a score or more
of other national organizations that represent the
self-employed.
After the Congressional session was well under
way, the ATA surveyed the political-legislative
climate and found it favorable for Jenkins-Keogh.
Then in early May the assembly asked its con-
stituent associations to go to work. They were
urged to have all members contact the House
Ways and Means Committee with requests that
the Jenkins-Keogh bill be reported favorably to
the House floor. Assembly strategists are confident
that if the committee hears from enough of the
people who would be affected, it will approve the
bill before adjournment. Then, if there isn’t time
for House action this year, that step can come
next year.
Economy has been the main obstacle in the
path of Jenkins-Keogh — the fear on the part of
the Treasury Department that passage of the bill
would mean a serious loss of income tax revenue.
However, the Treasury has never denied that the
bill is justified to equalize tax status for the self-
employed in relation to corporation employes.
Answering the economy argument, the Assem-
bly makes two points:
First, the set aside funds, invested in the coun-
try’s economy, woidd stimulate business and de-
velop far more in new income tax payments that
it would cost.
Second, because the self-employed who retain
their health rarely retire at any arbitary age, many
of them in the years past 65 would remain in a
tax bracket not significantly lower than when they
paid into the retirement fund.
Notes
When Congress votes the money, the new home
of the National Library of Medicine will be con-
structed at Bethesda, Maryland, near the National
Institutes of Health and the Navy Medical Center.
This site was selected by the board of regents at
its second meeting.
# w
At the request of Speaker Rayburn, the House
Interstate and Foreign Commerce Committee has
set up a special subcommittee with authority to
find out if government agencies are expanding
their operations beyond limits intended by Con-
gress. The subcommittee expects to continue its
investigations between the sessions of Congress.
■¥~ -vr
The continuing national health survey is under
way. Each month from now on, 140 Census
Bureau intervi ewers will visit 3,000 homes, ask-
ing questions about illness and disability. On
the basis of the data collected, the Public Health
Service will publish national and regional reports
on morbidity and mortality.
"Jr
Because of his achievements in the advance of
mental health, Dr. William C. Menninger has
been selected by the U. S. Chamber of Commerce
as “one of the great living Americans.”
* * *
Because of widespread interest aroused by Sen-
ate hearings, there is considerable pressure for
action before adjournment on legislation for some
form of federal control over union welfare funds.
One bill, by Senator Goldwater, would lay down
strict procedures, including regular audits.
676
JMSMS
Paris, too, knows and uses Pentothal
GEORGE SUYEOKA
reflecting . . . a pattern of clinical usage
followed the world over
706138
Pentothal Sodium has been in constant use for
23 years. In that time more than 2500 reports
have been published on Pentothal, covering
nearly every type of surgical procedure — making
Pentothal unmistakably the world’s most widely
studied intravenous anesthetic. Reflected in these
years of use and volumes of reports is a record
unsurpassed for safety, effectiveness and versa-
tility of use in intravenous anes- ^ ^
thesia. Do you have the literature? LAJlMjOxC
PENTOTHAL® Sodium
(Thiopental Sodium for Injection, Abbott)
"“UX |i 1 1 1 |i 1 1 1 1 1 1 1 1 1 1 1 1 1|
IN
ne, 1957
Say you saw it in the Journal of the Michigan State Medical Society
677
AMA News Notes
NEW “AMA IN ACTION” BOOKLET
An attractive new booklet describing “AMA in Ac-
tion” as it moves ahead toward better medicine, better
patient care, better distribution of medical services,
better informed public, and better public health will be
off the presses this month. This 44-page, illustrated
pamphlet points out various AMA services for physi-
cian-members and the public and lists benefits to both
the medical profession and the general public. Copies
of “AMA in Action” will be sent to AMA officers,
trustees and delegates, national opinion leaders, medical
schools, and pharmaceutical representatives. In addition,
limited quantities will be made available to state and
county medical societies for distribution to their key
officials.
AMA TO HONOR RADIO STATIONS
Eighty-seven radio stations across the country will be
honored by the American Medical Association this year
for broadcasting a minimum of ten complete AMA
health education radio transcriptions within the past
five years. Since 1954, a total of 265 radio stations
throughout the United States and Alaska have qualified
for this distinction. Many of the radio stations using
AMA electrical transcriptions are serviced directly from
the Bureau of Health Education through county medical
societies. In addition, thirteen state medical societies
function as state distributors, arranging the placement of
these programs directly with stations in their areas.
PROFESSIONAL LIABILITY FILM
A new dramatic film pointing up ways of preventing
professional liability claims and suits will be available
July 1 for medical society meetings. This new film,
titled “The Doctor Defendant,” is the second in a series
of films on various medicolegal problems being produced
by the Wm. S. Merrill pharmaceutical company in
co-operation with the American Medical Association
and the American Bar Association. Bookings may be
arranged through AMA’s Film Library. It was shown
for the first time Wednesday, June 5, during the
AMA’s annual meeting in New York City.
FOREIGN FILM PROGRAM
The largest international medical film exhibition in
history was staged by the American Medical Association
during its annual meeting June 3-7 in New York City.
Forty medical motion pictures, representing work by
medical scientists from a dozen foreign countries, were
shown in the Barbizon Plaza Hotel theater.
Two unusual Japanese films were among those shown:
(1) “A Study on the Intrauterine Selfmovement of
the Early Human Fetus” — the first motion picture ever
made of a living human fetus still in the mother’s
womb, and (2) a 25-minute film entitled, “Structure
and Function of the Middle Ear,” showing the actual
operation of the human hearing mechanism, including
vibration of the tympanic membrane (a drumhead-like
structure that takes sound from the air for transmission
to the brain).
Films from the following countries also were shown:
France, Austria, West Germany, Argentina, Switzerland,
Guatemala. Mexico, Canada, Italy, Brazil, and England.
The exhibition was sponsored by Johnson and John-
son, manufacturers of medical supplies, in co-operation
with AMA’s Motion Pictures and Medical Television.
USPHS LAUNCHES NATIONWIDE
HEALTH SURVEY
A new National Health Survey was instigated in
May by the U. S. Public Health Service. A household
interview survey was conducted in 330 sampling areas
throughout the country. Legislation enacted during the
last session of Congress authorized the Surgeon General
of the USPHS to make surveys and special studies of
the United States population to determine the extent
of illness and disability and related information.
The American Medical Association supported this
legislation while cautioning that any survey in this area
should be conducted in such a manner that all interested
parties can agree substantially with its conclusions.
Facts collected include statistics on the number, age,
sex, and other personal characteristics of persons suffer-
ing from diseases, injuries, or handicapping conditions;
the length of time that these people have been pre-
vented from carrying on their usual activities, and
whether or not the conditions have had medical atten-
tion. The last survey of this nature was conducted
twenty years ago.
The Council also announced that the household inter-
view phase of the survey is to be a continuing study for
an indefinite period of time. Field work will be handled
by the Bureau of the Census for the USPHS, following
primary sampling units already established in counties,
parts of counties, combinations of counties, or metro-
politan areas. At least one sampling unit is located in
every state.
MS MS ANNUAL MEETING
September 25-26-27, 1957
Civic Auditorium, Pantlind Hotel,
Grand Rapids
Make Your Hotel Reservation Now 4—
678
JMSMS
brand of prednisolone
Most active corticoid; minimal disturbance of electrolyte bal-
ance. White, scored 5 mg. tablets (bottles of 20 and 100) and
pink, scored 1 mg. tablets (bottles of 100).
PFIZER LABORATORIES Division, Chas. Pfizer & Co., Inc. Brooklyn 6, New York
une, 1957
Say you saw it in the Journal of the Michigan State Medical Society
679
Steroid-Nutritional Therapy
Is Constructive Approach for the
First Signs of Aging
Emphasis on Early Treatment Before ''Damage" Is Done
The first subtle suggestions of physiologic de-
terioration should not be dismissed if serious
somatic and metabolic disorders are to be
avoided. Prompt institution of steroid-nutri-
tional therapy may forestall and even reverse
premature “ dam-age” and help prolong the ac-
tive life of the patient.
Some of the most common symptoms of de-
clining gonadal function and nutritional insuffi-
ciency are vague pains in the bones and joints,
easy fatigability, decreased muscular tone, loss
of appetite, chronic mental fatigue and general
malaise. In older patients, these complaints are
frequently indicative of degenerative processes
when they cannot he attributed to a specific
cause.
The comprehensive formula of “Mediatric”
is specifically designed to provide three thera-
peutic services: 1. protect general metabolic
integrity; 2. preserve physiologic efficiency; 3.
prevent premature damage.
“Mediatric” supplies estrogen and androgen
in small amounts to exert a favorable influence
on bone and protein metabolism,1 restore mus-
cle tone and coordination,2 and increase the ten-
sile strength of the skin.3 The two steroids ap-
pear to have an additive metabolic effect, while
their opposing action on sex-linked tissue min-
imizes the incidence of untoward reactions.
Dietary supplements, including essential B
vitamins and ascorbic acid, ensure adequate
nutrition, prevent moderate anemias, and main-
tain efficient enzyme systems. The mood elevat-
680
ing effect of a mild antidepressant helps restore
emotional stability and increases mental alert-
ness.
Recommended dosages: Male — 1 tablet or 1
capsule (or 3 teaspoonfuls) daily, or as re-
quired. Female — 1 tablet or 1 capsule (or 3
teaspoonfuls) daily, or as required, taken in
21 day courses with a rest period of one week
between courses.
Bibliography on request.
“Mediatric”® Tablets and Capsules
Each capsule or tablet contains:
Conjugated estrogens equine
(“Premarin”® ) 0.25 mg.
Methyltestosterone 2.5 mg.
Vitamin C (ascorbic acid) 50.0 mg.
Thiamine mononitrate (Bx) 5.0 mg.
Vitamin B12 with intrinsic
factor concentrate 1/6 U.S.P. Unit
Folic acid U.S.P 0.33 mg.
Ferrous sulfate exsic 60.0 mg.
Brewers’ yeast (specially processed) 200.0 mg.
d-Desoxyephedrine HC1 . 1.0 mg.
Tablets— No. 752— bottles of 100 and 1.000.
Capsules— No. 252 — bottles of 30, 100. and 1,000.
“Mediatric” Liquid
Each 15 cc. (3 teaspoonfuls) contains:
Conjugated estrogens equine
(“Premarin”®) 0.25 mg.
Methyltestosterone 2.5 mg.
Thiamine HC1 (Bx) 5.0 mg.
Vitamin Bx 2 1.5 meg.
Folic acid U.S.P 0.33 mg.
d-Desoxyephedrine HC1 1.0 mg.
Contains 15% alcohol
No. 910— bottles of 16 fluidounces and 1 gallon.
Ayerst Laboratories
New York, N. Y. • Montreal. Canada £
JMSMS
Say you saw it in the Journal of the Michigan State Medical Society
dily effective— clinically proved
iidmamycin
des added certainty in antibiotic therapy particularly for
90% of the patient population treated in home or office. . .
cin 33 mg., tetracycline 67 mg.), bottles of 25 and 100. Sigmamycin
for Oral Suspension — 1.5 Gm„ 125 mg. per 5 cc. teaspoonful
(oleandomycin 42 mg., tetracycline 83 mg.), mint flavored, bottles
of 2 OZ. *Trademark
jectrum synergistically strengthened
CIN provides the antimicrobial spectrum of
ne extended and potentiated with oleandomy-
ilude even those strains of staphylococci and
;her pathogens resistant to other antibiotics.
(IGMamycin Capsules— 250 mg. (oleandomycin 83 mg.,
i 167 mg.), bottles of 16 and 100; 100 mg. (oleandomy-
Pfizer Laboratories, Brooklyn 6, N. Y.
Division, Chas. Pfizer & Co., Inc.
World leader in antibiotic development and production
PR REPORT
MEDICAL EDUCATION WEEK
The second annual Medical Education Week,
April 21-27, went off with a bigger bang than
last year because of increased activity on the part
of county medical societies throughout the State.
Press clippings flowing into the MSMS head-
quarters show a significant number of society-
sponsored hospital “open house” programs tied in
with one or more press releases pointing out the
local benefits accruing from the broad medical edu-
cation activity of Michigan’s medical schools.
To co-ordinate the state-wide program, MSMS
met with representatives of University of Michi-
gan Medical School and Wayne State University
College of Medicine. Each agreed to promote
certain aspects of medical education, thus pre-
venting duplication of press material.
MSMS arranged for Governor Williams to pro-
claim the April 21-27 week as Medical Education
Week which resulted in an Associated Press dis-
patch saluting expanded facilities and service. In
state-wide releases to all newspapers, radio and
TV stations, MSMS used the theme that “To-
morrow’s picture of health depends on the quality
of medical education of today” and outlined the
modern “triple play against disease” with the team
composed of the medical profession, the medical
schools and the allied medical groups.
Subsequent releases stressed the record number
of beginning medical students and the continuing
increase in the number of medical schools in the
nation.
DOCTORS VISIT LEGISLATORS
IN LANSING
County medical society representatives indicated
their interest in the affairs of state by visiting leg-
islators in Michigan’s Capital City.
The program, begun in January, continued
through the legislative session, which closed May
24.
By attending the legislative sessions with MSMS
staff members, the doctors had an opportunity to
impart the medical profession’s views on over-all
health questions to their elected representatives.
County societies participating included Gene-
see, Gratiot-Isabella-C.lare, Macomb, Washtenaw
and Wayne.
NEW FILMS AVAILABLE
“The Doctor Defendant” is the title of the
second film in the AMA “Medicine and the Law”
series which will be available for medical society
showings beginning July 1. The thirty-four-
682
minute motion picture deals with prevention
professional liability action.
The new film is a companion to “The Medi
Witness” — first in the series. Both producti
are presented in co-operation with the Amerii
Bar Association.
“The Doctor Defendant” dramatically prese
four case reports of situations which resulted
claims against physicians. In reviewing these
leged professional liability cases it also dem
strates how a county medical society’s review cc
mittee functions.
Advance booking dates may be arranged
writing the AMA Film Library or MSMS.
* * *
A new film, “Glaucoma, What the Gent
Practitioner Should Know,” is now available
showing before county medical societies and s
cialized audiences. The film is presented by
National Society for the Prevention of Blindr
and is available from them direct or through
MSMS Public Relations Library (606 Towns*
Street, Lansing, Michigan), without charge.
The motion picture explains the mechanism
glaucoma, symptoms aiding in diagnosis and
explanation of the rationale of treatment. I
a 16-mm sound film in color which takes twei
two minutes to show.
REGISTERED M.D.'S
The number of physicians registered in the Anter
Medical Association Directory for 1956 is 218,061 (1
and Canada), plus 1,791 (U.S. dependencies), a tota
219,852. This includes graduates of Canadian and
eign schools.
In the past eighteen years, the United States sch
have graduated 110,288 — almost exactly half those lis
if graduates from foreign schools and Canada, wl
number is not available, are disregarded.
More than half of our doctors have entered the p
tice of medicine since prepayment was an establi:
fact. Over 7,000 foreign graduates are serving as
ternes and house physicians in the United States.
NUMBER OF M.D. APPLICANTS
In 1955-56. Michigan had 4.1 entering freshmen i
ical students per 100,000 population as comparec
4.6 for the nation — one-half a student short. The 1
versity of Michigan accepted 201 freshmen students
of 600 applications, but those applicants had filed 2
applications. Wayne State University accepted 71
of 324 who had filed 1,058 applications. The w
UAited States accepted 7,602 freshmen from 54
applicants who filed over 70,000 all told.
— AMA Council on Medical Educt
JM
unique derivative of Rauwolfia canescens
Harmonyl
(Deserpidine, Abbott)
introduces a new degree of safety in
maj or tranquilizing — antihypertensive
therapy
Most significant: In extensive trials,
Harmonyl has produced less mental and
physical depression. And there are very
few reports of the lethargy seen with
many other rauwolfia preparations.
IVIore than two years of clinical evaluation
have proven Harmonyl a notably safe and
effective agent in cases ranging from mild
anxiety to major mental illnesses and in
hypertension. Harmonyl exhibited signifi-
cantly fewer and milder side effects in com-
parative studies with reserpine — while
demonstrating effectiveness comparable to
the most potent forms of rauwolfia.
Safety— plus marked clinical effectiveness
Harmonyl proved particularly effective, for
example, in tranquilizing a group of 40
chronically ill, agitated senile patients.1
Of particular interest is the observation
that patients became more lucid and alert
on Harmonyl therapy. And there was a
complete absence of side effects with
Harmonyl — although a similar group on
reserpine developed such side effects as
anorexia, headache, bizarre dreams, shakes,
nausea and vomiting.
Following another eight-month study of
chronic, hospitalized mental patients,
Ferguson2 stated:
• Harmonyl benefited at least 15% more
706185
overactive patients and proved more
potent in controlling aggression — requir-
ing only one-half to two-thirds the
dosage of reserpine.
• Patients experiencing side reactions on
reserpine often were completely relieved
when changed to Harmonyl.
Ferguson concluded: " The most notable
impressions were the absence of side effects
and relatively rapid onset of action with
Harmonyl .”
Comparative studies have shown Harmonyl
and reserpine about equal in hypotensive
effect. The tranquilizing action of the two
drugs also appeared similar — except that
few cases of giddiness, vertigo, sense of de-
tached existence or disturbed sleep were
seen with Harmonyl.
Professional literature is available upon
request. Harmonyl is supplied in 0.1-mg.,
0.25-mg., and 1-mg. tablets.
References: 1. Communication to Abbott Laboratories,
1956. 2. Ferguson, J. T. : Comparison of Reserpine and
Harmonyl in Psychiatric Patients: A Preliminary Report,
Journal Lancet, 76:389, December, 1956. *Trademark
1957
Say you saw it in the Journal of the Michigan State Medical Society
689
ACETYLCARBROMAL tablets
• Proved safe and effective by 6 years’
clinical use.
• Soothes the central nervous system,
produces calmness without hypnosis.
• Non-toxic, non-cumulative, non-addict-
ing, no known contraindications.
• Does not impair mental or physical
function.
• Orally effective within 30 minutes for
sustained action up to 6 hours.
• Economical.
Indications: Tension, nervousness,
anxiety and muscular spasm.
Supplied: White round tablets
Acetylcarbromal 5 gr. in bottles
of 100, 1000.
Write for samples and literature
There’s Always A Leader
MALLARD, inc
3021 WABASH, DETROIT 16, MICHIGAN
AMEF
Do you know what the letters AMEF sta
for? Every doctor of medicine should real
what the American Medical Education Foum
tion stands for. We should know that this foi
dation is an effort on the part of the doctors
this nation to support medical education and
search. We should know that if we contribute t
million dollars, the industries of this country \
contribute eight million.
We should know there are eighty-three, fi
time or part-time medical schools, which \
benefit.
We should know that the enrollment in <
medical schools has increased by 7,042 since 11
and that the graduates have risen from 4,565
6,845 last year.
Do you know your contribution can be e
marked for the school of your choice and thal
is tax deductible? One of our members contr
uted $1,000 as a memorial to a son lost in i
service. With the tax situation what it is, t
splendid contribution cost him about $500.00
We should know that only about 18 per a
of our membership are contributors. This foi
dation will never flourish, or realize its purp<
on such paucity. State, municipal and fede
government now furnish 47.5 per cent of the ba
Medical School operating budgets. Another
per cent may give our government the right
direct. It would appear that the control of me
cal care and education is rapidly disappear:
from the medical ranks.
This splendid foundation should be suppor
by every Doctor of Medicine in the United Stai
If that statement is true, then our House of De
gates of Michigan should request our delega
to the American Medical Association to int
duce a resolution at the next meeting of
AMA House of Delegates.
In the meantime, until a better way of si
port can be devised, will you mark the f
week in July to make your most necessary c<
tribution? Please mail to American Medical E<
cation Foundation, 535 N. Dearborn Street, C
cago, Illinois.
C. E. Umphrey, M
Chairman, AMEF Committee for Mic hit
Michigan is the largest State East of the Mississi
River — 96,720. square miles of which 57,022 square m
are land, 1,194 are inland waters, and 38,504 are Gi
Lakes waters. Michigan has the longest shore line
any State. It also has 11,000 inland lakes, and 36,1
miles of streams.
690
Say you saw it in the Journal of the Michigan State Medical Society
IMS
Trasenline-
c I B A
Summit, N. J.
integrated relief . . .
mild sedation
visceral spasmolysis
mucosal analgesia
TABLETS (yellow, coated), each containing
50 mg. Trasentine® hydrochloride (adiphenine
hydrochloride Cl BA) and 20 mg. phenobarbitaU
2/2228(4
June, 1957
Say you saw it in the Journal of the Michigan State Medical Society
691
You and Your Business
HOUSE OF DELEGATES PROCEEDINGS
*
The Proceedings of the Special Session of the
MSMS House of Delegates, held in Detroit,
April 27, 1957, are included in this number of
The Journal. For important information on
the status of prepaid medical care plans, see pages
753-776.
ANALYSIS OF 1957 MICHIGAN
CLINICAL INSTITUTE ATTENDANCE
Of the 1,654 doctors of medicine who attended
the March, 1957, MCI in Detroit, 946 came from
Detroit and Wayne County, the balance from
outstate and outside of Michigan. After Detroit,
Flint was next in line with an attendance of
eighty; Ann Arbor was third with sixty-six; Lan-
sing, fifty-three; Dearborn, thirty-nine; Pontiac,
thirty-seven and Grand Rapids, twenty-eight.
Seventy-three other Michigan cities sent two or
more physicians to the Institute. Eighty-seven
communities sent one doctor of medicine.
Of the ninety-one “foreign” doctors, Canada
sent thirty-seven and Ohio, twenty-three. Five
came from California and one from Arizona!
Attendance by specialties put the general prac-
titioner in the lead with a total of 486, followed by
231 surgeons and 216 internists. The obstetricians
and pediatricians tied with ninety each. A total of
238 residents and interns were present to attend
their own conference, one of the many “side
shows” of the annual Michigan Clinical Institute.
INTERNATIONAL COLLEGE OF
SURGEONS ANNOUNCES AWARDS
IN OBSTETRICS AND GYNECOLOGY
The Division of Obstetrics and Gynecology of
the United States Section, International College of
Surgeons, announced that two awards will be made
for the best manuscripts not exceeding 5,000 words
submitted by December 1, 1957. The first prize
will be $500 and the second $300.
Contestants must hold the degree of Doctor of
Medicine from an accredited college of medicine,
and ( 1 ) be interns, residents or graduate students
in obstetrics and gynecology, or (2) be teachers
of obstetrics and gynecology. Fellows of the Col-
lege are not eligible.
The two successful candidates will be asked to
participate in the scientific program of the Divi-
sion of Obstetrics and Gynecology at the 1958 an-
nual congress of the United States and Canadian
Sections, International College of Surgeons.
Details of the contest and the forms in which
the manuscript must be submitted may be obtained
by writing Dr. Harvey A. Gollin, secretary of the
Committee on Prizes, 55 East Washington Street,
Chicago 2, Illinois.
“The purpose of this contest is to advance the
art and science of obstetrics and gyncology, in
accord with the principles of the International
College of Surgeons and with the aims of the
College to extend the frontiers and elevate the
standards of all branches of surgery,” Dr. Ray-
mond J. Pieri of Syracuse, N. Y., chairman of the
Committee on Prizes, said.
WHAT’S IT WORTH TO YOU?
What’s it worth to you?
You are a member of a profession that for centuries
has been considered a very privileged one. Why? Our
profession is one of “Service.”
This profession differs from the so-called “Trade” in
that the latter is for profit first and foremost to the
individual or the concern for which he labors, while the
former is for the welfare of the patient first with profit
as a secondary consideration.
This concept practiced under the social order of free
enterprise has been an American heritage handed to us
to enjoy by our many colleagues who have practiced the
profession before us. We must preserve it for the genera-
tions who are to follow.
In the late thirties and early forties when socialized
medicine conceived by our government was about to
change our way of life, our delegates in the Michigan
State Medical Society came forward with the Blue
Shield Program that preserved the doctor-patient rela-
tionship.
Today, we are threatened again, not by government
but by the Community Health Association. The C.H.A.
has already begun to function in the Eastern part of
our State. C.H.A. feels that a greater scope of medical
care can be given for less money to the subscriber than
our own Blue Shield Program can offer.
If this is true, then it is up to us to re-evaluate our
program and do something about it. We must examine
our own conscience first. Have some of us taken advan-
tage of our Blue Shield Program? Have we been honest
with our subscriber or at times have we made our bills
higher than our own Blue Shield allowed and billed the
patient an extra sum?
Either we police ourselves and co-operate with what-
ever program our State Medical Society adopts or else
stand the chance of private interests taking over our
profession.
President Eisenhower not too long ago stated that
“the price of peace comes high.”
We may have to make concessions, we may have to
accept lesser remuneration for our labors, but what’s it
worth to you to keep the practice of medicine a free
enterprise? — E. J. Lauretti, M.D.. in President’s Mes-
sage, The Bulletin, Muskegon County Medical Society,
March, 1957.
692
JMSMS
JOUR N A L
of the Michigan State Medical Society
Issued Monthly Under the Direction of The Council
VOLUME 56 JUNE, 1957 NUMBER 6
Michigan Blue Shield Report
One of the most important problems the medi-
cal profession faces today is “Where Do We Go
from Here in Prepaid Medical Care”? There is a
steadily growing public demand for broader bene-
fits under prepayment than are currently pro-
vided under the Michigan Blue Shield Plan.
There are a variety of so-called Comprehensive
Health Care Plans in operation to a growing
degree in various parts of the country.
So important has the problem become, in the
opinion of your leaders in the Michigan State
Medical Society, that a special meeting of the
House of Delegates was held in the Blue Cross-
Blue Shield Building on April 27, 1957. The
day-long session covered every phase of the pre-
payment picture, including full reports on the
half-dozen more widely publicized programs now
providing to varying degrees comprehensive pre-
paid medical care and a detailed report on how
Michigan Blue Shield can meet the challenge of
this demand for broader prepayment programs.
What was reported, what was said in this day-
long meeting is of vital importance to every doctor
of medicine in Michigan. Naturally, it is an im-
possible task to reproduce in print verbatim every
word — important though they were. However,
the following pages are an inclusive summary of
all that went on at the session. We make it the
basis for our yearly report on Michigan Blue Shield
in this June issue of The Journal because we
feel it is material that every doctor in Michigan
should know and understand.
This report follows the chronology of the meet-
ing itself. That pattern was “How We Got
Where We Are,” “Current Attempts to Solve the
Problem,” “Where Do We Go with Prepayment?”
and “What Road Shall We Follow?”
How We Got Where We Are
(Condensation containing the highlights of the presentation made by L. Fernald Foster, M.D.,
Secretary of MSMS and President of Michigan Medical Service.)
Before we consider “How We Got Where We
Are,” I think we need a clear, short definition of
exactly “where we are.” It couldn’t be much
shorter or much clearer ; we are still in the posi-
tion of practicing medicine as a free enterprise
as we have all known it.
Therefore, the title probably should be “How
We Have Stayed Where We Are.” And the sub-
ject involves consideration of certain factors oper-
ative in the last twenty years that have preserved
aur status.
It became apparent in the late twenties that the
costs of medical care were rising rapidly. The
Michigan State Medical Society was aware that
this was a problem probably as early as anybody
in the field of health. Reason, of course, for the
increase in medical costs was the rapidly develop-
ing tempo of medical science. Your State Medical
Society, through its Council and Executive Com-
mittee, was among the hrst to conduct research
studies in the costs of medical care. This involved,
as some of you will recall, sending a delegation
to Europe to study the plans in England. Phis
and other similar studies led to development of a
fuNE, 1957
713
MICHIGAN BLUE SHIELD REPORT
device based on the insurance principle which
many of you have probably forgotten. It was
called “Mutual Health Service” and was a volun-
tary plan quite like our present “Michigan Medi-
cal Service.” However, it was never put in opera-
tion because of certain economic conditions exist-
ing at the time.
However, by the early thirties there developed
in this country a new social and political philos-
ophy. Many of us are still around who were active
in the research studies and the activities that finally
led to the medical prepayment program — our own
program — Michigan Medical Service. But there
are as many or more younger men to whom all of
this is a matter of hearsay. This history will help
refresh the memories of those who had an active
part in the development of Michigan Medical
Service and present the facts to those who have
entered the medical profession since.
Need For Action
I he new social and economic philosophy that
emerged in the early thirties was a philosophy
based on paternalism, and it was evident that it
lent itself readily to the institution of a new type
of medical practice — one that would fit into this
new political and social philosophy. It was per-
fectly evident at the time that something should
be developed by the medical profession to preserve
the private practice of medicine, with all the attri-
butes to which we have pointed so often: whole-
some competition, unrestricted initiative, and
maintenance of the patient-physician relationship.
I he Council set about developing some such
procedure. It seemed logical that the source of
such a development was the insurance industry.
This may have seemed logical, but it didn’t work.
The insurance industry flatly refused to have any
part of such a development because it lacked
actuarial data and specific information that it
said was necessary to develop plans, contracts, fees
and so forth. This left your Council with but two
alternatives: to develop on their own some sort
of prepayment insurance device or succumb to the
then actively developing programs in Congress.
The Council chose the first alternative on the
theory that if they should lose, at least they
would lose trying and not lose by default. They
set about developing what is now Michigan Medi-
cal Service.
The Council have only two commodities with
which to work in the development of this device.
One was participation of nearly 90 per cent of
the doctors in Michigan, and the second was the
will and determination to solve this rapidly grow-
ing economic problem. It was done by the trial
and error technique — a most cumbersome and in-
efficient way — but the only one at their disposal.
What emerged was Michigan Medical Service.
Many of you will recall that MMS, in its early
stages — which was pure trial and error — many
times found itself in bad shape. At the outset
everything was guess-work, and one cannot always
guess right. However, as time went on, statistical
information and actuarial data were compiled.
Michigan Medical Service emerged from the
woods and, from that point on, has operated on
a sound actuarial basis.
Set Pace
Incidentally, in this connection, it should be
pointed out that the actuarial statistics developed
by Michigan Medical Service were then utilized
by the commercial insurance companies in enter-
ing the prepaid medical care field and helping
them make the contribution they have since made.
They have frankly said that when they did enter
the field, it was because they had then acquired
the actuarial data that were definitely developed
by the Michigan State Medical Society in its
program.
We are the first to admit that Michigan Medi-
cal Service is not perfect, but we do believe, as a
number of us have said a good many times, that
for seventeen years it has saved the medical profes-
sion from the institution of a government program
of compulsion. It has provided a more democratic,
voluntary program instituted and controlled by
the medical profession itself. But the most im-
portant thing it has done, I believe, is to have
served the public better. What it did for the
medical profession I feel should better be con-
sidered a secondary result. Net result is that
for seventeen years it has served an important,
vital dual purpose.
Probably this device in its present form is not
now adequate to meet completely the new prob-
lems that are arising due to our changing eco-
nomics. That, I believe, is why this House of Dele-
gates has been called into session : to determine
what, if any, changes should be made in the de-
vice or whatever device is utilized to solve the
problems of 1957.
714
JMSMS
MICHIGAN BLUE SHIELD REPORT
Important Points
There are certain points I would like to em-
phasize. First is the fact that Michigan Medical
Service is not an insurance company. It was
developed on the basis that if the medical profes-
sion were to indulge in this activity, it should stay
within its prerogatives, and for that reason it was
developed on the basis of a service plan.
As you know, only the medical profession is in
a position to render medical service. A commer-
cial insurance company cannot give medical serv-
ice; all it can give is dollars.
All that the medical profession can give in any
program is service; it has no funds to give money,
so therein lies the difference between a service
plan and an insurance company. The question has
been raised many times whether, if the present
device operated by the State Medical Society were
to become an insurance company, the medical
profession had any prerogative to be in the
insurance business. The medical profession, from
time to time, has decried the fact that corpora-
tions practice medicine. So one might well imagine
that if we became an insurance company, the
insurance companies could say: “What right have
doctors of medicine to be operating an insurance
company any more than a corporation has to be
operating in the field of medical care?”
Michigan Blue Shield, as now constituted, is the
Michigan State Medical Society. Its corporation
is the House of Delegates, elected democratically
by the component county units. The corporate
body elects the directors, 75 per cent of which are
practicing doctors of medicine. They determine
the policies based on their knowledge of private
practice, as we understand it. The development of
Michigan Medical Service, as previously men-
tioned, for more than seventeen years has served
the purpose of giving the people a better service at
a price they could afford to pay and at the same
time preserving the private practice of medicine
as a free enterprise.
Had The Council failed in 1939, when this was
developed, those of you who have come into the
practice of medicine since that time might never
have known what the private practice of medicine
was. You probably would have been practicing
under some scheme of compulsion. We believe
that the development of Michigan Medical Serv-
ice has not only prevented the medical profession
from having been invaded by governmental agen-
cies, but by other agencies as well. Aside from
governmental agencies, there are other groups and
forces at work — particularly at present. There is
pressure from the commercial insurance compa-
nies and from various pressure groups. It doesn’t
make much difference, I believe, whether it is the
Government, or private agencies, or pressure
groups: if any of them succeed in directing the
practice of medicine, then we shall have lost a
heritage that we believe has been preserved for
us and has brought us to the point where we are.
Responsibility
The responsibility of the Michigan State Medi-
cal Society and its prepayment plan — Michigan
Medical Service — is to preserve the overall private
practice of medicine. Michigan Medical Service is
the device, I am convinced, that has made this
possible during the last seventeen years. I believe
we must realize there is only one banner under
which we all can rally — specialists, staff members,
county medical societies and rugged individualists.
That is the banner given you by your Doctor of
Medicine degree and the fundamental units of or-
ganized medicine. I think your Council believes
that its primary responsibility is to preserve the
overall practice of medicine. To do that means
that the problems arising from groups within the
profession have to be handled equitably, but with-
in the realm of being realistic and keeping Michi-
gan Medical Service — Medicine’s Plan — actuarial-
ly sound.
Too often, I think, the most significant factor
about the Blue Shield program that is overlooked
is its acceptance by the people of Michigan and
the country. Without doubt, the representatives
of Michigan Medical Service have done an excel-
lent job in presenting the Blue Shield plan. But
it is not because of super salesmanship by these
representatives that the Blue Shield Plans have
grown so vigorously. It is because the people have
wanted the service and protection they afford.
A Partnership
It is a partnership proposition entered into
between the patient and his doctor. Nothing must
be done which will disturb or negate that relation-
ship because the success of the entire voluntary
movement is based upon it. The interposition of
any party between the patient and the doctor is
an anathema to both for socio-economic and sci-
entific reasons.
June, 1957
715
MICHIGAN BLUE SHIELD REPORT
We who have the continuing responsibility for
the administration of our own Blue Shield pro-
gram face the task of giving all of the patients
what they want and are willing to pay for within
the basic philosophy of the Plan. But we are not
responsible for acceding to the wishes of pressure
groups, nor of solving solely by this machinery all
of the social and medical problems involved in
the care and treatment of the healthy and the sick.
To attempt this would be to accept a responsi-
bility not intended by the Michigan Medical Serv-
ice charter, nor possible within the scope of its
financial assets.
Current Attempts to Solue the Problem
(A report on representative types of prepayment programs made by Arch Walls, M.D..
President of the Michigan State Medical Society; Donald Thorup, M.D.. Delegate, Berrien
County Medical Society; and Max L. Lichter, M.D., Delegate. Wayne County Medical Society.)
The seven plans outlined are prototypes of the
various approaches to prepaid medical care. There
are, of course, many other plans in each area, far
too many to present in detail. However, these
seven incorporate the salient features in each
general area of approach.
They are classed as follows:
I. Plans controlled by medical societies
A. Michigan Blue Shield ( 1 )
B. Windsor (Ont.) Medical Service (2)
II. Plans not controlled by medical societies
A. Indemnity programs
1. Commercial Insurance (3)
2. Deductible or Co-insurance (4)
B. Group or Closed Panel Plans
1. Health Plan of Kaiser Foundation (5)
2. Health Insurance Plan of New York (HIP)
05)
3. Community Health Association (CHA) (7)
Each of these plans is outlined under the head-
ings of what the plan covers, how the physician
functions under the plan, how he is paid and how
much the program costs the patient.
Michigan Blue Shield
I. Services Covered:
A. Hospitalization through Michigan Blue Cross
(120 days on group coverage).
B. In-hospital surgical care, payment according to
benefit schedule.
C. In-hospital medical care, payment according to
benefit schedule.
D. In-patient x-rays, limit of $15 per admission,
according to benefit schedule.
E. Anesthesia by physicians — payment on basis of
time, according to benefit schedule.
F. Limited office surgical care.
G. Maternity — delivery only — flat fee according to
benefit schedule.
H. Emergency first aid treatment and x-ray, ac-
cording to benefit schedule.
I. Under supplemental rider, x-rays and EKG’S
supplemental to basic benefits and unlimited as
to number, paid in accordance with benefit
schedule.
II. Physician’s Function with Plan
A. Plan controlled by Michigan State Medical
Society.
716
1. Members of the House of Delegates of
MSMS are members of the Corporation.
2. Has a thirty-three-member Board of Direc-
tors. Two-thirds must be M.D.’s. Six repre-
sent the Michigan Hospital Association
and five represent the general public. All
board members are elected by Members of
the Corporation.
B. Physicians are paid by Blue Shield on a fee-for-
service basis.
1. Two schedules of benefits offered — both of
which were developed by MSMS and adopted
by the Plan’s Board of Directors. (Fees paid
to general practitioners and specialists are
the same.) They are considered as average
fees for average cases.
a. $2,500 Family Income Limit Plan ($2,000
if single).
b. $5,000 Family Income Limit Plan ($3,750
if single).
2. Participating physicians guarantee that fees
for contract benefits paid by plan are full
payment for persons with incomes less than
income limit of' their contracts.
3. Plan uses Advisory Boards from County
Medical Societies to recommend individual
fees for specific cases that are outside the
category of routine.
C. Physician works as a private practitioner on
fee-for-service basis. He reserves the right to
select patients he wishes to care for. His par-
ticipation in the Plan is optional. He may
resign as an individual from participation with-
out penalty.
D. Plan pays physician directly in all cases.
III. Plan’s Current Cost to Patient*
A. Group $2,500 Family Plan for medical-surgical
care is $3.25 per month plus $8.54 for compre-
hensive Blue Cross hospital coverage, semi-
private room service.
B. Group $5,000 Family Plan for medical-surgical
care is $4.50 per month, plus $8.54 for com-
prehensive Blue Cross hospital coverage, semi-
private room service.
C. Plan employs principle of community rating.
1. All groups regardless of size, type of em-
ployment, nature of work, age grouping or
race are charged the same rates for the same
coverage.
2. Group contracts do not exclude pre-existing
or chronic conditions.
*Supplemental x-ray-EKG coverage and extension of
days of care to 365 under hospital medical-surgical con-
tracts are available to qualified groups at additional cost.
JMSMS
MICHIGAN BLUE SHIELD REPORT
3. Deductibles and/or co-insurance are not
written-in features of any of the Plan’s sur-
gical or medical-surgical contracts.
4. Conversion privileges to individual status are
available to group subscribers when employ-
ment is terminated.
5. Provision is made to cover retired workers
for the same benefits at the same rates as
the active group when formal retired group
program exists.
Windsor Medical Service
I. Services Covered:
A. Hospitalization through Ontario Blue Cross.
B. In-hospital surgical care.
C. Office surgical care.
D. Maternity care ($50 delivery plus prenatal and
postnatal care, at so much per visit).
E. Medical anesthesia — payment by time.
F. X-ray — diagnostic and therapeutic — no maxi-
mum.
G. BMR, EKG, refractions, annual medical exami-
nation as out-patient.
H. In-hospital medical — no limit on number of
visits except as determined on each individual
case by Medical Director.
I. Consultation, with prior authorization by Plan.
J. Shock treatments.
K. Diagnostic hospital admissions.
L. Home and office calls.
M. Waiting periods for tonsillectomies and appen-
dectomies, hernias, gynecological cases, obstetri-
cal cases and refractions.
II. Physician’s Function with Plan
A. Controlled by Essex and Kent County Medical
Societies.
B. Board of Directors consists of ten members:
seven M.D.’s and three lay people.
C. Free choice of physician and fee-for-service
based upon a schedule.
D. Plan pays about 90 per cent of schedule, when
pro ration of income is adjusted to services.
E. Plan fee schedule is about 89 per cent of Michi-
gan Blue Shield $5,000 plan.
F. Specialists are paid higher fees for consultation
than general practitioners.
G. Non-participating physicians are not paid by
Plan. Payments made to subscribers in these
instances.
H. Medical Director adjudicates all disputes be-
tween subscribers and Plan and doctors and
Plan — decision is usually final — can appeal to a
special committee who report to the Board.
I. Medical Director reserves right to determine
adequate amount of medical care and Plan pays
accordingly — doctor can’t charge extra to pa-
tient if Plan reduces allowances and patient is
under income.
J. The Plan polices itself through its Board and
Committees. Reports are that this effectively
reduces over-utilization and helps to stabilize
rates to subscribers.
K. Plan may cancel participation of M.D.
L. Plan is full service for families under $6,500
incomes — usually accepted for everyone.
M. 35 to 40 per cent of plan benefits are rendered
outside hospital.
III. Plan’s Cost to Patient
A. Group plan for a family . . . $7.90 per month,
plus $6.30 for Ontario Blue Cross hospital cov-
erage under comprehensive contract.
B. Individual plan for a family . . . $8.50 per
month, plus $5.90 for Ontario Blue Cross hos-
pital coverage under a non-group contract.
C. Plan employs principle of community rating.
D. Plan does not use deductibles or co-insurance.
June, 1957
Commercial Insurance Contracts
I. Services Covered:
A. Hospital insurance, usually on basis of fixed
amounts for room and extra services.
B. In-hospital medical care per schedules.
C. Office and hospital surgical care (including
O.B. delivery) per schedules.
D. Emergency accident care (includes out-patient).
E. Home and office calls — with and without deduc-
tibles.
F. Out-patient diagnostic services on a deductible
basis or maximum per year allowances. (No
schedule on x-rays)
G. Dread disease riders up to $5,000 or $10,000.
H. Major medical coverage — usually inclusive of
all charges for hospital, medical, drugs and
appliances with deductibles and co-insurance.
(No schedule of fees)
II. Physician’s Function with Carrier
A. Physicians are totally unassociated with insur-
ance plans and have no voice in policy decisions
covering payments for medical care.
B. Insurance plans controlled by stockholders and
lay Corporation Boards of Directors.
G. Physician is paid on fee-for-service from the
insured member. Insured member looks to in-
surance company for claim. Payment, unless
assigned to doctor, is made to patient.
D. Each insurance company has a wide variety of
fee schedules which it sells to insurance con-
sumer. Usually, the one selected is determined
by its price to the insured. Fee schedules range
from $100 schedules to $150, $200, $225, $250,
$300, $350, $400 and so on.
E. Insurance plans do not seek fee recommendations
from the Michigan State Medical Society nor do
they have County Society fee adjudication
Boards to assist them in the determination of
fees for unusual and complicated procedures.
F. Physician reserves the right to choose his
patients.
G. Insurance plans generally will get together any
kind of a plan desired by a group — but on an
indemnity basis and scaled to fit a predetermined
premium charge.
III. Cost of Insurance Plans to Patient
A. Cost varies with level of benefits selected by
insured.
B. Cost of group contracts is determined by group
utilization since insurance plans use the prin-
ciple of risk selection and experience rating,
applied to individual groups.
C. Cost of group contracts is also influenced by
type of employment and age grouping.
D. Usually, conversion from a group status to an
individual status upon termination of employ-
ment is not offered.
E. Seldom offers same coverage at same rates to
retired workers as are available to active em-
ployes.
F. Many groups of employes are considered un-
desirable by insurance companies and are
dropped or never written by them.
General Electric Comprehensive Medical
Expense Program
I. Services Covered
A. Is part of an insurance program providing Life
Insurance, Accidental Death or Dismemberment
Insurance for employes, Weekly Sickness and
Accident Insurance for employes, Comprehen-
sive Medical Expense for employes and depen-
dents, and Maternity Benefits for female em-
ployes and dependent wives.
B. There are two classes of expenses:
1. Type A. covers Hospital room and board,
717
MICHIGAN BLUE SHIELD REPORT
special hospital services required for medical
or surgical care; operating rooms, drugs,
dressings and blood transfusions; anesthetics;
surgical fees; diagnostic x-rays; infant care.
In any one calendar year, first 25.00 is paid
by employe and the next $225.00 is paid by
Plan. For additional expense, employe pays
15 per cent and Plan pays 85 per cent.
2. Type B. Covers services of physicians, in-
cluding specialists, other than for surgery;
diagnostic laboratory work, x-ray and radi-
um treatment, oxygen therapy and blood
transfusions not covered under Type A. It
also covers services of most registered grad-
uate nurses; drugs and medicines requiring
prescription and rental of such equipment as
iron lung and artificial limbs.
In any one calendar year, first $50.00 is paid
by employe. After that, employe pays 25
per cent and Plan pays 75 per cent.
3. Combined maximum benefits for Type A.
and Type B: expenses for each covered
individual — $15,000 in total with maximum
of $7,500 in any one calendar year.
4. Benefits determined separately for each in-
individual. Employe pays no more than first
$50 for any combination of both Type A
and B expenses for any one calendar year.
5. Benefits for semi-private hospital accommo-
dations are provided without dollar limit.
6. Maternity Benefit (in lieu of all other
benefits) :
Normal Delivery $150
Caesarean 225
Miscarriage — up to 75
For severe complications of pregnancy or
resulting from childbirth, Plan pays 75 per
cent of amount exceeding $150 (paid by
employe) up to $5,000 for any one preg-
nancy.
7. Psychiatric treatment out of hospital will be
paid by Plan up to 50 per cent. If in hos-
pital, benefits will be paid on basis of Type
A and Type B.
II. Physician’s Function under Plan
A. Organizational structure
1. Through Metropolitan Life Insurance Com-
pany. In effect until October 1, 1960.
2. Care is furnished through regular private
practice channels. Patient has complete free
choice.
B. How physician is paid.
1. Is paid his usual fee for service rendered
subject to deductible and co-insurance provi-
sions of Type A, Type B and Maternity
Benefits coverage.
2. Collects employe’s portion of fee directly,
and Plan’s portion from insurance carrier.
3. There is no fee schedule. Benefits are based
upon fees which are “reasonable, necessary
and customary.”
C. How he works under Plan.
1. Physician’s co-operation is essential tO' suc-
cess of Plan. Must guard against taking un-
fair advantage of the insurance program.
As Elmer Hess has said: “Insurance per se —
does not create new wealth and ... is no
justification for increasing an otherwise rea-
sonable fee for a professional service.”
2. Physician renders his service upon usual
basis of private practice. Necessary consulta-
tions are permitted. Surgical assistants are
paid. Services can be rendered in the hos-
pital, in the office, at home — wherever phy-
sician feels patient will receive best care.
III. Cost to Employe
A. Is based upon whole Insurance Plan.
1. For employe alone 0.9 per cent of normal
annual straight time earnings.
2. Comprehensive Medical Expense Insurance
and Maternity Benefits for dependents, addi-
tional 2.0 per cent of normal straight time
earnings.
3. Example: Employe earns $6,000 per year
straight time wages. Cost of Plan: Individual
Employe, $54.00; Employe and dependents,
$174.00. This is for entire package.
4. Balance of cost paid by General Electric.
Health Plan of Kaiser Foundation
I. Services Covered
A. Diagnosis and treatment (surgical and medical)
in hospital and home and office, by specialists,
with no limits on number of visits, physical
checkups, pediatric care, eye examination for
glasses.
B. Dependents pay one half of x-ray and labora-
tory fee in most contracts.
C. Tonsillectomy $15 extra for subscriber to $35
extra for dependents.
D. Ill days hospitalization for subscriber; sixty
days for dependent, with additional fifty-one
days at one half private rate.
E. $1.00 for each office visit. $3.50 and $5.00
house call charge, depending on time of day.
F. Obstetrics $60 for subscriber; $95 for dependent
after ten months’ membership.
G. Pre-existing conditions covered at one half pri-
vate rate in most groups.
H. Drugs and appliances not furnished.
I. Free choice of physician within group.
J. Special provision for care outside service area.
II. Physician’s Function under Plan
A. Organizational structure
1. Kaiser Foundation.
2. Kaiser Health Plan (is regional) contracts
with doctors and hospitals for services on
behalf of its subscribers.
3. Kaiser Foundation Hospitals own all hos-
pitals and clinic buildings and rent space to
doctors.
4. Permanente Medical Group in Bay Area has
300 physicians, about seventy of whom are
partners and balance are salaried.
B. How physician is paid.
1. Group is paid a capitation fee by Plan.
Extra charges to member as well as fees
from private patients accrue to Kaiser Foun-
dation Group.
2. Physician is employed initially on salary
basis. After three years of satisfactory service
he may become a participant in group. After
an additional two years, he may purchase a
partnership in Group. Income depends upon
senior status and degree of responsibility.
C. How physician works.
1 . Group divided into specialty services in each
facility, each headed by a chief. Intra and
inter service consultation is encouraged. Prac-
tically no general practitioners are em-
ployed.
2. Work five and one half days a week, seeing
patients in own service by appointment. All
administrative details handled by ancillary
assistants.
3. Junior members rotate house calls, night
and emergency coverage.
4. Vacation periods, educational privileges*
sick benefits depend upon physician’s status
with group.
718
JMSMS
MICHIGAN BLUE SHIELD REPORT
III. Cost to Patient
A. Depends upon class of coverage. Examples
based upon family unit : Group — Same benefit
for subscriber and dependents — $14.00 per
month; Group — Subscriber benefit and usual
dependent — $11.40 per month.
B. Groups pay $2.00 registration fee.
C. Approximately 600,000 members.
Health Insurance Plan (HIP)
I. Services Covered
A. Complete care including home, office and hos-
pital by general practitioners and specialists.
B. Out-patient diagnostic and laboratory proce-
dures.
C. Eye examinations, visiting nurse service, periodic
health examinations, immunizations.
D. House calls at patient’s request between 10:00
p.m. and 7:00 a.m. at extra charge of $2.00.
This is the only extra.
E. Free choice of group and then of physician
within group.
II. Physician’s Function under Plan
A. Organizational structure
1. A central “headquarters” which collects
dues, disburses to physician groups, sets
standards for initiation of groups and main-
tenance of standards of medical care, de-
velops appropriate statistics, develops sys-
tem of patient records and maintains their
completion and collection, initiates subscriber
as well as physician educational programs
relative to the plan; conducts surveys con-
cerning utilization and quality of medical
care furnished members; administers a pen-
sion fund set up for physicians.
2. Physicians form autonomous medical groups
and approach plan for participation. Must
conform both in composition and physical
facilities to criteria laid down by plan.
Groups are partnerships with additional
physicians on a salary basis. Limited, infre-
quently used specialties paid on a fee basis
through a special fund contributed to by
all groups. Groups must finance own build-
ing and equipment. Criteria, in addition to
basic, further depend upon number of per-
sons group contemplates caring for. All
groups responsible to central office through a
fifteen-member Medical Control Board, a
policy-establishing mechanism.
B. How physician is paid.
1. Group receives annual per capita fee of
$31.20 (at present) for each member who
elects to use group.
2. After administrative and operating expenses
are paid, as well as salaries, collected funds
are apportioned to group partners on basis
of responsibility, training and seniority.
C. How physician works under plan.
1. Almost all physicians work in Center part-
time. Most have own private office for pri-
vate practice but even here many will see
HIP members.
2. As far as possible, each patient is first seen
by a general practitioner (who represents
about 40 per cent of the 1.100 men in the
plan) who serves as the personal physician
and who acts as the referral agent and is
responsible for follow-up of treatment as
well as patient’s compliance with consulta-
tive referrals.
3. House calls rotated through partners of
group with main responsibility falling on
general practitioners.
4. Patients are seen by appointment with phy-
June. 1957
sician of choice. New patients are assigned
on rotation. Provision for emergencies and
drop-ins.
5. Non-members seen at Center with fees
based upon a schedule and accruing to group.
Part-time physicians (even partners) con-
duct private practice in own separate office.
6. Hospital care is given at hospital of which
physician is a staff member or where he has
privileges.
7. Group contracts with central office to furn-
ish agreed medical services to members.
III. Cost to Patient
A. Standard plan, designed for individuals with
base salary of not more than $6,000 or families
with income of not more than $7,500, has
monthly cost of $3.56 for individual; $7.56
for couple, and $10.68 for family. At least
one-half must be paid by employer.
B. Subscriber earning more than in standard plan
pays 20 per cent more.
C. Usual enrollment is group of ten or more sub-
scribers, though recently individual enrollment
in apartments or housing projects has been
undertaken.
D. All subscribers must carry own hospital insur-
ance and it must be Associated Hospital Service
(Blue Cross).
Community Health Association
No specific plan has been announced or pub-
lished. All information relative to this plan should
be regarded as hearsay although much probably
represents what will prove to be definitive.
I. Services Covered
A. Apparently the coverage will be comprehensive
in home, office and hospital with diagnostic and
laboratory service. There is no information con-
cerning exclusions. There is no information
concerning extras. There is no information
concerning status of dependent coverage.
B. Apparently plan is based upon combination of
features of HIP and Kaiser Plan. At present,
it is said that CHA does not contemplate build-
ing own hospitals.
C. Apparently premium will include hospitalization.
It may be that CHA will then negotiate for
hospitalization directly with hospitals (though
on what basis is presently not known) or will
purchase hospitalization from Blue Cross.
D. It is said that in beginning, CHA will start on
a small scale experimental basis. One local
union (for example) will be offered the plan.
Within this group there will be further offered
to the individual union member the choice of
accepting CHA or continuing his present plan
(or any modification thereof). It is said that
this type of choice will always be a policy of
the UAW-CIO. It is said that CHA eventually
wishes to offer its plan to any member in the
community.
II. Physician’s Function under Plan.
A. Organizational structure
1 . CHA will have a Board of Directors who
will decide and control every aspect of the
plan.
2. There will be a CHA Medical Director,
responsible solely to the Board. His respon-
sibilities have not been announced.
3. Apparently there will be “built-in mechan-
isms to make possible the rendering of high
quality medical care.” It may be that this
will be accomplished (policy-wise) by the
719
MICHIGAN BLUE SHIELD REPORT
establishment of a Medical Advisory Com-
mittee (to the Board) built around a Uni-
versity Medical Center. This Committee,
having no executive function, purportedly
would be sensitive to trouble spots, advise
on standards and policies, have no vested
interest, and would eliminate local politics.
It would screen all physicians having an in-
tegral role in the program.
4. Groups of physicians would be established
to provide services of plan. There is no in-
formation concerning criteria for establish-
ment of groups, financing of group facilities
and equipment, minimum number of mem-
bers a group must care for. However, it
has been suggested to the Board that it
is dangerous to permit groups to have total
autonomy. Hence the group medical direc-
tor, its executive officer, should have the
title of Associate Medical Director of the
plan.
B. How the physician is paid.
1. No official pronouncement has been made.
Best information at present is that all physi-
cians will be on a salary, to be paid directly
by the CHA.
2. No information is available from any source
concerning care of non-member (or private
patients) and fees so derived.
C. How the physician works.
1. No details are available. It is presumed that
the 40-hour week will provide the basis for
working hours.
2. All of the standard reasons for attracting
physicians to this type of group practice
have been mentioned at one time or another.
3. Apparently the general practitioner will be
“the cornerstone” of medical care, as ad-
vocated by HIP.
D. All physicians, presently having hospital staff
appointments or privileges, will be expected to
maintain them and utilize them for the mem-
bers of the plan. Hospitals, apparently, will be
expected to see that staff membership or priv-
ileges are not jeopardized by the physician’s
participation in a group under the CHA plan.
E. No information is available concerning the ac-
tual functioning of physicians within the plan
or the groups. It would seem, however, that
“the quality of medical care” furnished by each
physician will be subject to constant scrutiny
as well as periodic evaluation. What this is
intended to mean is not clear, as yet.
III. Cost to Patient.
A. There is no information, or even faint hint, on
this subject. It is thought, however, that costs
will be competitive with existing plans of Blue
Cross-Blue Shield and commercial insurance.
Where Do We Go with Prepayment?
(Report by Jay C. Ketchum, Executive Vice President of Michigan Medical Service.)
Michigan Medical Service (Blue Shield) now
provides coverage for medical-surgical expense,
according to its various contracts, to almost one-
half of the people of Michigan, some three and
one-half million. The benefits of coverage have
been, with a few exceptions, limited to hospitalized
cases. Little in the way of diagnostic services has
been provided.
There has been voiced an increasing desire for
extension of coverage into the diagnostic services
without the requirement for hospitalization. De-
mands for extension of benefits to other than hos-
pitalized cases are heard, not only from large
numbers of subscribers but from many physicians
as well. Certainly, restricting payments to services
rendered to in-hospital bed patients does affect
medical practice, particularly as to minor surgical
and diagnostic procedures. Coverage for long
periods of hospitalized illness, including conval-
escence, has been requested. In the main, but by
no means exclusively, there have been requests
for adjustment of our service income ceilings to
more nearly reflect present economic conditions,
voiced by the representatives of large organiza-
tions of our subscribers.
A spokesman for Labor, Dr. Morris Brand, last
December in the AFL-CIO News stated Labor’s
aims in the field of prepayment for health care:
Dr. Brand stated that since Congress has not
enacted legislation to set up a national insurance
program — which most labor unions favor — unions
have had to find other sources of health insur-
ance coverage for their members, mainly Blue
Cross-Blue Shield and commercial carriers.
However, Dr. Brand continued, since home and
office care is rarely offered in these plans, some
“labor groups have established direct service medi-
cal centers where services are actually provided
rather than cash indemnities to cover part of the
costs. The latter type of plan has proven more
popular with members because there are no bar-
riers to the service, preventive services are usual-
ly included in the benefits and there are no hidden
bills cropping up after the services are rendered.”
What Doctor Brand Thinks
In general. Dr. Brand believes that:
“The extent to which commonly available insurance
programs meet a family’s health needs is not too im-
pressive to Labor.” He says that indemnity payments
720
JMSMS
MICHIGAN BLUE SHIELD REPORT
are “not a satisfactory method of paying for services
and are a base upon which some physicians too fre-
quently add substantial charges. Also the emphasis on
hospital and surgical coverage as in the case of most
plans without substantial out-patient benefits is fre-
quently a cause for unnecessary hospitalization. Also,
as a result of inadequate concern for operating efficiency
in hospitals and an unwillingness to enforce legitimate
controls, there are unjustified premium increases.”
According to Dr. Brand, these are Labor's goals
for better health plans:
1 . Complete prepayment for medical care without
co-insurance and deductible features and hidden
added costs.
2. Comprehensive benefits — only if the range of health
services is complete will the individual’s health
needs be effectively and economically met.
3. Rational organization of medical services — on the
basis of group practice, and
4. Control of the quality of medical services which
must be built into medical care plans.
Mr. Walter Reuther, in his President's Report
to the UAW 16th Constitutional Convention,
April, 1957, confirmed Dr. Brand’s statement.
Efforts to develop a $6,000 family income ceil-
ing service contract have consumed so much time
and, in relation to the fees proposed therefor,
would require subscriber rates of such amount
that we are led to believe the results would not
be acceptable to the interested subscriber groups.
The minimum benefits needed right now to sat-
isfy the market seem to be approximately as fol-
lows:
Surgical services, in or out of the hospital
Obstetrical services, in or out of the hospital
Medical (non-surgical) services in the hospital
Anesthesia services, in all surgical cases
Diagnostic radiology, in or out of the hospital
Therapeutic radiology, in or out of the hospital
Physical therapy, in or out of the hospital
EKG, BMR. EEG, EG, in or out of the hospital
Pathological tissue examinations, in or out of
the hospital
These services are to be limited only by the ap-
plicable scheduled fees.
Coverage for the services of consultants and
surgical assistants is also desirable but presents
difficult problems.
For Example
Extensions of benefits to those services per-
formed outside of the hospital present unique
problems in that certain elements of control of
utilization inherent in the hospitalized case are not
present outside. Abusive or ill considered utiliza-
tion of benefits can accumulatively increase sub-
scriber dues to an unreasonable and perhaps un-
bearable degree. Conventional insurance methods
toward control, such as deductibles and co-insur-
ance, might provide a degree of control and re-
duction of subscriber dues. These methods, how-
ever, appear to be unacceptable in health care
prepayment to the representatives speaking for
many of our subscribers. It is extremely difficult,
if not impossible to determine at what point a
particular deductible amount or co-insurance per-
centage becomes not just inhibitive as to elective
or abusive use, but in effect, prohibitive as to
utilization of needed services. These representa-
tives insist that control of abusive utilization must
be assumed by the Profession and the hospital.
Deductibles and co-insurance would undoubted-
ly receive much more acceptance if the maximums
contemplated by our service schedules were cer-
tain of acceptance. It seems obvious that assur-
ance of acceptance of our schedules of fees can
be given only if there is some arrangement for
some form of policing of charges by the Profession.
An experiment by Blue Shield in Wisconsin pro-
vides for payment of physicians’ usual and reason-
able charges. Fee schedules as such have been
completely abandoned (in this experiment). How-
ever, the Medical Society has assumed the full
burden of policing charges, even to entering into
court cases as co-defendant with the patient
against what are considered unreasonable charges.
The scope and nature of benefits provided by
Blue Shield are not the only shortcomings com-
plained of by our subscribers. Mostly, these are
restrictions imposed upon Blue Shield by its re-
lationship to, and the attitudes of, organized medi-
cine. There is, for example, the difficulty the
subscriber experiences in determining the partici-
pating or non-participating status of a particular
physician. It seems unfair to our subscriber when
we promise service benefits and then refuse to
assist him in receiving the benefits. It is just as
difficult to demonstrate to many of our participat-
ing physicians that there is any justification for
participation when the non-participating physician
contributes nothing to the success of the Plan but
enjoys its advantages. It is equally difficult to
explain our attitudes toward other practitioners,
June, 1957
721
MICHIGAN BLUE SHIELD REPORT
such as dental surgeons, chiropodists and osteo-
paths, who legally render service covered by our
contracts, who are willing to abide by our terms
of participation, but who are not permitted that
formal arrangement with Blue Shield.
Rejected
The concept of providing prepayment for only
the very lowest income classes has been rejected
by most of the public. Many persons and groups
of persons are convinced of the propriety and
value of prepayment regardless of incomes and
are unable to understand why the Profession is
unwilling to deal with all members of a group
on a service basis.
The insurance companies in this field have
underwritten coverages for large numbers of peo-
ple. The coverage, quite similar to Blue Shield as
to type and scope, is, of course, provided on the
indemnification basis. The acceptability, to many
groups, of the indemnity insurance is primarily
based on price competition. It is standard prac-
tice in the health insurance industry to promulgate
rates for a particular group of assureds in relation
to the experience of that group. The result of
this practice is that, based on price competition,
much of the preferred (or so-called “cream”)
business is underwritten by insurance companies.
Michigan Medical Service, being committed to
provide the greatest good to the greatest number
at a fair cost, utilizes what is commonly referred
to as community rating; that is, for identical cov-
erage identical rates are charged. This makes it
possible for all, regardless of age, composition of
group, race, occupation, etc., or experience within
a segregated group, to enjoy protection at an av-
erage cost for all in the community in which Blue
Shield operates.
The practice of experience rating, carried to
its ultimate conclusion, can result in many of the
people, the preferred risks, being removed, for
rating purposes, from the total community (the
total average) . Thus, the remainder, being not
so preferred, must bear a higher proportion of
the total cost of coverages. This higher propor-
tion of cost will, as it increases, become an effec-
tive prohibition to some, particularly the aged and
lower income classes. When these can no longer
afford to secure voluntary protection, they will
look elsewhere, perhaps to Government, for a
method. That the traditional insurance approach,
based on a profit motive, has failed to restrain
722
Government intervention has been demonstrated
in other lines of coverage. While not the only
example, the necessity for states to establish Gov-
ernmental controls, monopolistic funds, openly
competing State operated underwriters and re-
straining laws in Workmen’s Compensation, is il-
lustrative.
Major Medical
A comparatively new form of health care cov-
erage, the so-called “Major Medical” contract, is
receiving considerable acclaim in insurance circles,
as the answer to Blue Gross-Blue Shield compe-
tition. This form provides, subject to a deductible
provision from $100 to $500 but sometimes as low
as $25, and co-insurance above the deductible at
20 or 25 per cent but sometimes as low as 10
per cent, on almost all types of care of a patient,
including hospitalization, physician, surgeon,
drugs, appliances, convalescence, private duty
nursing, et cetera, at home, doctor’s office, et
cetera. The only other limitation of any con-
cern is related to time, during a period of one,
two, three years or even longer, for a total ag-
gregate cost unallocated as to type of benefit, of
$5,000, $10,000 or even $25,000. In one case,
of which we know, there is no time limit and no
dollar limit. This, at first glance, seems to have
a great deal of merit. However, students of the
problems of the total population concerned with
the final effect on medicine are aware of grave
danger. Remember that the aggregate maximum
amounts are not allocated and no limit is placed
on any one item. The individual charges by
individual doctors, hospitals, nurses, are expected
to be reasonable. It is unlikely that there will be
many flagrant abuses (although some have been
reported) of the open-end provisions as to fees or
charges. The real danger in Major Medical lies
in the possibility and probability (already well
documented) of a gradual but none-the-less ap-
preciable and consistent increase in charges for
each service, simply because of the existence of
the insurance. It is just not realistic to expect
individual doctors to resist such temptation. Such
increase, accumulated, in the costs for each unit
of millions of services, can ultimately effectively
raise the cost of medical care to the point of
creating the demand for intervention, the very
thing medicine has hoped to avoid by reliance
upon insurance.
Demonstrating that informed representatives of
JMSMS
MICHIGAN BLUE SHIELD REPORT
our largest groups of subscribers are aware of the
dangers, there is, among many examples, the
evaluation of “Major Medical Expense Insurance”
by Jerome Pollack, of the UAW-CIO Department
of Social Security. He says: “The insurance is
without valid controls to prevent an unwarranted
inflation in health service costs.” His entire state-
ment of conclusion is extremely informative and
should be referred to.
Closed Panels
The closed panel practice prepayment schemes,
of which we have varying degrees of intelligence,
consist of mechanisms whereby groups of profes-
sional persons are brought together under a single
management to provide services for certain eligible
people or groups of people. The arrangements be-
tween the management and the professional per-
sonnel may vary from salaried to per-capita (or
capitation) ; may be full or part time; equipment
and facilities may be furnished by management
or the professional individual. Control and status
may be determined by professional personnel, by
management and professional representation or
exclusively by management. These groups may
provide limited type and scope of benefit or up
to almost all inclusive services. They may or may
not require some payment at time of service in
addition to prepayment dues. Much can be said
of the advantages and disadvantages of these
schemes both from the professional as well as
from the patients’ point of view. There may be
much to be said of the effect on the quality of
medical care, on the patient-physician relation-
ship, on the earnings of the physicians and the
freedom to practice. Voicing my opinions in this
matter would help you but slightly, if at all, unless
you have an adequate knowledge of your own on
which to base judgment and after all, it is really
the concern of the physicians, individually and
collectively.
There are plenty of examples of Government’s
intervention into the provision of personal medi-
cal care. The most recent and dramatic example
is “Medicare,” the program for provision of care
for dependents of servicemen. This program, ad-
ministered in Michigan by Blue Cross and Blue
Shield, was adopted after long study by many
interests, including your American Medical As-
sociation. It can be said that the program, as
finally instituted, was not what organized medicine
would have preferred but constituted the best
compromise possible. Effective July 1, this year,
the Government, by grants in aid to States, will
assume further obligations for medical care, by
virtue of the Welfare Act of 1956, for four more
categories of its citizens. Under consideration in
the present Congress, is a proposal for the Gov-
ernment to provide certain health care benefits
to the beneficiaries of OASI. Over the years,
many of the provisions of the original Wagner-
Murray-Dingell Bill, have been enacted into law,
leaving compulsory health insurance as almost
the only phase still to be realized by its propon-
ents.
Medicine’s Decision
Failure of voluntary means for providing health
care can only result in compulsory methods being
employed. The people have been told that vol-
untary methods can provide the answers. The
voluntary plans have shown great ability so far
and have led the people to expect more and
better results. If the medical profession wants
Blue Shield as its method in preference to other
alternative attempts, and, if Blue Shield is inade-
quate for current needs and requires change or
expansion to make it adequate, then Blue Shield
can do the job, but — it can do only what the
Profession wills it do; it can be only what Medi-
cine wants it to be. Blue Shield in Michigan is
Medicine’s responsibility and will work as well as,
and only as well as your cooperation will permit.
Only if the medical profession is convinced of
the value of the service benefit approach, under
the control of Medicine, on a fee-for-service basis,
with free choice of physician; convinced that this
is the most acceptable device; convinced of the
necessity of a workable plan as an alternative to
the various other schemes in existence and po-
tential ; only if the Profession is willing to do what
is necessary to make its Plan work should you
continue to sponsor, direct and concern yourselves
with Michigan Medical Service. If you are con-
vinced of these things, then you must take an
active part, acquire the necessary intelligence,
make decisions and be willing to support with
a united effort.
The Medical Profession must speak as one,
direct as one, and act as one. It is not sufficient
that the Profession express itself critically and
with many voices. We shall be unable to satisfy
completely fifty-four county medical societies and
eighteen or nineteen different specialty groups
June, 1957
723
MICHIGAN BLUE SHIELD REPORT
with oftentimes opposing views. Members of the
profession must communicate with all segments,
all the many specialty groups, all the components,
all the individual physicians. They must consider
all the different interests, evaluate all the special
problems. They must agree, compromise and
reach decision. They must then direct and sup-
port united action in behalf of all the profession.
The only banner about which all of Medicine can
rally is that of its parent Society — first, the AMA ;
second, the state societies; third, the county so-
cieties— and then the specialty groups. Dr. Austin
Smith, Editor of The Journal of the AMA at
Lansing on March 6 of this year, made a strong
plea for all doctors and all segments of medicine
to resolve their differences and join hands in a
united front to prevent the catastrophe that has
overwhelmed the profession in many other coun-
tries.
Dr. Dwight Murray, in his presidential address
to the AMA at Seattle, last fall, warned:
“No nation can merely reap the benefits of freedom ;
it must also sow the seeds of freedom. In medicine
the situation is the same. If an apathetic profession takes
its freedom for granted, it will be the beginning of the
end. . . .”
“The day has come, gentlemen, when we can no
longer look upon medical economics and social changes
merely as issues to be considered during our limited
leisure hours. . . . We must now pay daily attention
to these matters. . . . They must be a vital part of
our life.”
What Road Shall We Follow?
(Condensation containing the highlights of the presentation made by George W. Slagle. M.D.,
President-Elect of MSMS)
The previous speakers have outlined the story
of prepayment. We have heard the story of Blue
Shield, of private carriers, of closed panel plans
and of projected union plans. The facts of life,
insofar as these problems are concerned, have
been placed before you.
This leads us to a forking in the road. Which
road do we want to follow? Do we want to adjust
our thinking and planning of Blue Shield to
present day needs and make it even more success-
fid than in the past, or do we want to disregard
the warning clouds on the horizon and lose our
plan — the doctor’s plan — by default? As has been
stated many times today, Michigan Medical Serv-
ice is the fiscal agent for MSMS; you as Delegates
are its “stockholders” and elect its Board of Di-
rectors. Each of us through you, as our Delegates,
has a personal interest and responsibility in the
future of our Blue Shield.
Now, if you will permit me to assume that the
huge majority of the members of MSMS, which
I believe to be true, want MMS to be continued
and to be broadened in scope and coverage, then
I would like to present to you the thinking of
many of your confreres and duly elected represen-
tatives.
Improved Lines of Communication
It is readily agreed by those close to the problem
that the lagging enthusiasm on the part of many
physicians in Blue Shield involves a breakdown
in communication. The rapid growth of the
Blue Shield Plans has created a problem in main-
taining a constant flow of information to the
participating doctor. At this point, I might ask
the question, “Why the lack of 100 per cent active
physician participation?” A combination of fac-
tors has probably been responsible. For example,
general prosperity has eliminated the need for
assurance of his fees, and in some physicians’
thinking it has eliminated even the need for pre-
paid health insurance. The false notion that a
third party is dictating his fees is probably another
factor.
Through the years, the Plans have risen to the
demands of the public, and without adequate ex-
planation to the participating physician, have
given the appearance of encroachment on his in-
dividuality and the free practice of medicine. We
must let it be known that Blue Shield earnestly
and sincerely wants, needs and welcomes con-
structive criticism and suggestions from physicians
and that no suggestion or criticism is too trivial
724
JMSMS
MICHIGAN BLUE SHIELD REPORT
or irrelevant to receive careful attention. Through
these methods, in a spirit of good will and deter-
mination, we doctors will assure a continuation of
the improvement and success of Blue Shield under
the aegis of the profession.
It has been suggested that our professional re-
lations force be further enlarged to comprise
groups of participating physicians to combat lack
of information among our colleagues in the in-
formal atmosphere of our hospital lounges. In
this regard each of us, after this particular meet-
ing, can play a tremendously valuable part.
Through improved dissemination of information
and an awakened interest of the profession in
Blue Shield, we believe that all problems can be
met and solved as each physician exercises his
fair share of influence in the determination of
policies that will best serve his patients.
Liberalization of Contracts
There can be no argument that the ideal con-
tract would give complete coverage of the in-
dividual from womb to tomb for a single sub-
scription fee. But contrary to the belief of some
individuals and groups, this contract would carry
a substantial “price tag.” There is no such thing
as “free” coverage; it costs, and someone has
to meet that expense. However, as has been out-
lined, plans for greater coverage for the subscriber
are in the “hopper” and are being developed and
will be made available at a cost that is actuarially
sound and within the limits of ability of the
subscriber to afford. It is imperative that this be
done if we are to discharge our duty to the public
(our subscribers).
Supervisory Control of Patients, Hospitals
and Doctors
For any plan to be successful, it has become ap-
parent that faulty or improper utilization or extra
cost to the carrier or subscriber must be kept
at a minimum. We believe that this is not a one-
way street; that it is not the infrequent doctor who
is solely at fault or that it is his sole responsi-
bility. The subscriber must be shown that his re-
quest for unnecesary care, or services not covered
in his contract will eventually result in increased
premium rates and if sufficiently great might spell
the demise of all voluntary health insurance. In
addition, the hospitals must assume their rightful
duty in controlling excessive and prolonged medi-
cation, so-called extras and undue overstay.
Where and how we doctors fit into this program
is the problem. Some years ago, it was recom-
mended by the MSMS that review committees
be appointed by each individual hospital staff in
an attempt to find a solution to the problem we
faced at that time. Some are still functioning,
but I dare say most have been inactive for some
time. Whether or not something along this line
is the answer to the proper supervisory control
of our present and contemplated Blue Shield
coverage or that some other method should be
devised must rest with the individual hospital
staff, county society and/or this House of Dele-
gates. Certainly suggestions and recommenda-
tions that may come from resolutions and dis-
cussions in Reference Committee will be eagerly
awaited, and we hope that this problem will be
given serious consideration.
Action and Philosophy of the Profession
The following remarks are the result of the
thinking of many individuals, and committees,
who have studied this problem over many months
and are not solely original with me. They will
apply not only to the matter of prepayment
health service but also to the role government
and/or other pressure groups may seek to play.
In the past, we have been faced with a frontal
attack and we knew, to a large degree, what
we were up against, but now most of it is a
flank attack, the endeavor to get a “foot in the
doorway.”
Replace Apathy with an Active, United Pro-
fession.— Today there is a greater need for a
united, forceful and informed profession than
ever before. The basic reason for this special
meeting of the House of Delegates was to give
to you the information as to all the facets of pre-
payment of health care as of this moment.
Through you primarily, and with the help of
others, it is hoped that each individual member
of MSMS will be better informed so that after
due deliberation, considered decisions may be
made. Once those decisions are made by the
majority, then it is incumbent upon each of us
to make it as nearly unanimous as humanly
possible. The road of apathy and disunity can
only lead to disorder and possible disintegration,
and we must sound a warning to all our colleagues
who don’t care, or who are pulling in the op-
posite direction. As I said before, we must be-
June, 1957
725
MICHIGAN BLUE SHIELD REPORT
come a fighting unit to keep the Doctors Plan
truly all doctors’ plan, to make it the best, and to
give service to our subscribers so that the public
will prefer the Doctors Plan to panel practice,
organizational practice, governmental practice or
any other scheme involving third party control.
Free Choice of Doctors. — That the patient
should have the free choice of physicians has
been said many times before by many people,
but to us it should never become a trite saying.
We must continually prove to our patients that
this right is an important one; one that under
any of the methods stated before could easily be
lost through directive of an intervening third
party. Oh yes, some plans maintain that when
the individual joins their group that they have
freely chosen their physician, even though it is
actually a group of salaried doctors. Ridiculous!
Free Conduct in Medical Treatment. — As Presi-
dent Dwight H. Murray of the AMA has so suc-
cinctly stated :
“Another freedom closely tied to freedom of choice
is freedom in the conduct of medical treatment.”
There should never be a third party telling you
and me how we should treat and care for our
patients. It is well known that closed panel plans
claim to run more cheaply than Blue Shield plans.
This is mainly because, by directives, the amount
and type of laboratory examinations can be limit-
ed, the amount of time spent with the patient
can be designated and the treatment streamlined.
It may be cheaper but it’s “short-change medi-
cine.”
The dangers of shifting responsibilities for medi-
cal care from the patient and doctor to a third
party are obvious. The caliber of medical care
cannot be as high as that which you and I give
the patient. Initiative succumbs to dictation and
the doctor becomes a “clock-watcher.”
Free choice of physician and free conduct of
care engender a mutual confidence and trust be-
tween the patient and the doctor that is so nec-
essary for the well-being of the individual. Re-
move this bond and the practice of medicine as
you and I have known it, that priceless heritage
passed on to us through the ages, is lost — and
once lost, can never be regained.
This philosophy of our profession is not new,
it is not something esoteric, it is an every-day
working concept that we all feel, share and be-
lieve in. It is the driving force that enabled us
to become doctors of medicine, that carries us
through our long hours of work, our problems and
tribulations, and above all, really endears us to
our patients.
What Do the People Want?
Of great importance also is the fact that any
general service by professional people which is
to be sold must ( 1 ) be what the public wants
and/or needs; (2) be within reach of the aver-
age man’s income.
I propose that we find out what the public
really wants and that we get incontrovertible evi-
dence to that effect. This will help us greatly
when we talk to certain pressure groups who
would have us believe that the real wants of the
people are the same as the demands made by
the leaders of pressure groups. I question whether
these pressure groups actually speak the will of
all of the people — or of a majority of the people
- — who subscribe to Blue Shield.
In other words, I propose that we go to the
people through a survey or study that will give
us part of the knowledge we need upon which to
predicate any changes in our service as well as
the information necessary to meet any false claims
that may be made.
I propose, further, that this study or survey
determine the extent and willingness of people
to pay for certain categories of medical and sur-
gical service so that we can better determine upon
the most attractive, as well as the most valuable,
package to offer. For example: would the people
prefer to have home and office calls covered
rather than x-rays? Would our subscribers be
more willing to pay for coverage of certain diag-
nostic procedures than minor surgery? . . . and
so forth.
I do not mean that services offered through
Blue Shield should be limited to the most popular
of the services, for we would all agree that such
would be medically and scientifically unsound.
Furthermore, Blue Shield must represent all the
profession and if it does not offer the broad variety
of medical and surgical services it cannot do that.
I merely indicate that with knowledge of what
the public really wants, with knowledge of what
the people are most willing to pay for, and with
726
JMSMS
MICHIGAN BLUE SHIELD REPORT
these knowledges weighted by our own medical
knowledge of what the public needs and what is
actuarially possible within the limits of the public
purse, we can arrive at the most attractive offer
consistent with the public interest, consistent with
our philosophy and consistent with the reasonable
cost of our services.
Action, United
The actions we must take to preserve and im-
plement these basic concepts must be arrived at
by you and our confreres back home after due and
careful deliberation. These must not be hasty
decisions but a result of clear thinking and in-
terpretation of the information given to you.
The stand our united Society takes can, and will
have far-reaching effect. Let us work for what
is best for all the people and for the profession
as a whole and attempt to sublimate any indi-
vidual personal or selfish wish. Let us see the
forest and not the trees!
MICHIGAN MEDICAL SERVICE PAYMENTS TO DOCTORS OF MEDICINE
By County of Residence, 1940 to December 31, 1956
Per Cent
of
Total Total
1.
Alcona
....$ 52,527.00
.02
2.
Alger
21.308.50
.01
3.
Allegan
505.564.75
.23
4.
Alpena
1,020,214.87
.46
5.
Antrim
42,831.50
.02
6.
Arenac
121,413.00
.05
7.
Baraga
139,442.25
.06
8.
Barry
195.811.10
.09
9.
Bay
3,283,081.32
1.47
10.
Benzie
94,759.00
.04
11.
Berrien
1.519,086.21
.68
12.
Branch
615,800.85
.28
13.
Calhoun
2,177,583.58
.97
14.
Cass
104.051.50
.05
15.
Charlevoix
259.089.00
.12
16.
Cheboygan
421.770.25
.19
17.
Chippewa
1,315,216.25
.59
18.
Clare
47,886.25
.02
19.
Clinton
806,206.25
.36
20.
Crawford
164,508.75
.07
21.
Delta
513.266.50
.23
22.
Dickinson
361,154.75
.16
23.
Eaton
484,842.87
.22
24.
Emmet
1,125,643.27
.50
25.
Genesee
.... 14,164,582.22
6.34
26.
Gladwin
98,351.99
.04
27.
Gogebic
222,314.90
.10
28.
Grand Traverse ..
1.322,240.20
.59
29.
Gratiot
449,276.75
.20
30.
Hillsdale
627,160.27
.28
31.
Houghton
568,349.25
.25
32.
Huron
538,841.50
.24
33.
Ingham
7,600,981.34
3.40
34.
Ionia
682,278.25
.31
35.
Iosco
130,706.00
.06
36.
Iron
73,963.00
.03
37.
Isabella
764,774.55
.34
38.
Jackson
1,279,756.08
.57
39.
Kalamazoo
.... 2,819,159.25
1.26
40.
Kalkaska
10,599.75
.01
41.
Kent
.... 8,962,244.70
4.01
42.
Keweenau
2,733.00
.00
43.
Lake
8,634.25
.00
44.
Lapeer
511,012.00
.23
45.
Leelanau
109,024.25
.00
Per Cent
of
T otal
T otal
46.
Lenawee
$ 774,420.75
.35
47.
Livingston ....
339,245.00
.15
48.
Luce
137,746.30
.06
49.
Mackinac
23,034.75
.01
50.
Macomb
3,334,082.90
1.49
51.
Manistee
157,160.75
.07
52.
Marquette ....
847.900.89
.38
53.
Mason
285,598.25
.13
54.
Mecosta
264,406.75
.12
55.
Menominee .
225,390.25
.10
56.
Midland
124,592.15
.06
57.
Missaukee ....
131,556.25
.06
58.
Monroe
752,712.00
.34
59.
Montcalm ....
491.377.25
.22
60.
Montmorency
14.885.50
.00
61.
Muskegon ...
1,777,278.93
.80
62.
Newago
168,045.45
.08
63.
Oakland
12,296,484.03
5.50
64.
Oceana
317,158.75
.14
65.
Ogemaw
317,122.50
.14
66.
Ontonagon
195,305.25
.09
67.
Osceola
281.189.50
.13
68.
Oscoda
1,891.00
.00
69.
Otsego
152.636.29
.07
70.
Ottawa
1,102,624.05
.49
71.
Presque Isle .
267,1 18.00
.12
72.
Roscommon .
20,984.75
.01
73.
Saginaw
6.851,830.31
3.07
74.
St. Clair
2,595,275.50
1.12
75.
St. Joseph ...
397,126.74
.18
76.
Sanilac
319,116.25
.14
77.
Schoolcraft .
172,323.50
.08
78.
Shiawassee ...
1.432.137.75
.64
79.
Tuscola
566,176.85
.25
80.
Van Buren .
898.568.50
.40
81.
Washtenaw .
8,226,460.84
3.68
82.
Wayne
. 95,069,705.59
42.54
83.
Wexford
589,776.50
.26
Total Payments to
Michigan M.D.’s
$198,260,489.65
88.71
Outstate etc
. 25,231,086.61
11.29
Grand Total
$223,491 ,576.26
100.00
June, 1957
727
A Method of Closing the Cataract Incision
Combining a Corneoscleral Suture and a Large
Sliding Conjunctival Flap
W. C. Behen, M.D.
Lansing, Michigan
Q UCCESSFUL removal of a cataract within its
^ capsule requires a full half-limbus incision.
This relatively wide incision in turn requires sur-
gical closure with sutures.
Two factors are of equal importance in this
closure :
1. To secure adequate strength in closure of
incision,
2. To secure adequate sealing of incision.
The first, or strength factor, is best secured by
some type of corneoscleral suture. The second, or
sealing factor, is best secured by a large sliding
conjunctival flap. This flap, drawn down from
above, temporarily buries the corneoscleral suture
and also covers the entire incision line. Thus,
only by combining a corneoscleral suture with a
large sliding conjunctival flap is completely ade-
quate surgical closure secured.
Adequate strength of incision closure, obtained
only by some type of well-placed corneoscleral
suture, is the best insurance against vitreous loss.
This applies to vitreous loss at the time of opera-
tion or later during convalescence and is of such
obvious importance than no more need be said
concerning this complication.
Adequate sealing of the incision, obtained only
by a large sliding conjunctival flap, while adding
but little to the strength of the closure, is the best
insurance against delayed restoration of the an-
terior chamber. This delay in the reforming of
the anterior chamber is not infrequent, and can
result in many unpleasant and serious conse-
quences.
Postoperative complications attributable to de-
lay in reformation of the anterior chamber include
such situations as prolapse of the iris, hemorrhage
from iris, infection of the open incision, intraocu-
lar infection, iridocyclitis and degenerative changes
of the cornea or vitreous with subsequent opacity
of these structures. Secondary glaucoma may fol-
low occlusion of the drainage angle by anterior
synechia forming at the iris base, or by epithelial
ingrowth and proliferation through the delayed
closure of the incision.
Some modification of the following technique
may suit you better. It does not matter just how
this procedure is done provided both required
features of closure, strength and sealing, are ac-
complished. Any type of well-placed corneoscleral
suture will do, provided it is followed with a suf-
ficiently large sliding conjunctival flap to cover the
entire incision line. However, the principle of
burying both a well-placed corneoscleral suture
and the entire incision line with the sliding con-
junctival flap must be carried out. Neither pro-
cedure alone is sufficient: combining them gives
adequate surgical closure. During the past five
years I have performed operations by this method,
and now use the following technique:
Starting as in a simple enucleation, the limbal
conjunctiva is circumcised as close to the cornea
as possible, leaving no epithelial tags attached to
the edge of the cornea to get caught later and
implanted in the incision. This circumcision is
done throughout the upper three-fifths of limbus.
The conjunctiva is now undermined far back so
no tension will be present when the flap is later
slid down over the corneoscleral suture and the
entire incision line. After the flap is thus pre-
pared, it spontaneously retracts out of the way and
allows an easy opportunity to place the simple
corneoscleral suture.
Using a Davis-Geck double-armed black silk
suture, No. Seven-0, with an atraumatic needle, a
very simple horizontal corneoscleral suture is
placed, one bite in the cornea and one in the
sclera. Firm corneal and scleral fixation is ob-
tained by using a Burch double-pointed corneal
pic. This firm fixation makes the placing of the
corneoscleral suture relatively easy. It is impor-
tant that these parallel bites be spaced exactly
728
JMSMS
CLOSING THE CATARACT INCISION— BEHEN
opposite each other laterally, that is in the same
vertical meridian, to avoid torsion of the lips of
the incision in closure. When the needle has en-
tered for the scleral bite and before the needle is
entirely through, if it is found that the bite is not
exactly opposite the corneal bite, the needle must
be withdrawn and reinserted so that it will be
exactly opposite the corneal bite. Needless to say
both the placing of the corneoscleral suture and
the tying of the corneoscleral suture should be
done under the best of visual conditions, prefer-
ably under loupe inspection.
With the corneoscleral suture accurately placed,
and the suture loops laid well back out of the way,
a full half limbus incision is made with a Graefe
knife — emerging between the corneal bite and the
scleral bite of the corneoscleral suture; these two
bites having been placed about 2 mm. apart. For
those who wish to use a keratome incision with
lateral scissors enlargement this substitution could
be made without any change in technique, and
with probably slightly less danger of cutting the
suture.
After an iridectomy, either peripheral or com-
plete, and after the lens has been extracted, the
iris pillars may be replaced either before or
after the corneoscleral suture is tied, depending
somewhat upon the apparent need for haste in
tying the corneoscleral suture. This suture should
be tied with a simple square knot and not too
much tension used to avoid wrinkling or invert-
ing of the edges of the incision. A tension knot
should be avoided as it is apt to invert the edges.
The suture, when properly placed and tied, now
appears as a box-like or mattress-like square suture
entirely without, and lying across the surface of
the incision, rather than incorporated within any
portion of the lips of the incision. Fairly long
ends are left on the suture, approximately 2 to
3 mm. This will assist in its removal at a later
date.
The conjunctival flap is now ready to be slid
down, and, for this purpose it is both convenient
and economical to use the discarded ends of the
double-armed suture which has already served
for the corneal suture, each end being now armed
with a single needle. These lateral conjunctival
sutures are inserted at approximately 1 : 30 and
4:00 o’clock on the limbus and 10:30 and 8:00
o’clock on the limbus. Slight variation in the
position of these sutures may be used, or they may
be removed and re-inserted, or additional sutures
may be used in order to get adequate coverage
of the incision line. If the flap seems a little tense
in any area, it may be snipped slightly in the
center with scissors to relieve any undue tension
on the cornea. Usually two simple lateral sutures
will suffice to give adequate incision coverage. In
tying the conjunctival sutures, the first knot of
each suture should be a tension knot. Otherwise
there is a tendency, due to the retracting of the
flap, for the first knot to become partly untied be-
fore the second knot can be placed. These con-
junctival sutures cut out spontaneously after the
fourth or fifth day, allowing the conjunctival flap
to automatically retract upward and expose, or
at least partly expose, the corneoscleral suture.
The corneoscleral suture is not removed until
about the twelfth day, thus insuring against any
accidental opening of the incision during its re-
moval. If the suture is not completely exposed
by the spontaneous upward retraction of the con-
junctival flap, it may easily be exposed fully by
teasing upward the still slightly loosened edge of
the conjunctival flap. This upward teasing of
the edge of the conjunctiva may best be done by
a cotton applicator saturated with cocaine and
adrenalin. This gives a well-anesthetized and
bloodless field for the removal of the suture. If
the suture is still slightly buried and does not
readily present itself for a scissors removal, a very
easy way to remove it is to slide the point of a
cataract knife, cutting edge out, under one of its
loops. This procedure should be done under
loupe inspection thus guaranteeing against any
trauma in its removal.
If by accident the corneoscleral suture should
be cut at the time of making the incision, or if
the corneoscleral suture should break during the
process of tying it, then no attempt should be
made to slide down the conjunctival flap without
first reinserting and tying down a new corneoscler-
al suture; otherwise the conjunctival flap, when
sliding downward, will likely catch in the edge
of the only partly closed incision and may result
in unexpected complications. Under such cir-
cumstances the wound is probably already partly
gaping, and any attempt to slide down the con-
junctival flap will simply make matters worse.
Rather than attempt to do this, it would be safer
to close the eye at once without further manipula-
tion.
June, 1957
729
CLOSING THE CATARACT INCISION— BEHEN
The use of a sliding conjunctival flap alone
to close the cataract incision, as suggested orig-
inally by Kuhnt, has largely been discarded. I
believe that the reason this method is not more
generally used today is that it is difficult to ac-
complish and is actually an unsafe procedure
unless the lips of the incision are first securely
closed with a corneoscleral suture. A sliding con-
junctival flap, if used without a primarily placed
corneoscleral suture, must be pulled down simul-
taneously on both sides. This is a bothersome
procedure and requires trained assistance. Such
is not the case when a corneoscleral suture is
first used to give a firm smooth non-buckling base
over which the conjunctival flap slides easily and
smoothly without any catching in the wound or
tendency of the corneal lip to buckle. This
tendency of the cornea to buckle is a definite dan-
ger when the corneoscleral suture is not used first.
I wish — at the danger of repetition — to empha-
size the fact that if this method of closing the
cataract incision has any merit, and I believe it
has, it is because of the combining of two older
procedures, namely, a sliding conjunctival flap
and a corneoscleral suture.
Routine therapeutic procedure consists of : 3
grains of phenobarbital several hours prior to
operation, one drop of 1 per cent silver nitrate in
eye several hours prior to operation, blocking of
the seventh nerve, retrobulbar ciliary novocaine
block with 1 or 2 minims of adrenalin added if
the patient’s blood pressure is within normal
limits, cocaine and adrenalin surface anesthesia,
homatropine at beginning of preparation. If
capsule has been delivered without rupture, eser-
ine is used; if capsule has ruptured, and any
cortex remains, atropine is substituted for eserine.
White’s ointment and routine dressing complete
the procedure.
Patients upon whom this method of cateract
closure has been used may with safety be allowed
a great deal more freedom than with former meth-
ods of closure. I have no hesitancy in allowing
them to turn upon either side within six hours
after operation. If necessary, and conditions in-
dicate, they may get out of bed safely on the
second or third day, although this is not a routine
procedure. Such increase of postoperative free-
dom and mobility is of course in direct conformity
to the new era of ambulation being allowed all
surgical patients, particularly elderly surgical pa-
tients.
In a series of 100 consecutive cases upon whom
this type of closure was done, all but four are
able to read ordinary newspaper print as a final
visual result There were no eyes lost. Post-
operative astigmatism has been reduced by an
average of one or more diopters over previous
results. There is more postoperative redness pres-
ent in these cases for a few weeks than in cases
where no large conjunctival flap has been used;
however, this redness is not true pathologic red-
ness and has no apparent clinical significance. Of
the above 100 cases all but three had good an-
terior chambers present at the first dressing on the
third day. The delaying factor in one of these
three was a very slight incarceration of one iris
pillar. One patient became confused, got out of
bed, and removed all his dressings three hours
after operation. Upon examination he was found
to have a well formed anterior chamber.
In conclusion, this procedure adds no more
than five minutes to the time required for the
usual cataract operation. Most of the manpula-
tion is done prior to the section when the savings
of a few minutes of time is of no importance. It
adds no risk to the operation, and, at least in
my hands, has materially lessened complications
and given better end results.
POLIO PUNCH LINES
Three newspapers carried these punch lines in
editorials recently in an effort to get people under forty
inoculated against polio:
“It seems odd to have to encourage anyone to take
shots — almost as odd as it would be to have to en-
courage a hungry man to eat or a drowning man to
reach for a life preserver.” — Louisville Times.
730
“A nation which for years cheerfully contributed funds
to find protection from polio soon may be in the odd
position of having to raise money to get people to use
it!” — Long Island, N. Y., Star-Journal.
“The means of licking a very serious disease are at
hand. But vaccine does not climb down off a shelf
and inject itself.” — Charlotte, N. C., Observer.
JMSMS
Spring Valve Mitral Prosthesis
Report of One Case with One-Year Follow-Up
By James H. Wible, M.D., Lyle F. Jacobson, M.D., Prescott
Jordan, Jr., M.D., Charles G. Johnston, M.D.,
and Harper K. Hellems, M.D.
Detroit, Michigan
A SATISFACTORY method for the surgical
treatment of mitral insufficienecy has been
sought for many years. Many approaches to the
problem have been made. The currently promi-
nent methods are the circumferential suture1 and
polar cross fusion.2 These two methods are ad-
vocated primarily for those patients who have
their insufficiency resulting from a dilated mitral
annulus with pliable leaflets; not a calcified and
fixed valve.
Despite the anatomic deformity, insufficiency
results from a loss of effective, coapting, valvular
tissue; an absolute or relative loss. It has been our
working premise, therefore, that this deficient area
can best be corrected with a prosthesis. The
frame for such a prosthesis was fabricated from
a spring alloy made by the Elgin National Watch
Company for use in the main spring of their
watches.* * The frame was then covered with com-
mercially available nylon (Fig. 1). These devices
were placed in the left ventricles of experimental
animals (Fig. 2) and were found to control both
induced and spontaneous organic mitral insuffi-
ciency. No deleterious effects were found upon
following the animals for many months and the
valvulogenic properties of the prosthesis were
noted. 3,1
After obtaining encouraging results from fol-
lowing these animals for twenty-two months, it
was felt that clinical trial was warranted. One
functional Class IV patient was selected who was
rapidly deteriorating because of pure mitral in-
sufficiency.
Case Summary
M.S., a woman thirty-three years old, is a patient who
has been followed in this hospital for many years. In
her past history, there were no symptoms of rheumatic
fever. At age fourteen, she developed the onset of
From the Departments of Medicine and Surgery,
Wayne State University College of Medicine, Detroit
Receiving Hospital, and Dearborn Veterans Administra-
tion Hospital. Aided by grants from Michigan Heart
Association, Receiving Hospital Research Corporation,
and Public Health Grant H-2553.
*Material and technical advice, courtesy Mr. Thomas
R. Green, Elgin National Watch Company.
June, 1957
bronchial asthma and she has been known to have a
“heart murmur” for the last nine years. The first
episode of heart failure occurred in 1953 and responded
well to digitalization. At that time, she had only slight
cardiac enlargement. In the ensuing three years, the
patient was admitted to the hospital at increasingly
frequent intervals in failure. For one year prior to
operation, she had been totally incapacitated because
of profound fatigue and marked exertional dyspnea —
able to take only a few steps without resting. By serial
x-ray examination, there had been rapid enlargement
of the left ventricle.
Physical examination at the time of admission to the
hospital on March 26, 1956 revealed temperature 98®,
pulse 132, respiration 32, blood pressure 135/90. Gen-
eral appearance was of a chronically ill woman with
apprehension and shortness of breath.
Neck vein distention at 45°.
Lungs: moist rales at both bases.
Heart: frequent extrasystoles, PMI 15 cm. left of
the sternal border. Grade 4+ apical murmur with
marked systolic thrill. Grade 2 mid-diastolic murmur.
Liver: 5 cm. below right costal margin.
Extremities: 4+ pitting edema. ;
Circulation time 33 seconds arm to tongue.
Venous pressure 120 mm h2o.
EKG: non-specific myocardial damage and left ven-
tricular hypertrophy.
Hemodynamic studies, performed in January, 1955,
when the patient was out of failure, showed normal
cardiac output and normal pressures in the pulmonary
artery and pulmonary capillary bed; the latter ex-
cluding significant organic mitral stenosis.
The patient was treated intensively with digitalis,
mercurial diuretics, salt restriction and bed rest with
resolution of the signs of acute failure. It was felt that
this was the optimal time in this patient’s course to
offer operative intervention.
On April 5, 1956, this patient was taken to the
operating room and a routine left thoracotomy was per-
formed through the bed of the fifth rib. Upon opening
the chest, the blood pressure dropped to 50/0 and re-
mained at this level or lower throughout the remainder
of the procedure. The mitral valve was explored and
there was a marked regurgitant jet noted. (Grade V on
a scale of O-V as estimated by digital palpation.) In ad-
dition, the anterior leaflet was freely movable, the pos-
terior leaflet was thickened and rolled under, and there
was no element of stenosis found. A prosthesis was in-
serted that stopped only part of the jet. At this time,
the left ventricle began to dilate and the beat became
731
SPRING VALVE MITRAL PROSTHESIS— WIBLE ET AL
ineffectual. The prosthesis was immediately removed and
massage was instituted which improved the beat but
not the dilatation. A somewhat larger prosthesis was
inserted, but the effect upon the jet could not accurately
be determined because of the marked hypotension at that
Fig. 1. Prosthetic frame; nylon covered and shaped
prosthesis.
time. By palpation, however, the prosthesis could be felt
to be in the proper position and to move as it should to
be functional. It was sutured in place and almost im-
mediately decrease in the dilatation of the left ventricle
was noted. The chest was closed and one hour later
the blood pressure had returned to the preoperative
level and the patient responded from her anesthesia.
The postoperative course was uneventful, and the pa-
tient was discharged from the hospital on the fifteenth
postoperative day.
The following early and long term observations have
been made :
Grade 2 + systolic murmur one hour postoperative.
No alteration in bleeding, clotting, clot retraction or
prothrombin times.
No free serum hemoglobin.
Continued normal platelet count.
BSP unchanged from normal.
BUN unchanged from normal.
Transient rise in serum bilirubin cleared by the 1 1th
postoperative day.
Hemoglobin stabilized at 10.5-11.5 grams at one
month.
Transient rise in reticulocyte count with return to
normal at one month.
Ten hours postoperative, the patient volunteered she
could “breathe easier.”
Seven days postoperative, she could walk 90-foot hall
in the hospital without respiratory distress.
She was able to lie flat in bed the eighth postoperative
day.
Fluoroscopy revealed the prosthesis to have directional
motion with about 15° to 20° up-and-down motion.
Teleoroentgenograms first showed some decrease in
heart size at six weeks and gradually decreased in size
to one year.
One month postoperative, the patient was readmitted
with a febrile episode suspected of being subacute bac-
terial endocarditis but never proven by culture. Therapy
was given for three weeks, and the patient became
afebrile after thirteen days of treatment. The apical
Fig. 2. Technique of retrograde insertion of pros-
thesis.
murmur regressed to grade III + . Subsequent to this,
the patient has had intermittent episodes of unexplained
auricular tachycardia which have resolved spontaneously.
Discussion
Follow-up of this patient for one year has con-
firmed many of the observations made in animals.
First, there has been no evidence of alteration of
the blood elements, i.e., no hemolysis or altera-
tion in clotting mechanisms. By fluoroscopy, con-
tinued directional motion is noted. Since the pa-
tient is still living, we have not been able to show
that the prosthesis has been covered by endothelial
tissue as occurs in the animal. However, there
has been no evidence of embolization either of
clot or the prosthesis itself as has been reported
with other foreign bodies placed in the left ven-
tricle.5,6
It has been the clinical impression of the com-
bined medical and surgical group that has fol-
lowed this patient closely in clinic that her rapid
downhill course has at least been modified. Sub-
jectively and semi -objectively, the patient is im-
proved in that she can climb a flight of eight steps
without distress. She is able to get about to do
732
JMSMS
SPRING VALVE MITRAL PROSTHESIS— WIBLE ET AL
part of her housework and shopping. Objectively,
serial chest x-rays show a reversal of the rapid
increase in size of the heart to some reduction in
overall size (Fig. 3).
With the results obtained in the one patient
with far-advanced mitral insufficiency, we have
been encouraged to proceed to further clinical
trial of the spring valve in an attempt to deter-
mine whether it might have a place in the arma-
mentarium for the control of valvular heart dis-
ease.
Summary
1. The basis for the clinical trial of the mitral
spring valve is discussed.
2. Clinical summary of one patient with one
year follow-up is presented.
3. Encouraging results lead us to believe fur-
ther clinical trial is indicated.
Bibliography
1. Glover, Robert and Davilo, Julio: The treatment
of mitral insufficiency by the purse-string technique.
J. Thoracic Surgery, 33:75, 1957.
2. Nichols, Henry T.: Mitral insufficiency: Treat-
ment of polar cross fusion of the mitral annulus
fibrosus. J. Thoracic Surgery, 33:102, 1957.
3. Jordan, Prescott, Jr., and Wible, James H. : Spring
valve for mitral insufficiency. Arch. Surgery, 71:
468, 1955.
4. Wible, James H., Jacobson, Lyle F., Jordan, Pres-
cott, Jr., and Johnston, Charles G.: Spring Valve
Prosthesis for the Control of Valvular Insufficiency.
Surgical Forum, Clinical Congress, American Col-
lege of Surgeons, 1956.
5. Denton. G., Seymour, T., and Wiggers, C.: A
Follow-up Report on the Development of a Plastic
Prosthesis for the Atrio-ventricular Valve. Surgical
Forum, Clinical Congress, American College of
Surgeons, 1953.
6. Harken, D., Black, H., Dexter, L., and Ellis, L.:
The Surgical Correction of Mitral Insufficiency.
Surgical Forum, Clinical Congress, American Col-
lege of Surgeons, 1953.
Fig. 3. Superimposed before and after teleoroentgenograms and lateral
projection (prosthesis retouched for printing).
GRAND RAPIDS TORNADO SUMMARY
At a recent meeting of the Committee on National
Defense, W. B. Prothro, M.D., reported briefly on the
Grand Rapids tornado and the fact that about thirty
minutes prior to the time the tornado hit, a TV train-
ing course had just been broadcast advising what to do
in a tornado. It was felt that this helped in some respect
those persons who happened to be watching at the time.
The alert was out by 3:00 p.m., ambulance personnel
were ready at the time the storm hit. Casualty care
station was set up at the Grand Rapids Armory for
screening of patients before they went to hospitals. Lights
were out for a couple of hours in two hospitals, and
since that time auxiliary equipment has been secured
in case such an emergency should arise again. Doctors
and nurses were alerted and on the job promptly. Blood
banks were in full use by 10:00 p.m., and far more
prospective donors available than needed.
The Committee was informed that the Grand Rapids
June, 1957
hospitals were able to absorb the number of casualties.
There were 181 homes destroyed, 144 damaged, forty
trailers destroyed, thirty-four damaged, seventeen persons
killed, 219 injured. The Committee was further in-
formed that dead animals became a problem and needed
to be hauled away. Excellent response was secured in
housing the displaced persons in private homes, hos-
pitals, hotels, and good care was taken of all those in
need. Feeding stations were established and, although
they were not too busy, large quantities of prepared food
were contributed by the hospitals, with all material
being donated without question by various suppliers.
The problems that existed were communication; chain
of command, who was to be in charge; lack of top level
direction; medical identification cards; and traffic jam
at the hospitals themselves. The hospital kitchens pre-
pared 12,000 meals and trucked them out to the points
in the area needed.
733
Detroit Surgical Association
Meeting of November 26, 1956
DIVERTICULA OF THE CECUM:
A REPORT OF SEVEN CASES
WILLIAM J. MILLER, M.D., and
JOSEPH A. WITTER, M.D.
Diverticula of the cecum are more common
than has been thought. They occur in 0.7 per
cent of cases of diverticulosis of the left colon.
It is thought that they are due to the retention
of a transient appendix which appears early in
fetal life. They usually show all three layers of
the bowel wall, but differentiation between “true"
and “false” types may be unsatisfactory. The di-
verticula may become inflamed, producing the
clinical picture of an acute condition of the
abdomen, usually diagnosed as acute appendicitis.
A definite differential can be made only by lapar-
otomy in the acute phase. When the diagnosis
can be made without operation, conservative man-
agement may be best. At surgery, simple excision
is recommended. Resection and primary anasto-
mosis carry a much higher mortality rate. The
most frequent complications are perforation and
abscess formation.
Seven cases of cecal diverticula are reported
from the Highland Park General Hospital. Six
were diagnosed at operation for acute appendici-
tis. One was found radiologically in a patient
with a peptic ulcer. Surgical treatment was car-
ried out by excision or inversion in three of the
cases in which operation was performed. Two
others had a resection and anastomosis in two
stages. One patient operated upon had cecal di-
verticula uninvolved by his appendicitis. They
were not excised.
The diagnosis was confirmed microscopically
in those cases in which the lesion was described.
Pulmonary embolism and adynamic ileus com-
plicated two cases, but all patients recovered.
OBSERVATIONS ON THE TREATMENT
OF ATRESIA ANI
D. W. McLEAN and T. C. ARMINSKI
(Read by title)
LETHAL COMPLICATIONS
OF NASAL OXYGEN
W. W. GLAS, M.D., and JACK W. MARRS, M.D.
Nasal oxygen has been widely used for the treat-
ment and prophylaxis of shock and respiratory in-
sufficiency. Depending upon a variety of factors,
acute gastric and gastro-intestinal dilatation can
occur from nasal oxygen with fatal results.
Seven clinical cases are presented, two in de-
tail. Six of these patients died from the acute gas-
tric dilatation.
Experimental gastric dilatation in dogs revealed
marked changes in respiration, cardiac action and
blood pressure, with death due to respiratory
failure.
Early recognition of this syndrome is imperative
to avoid death. A method of treatment for severe
gastric dilatation, which is experimentally satis-
factory, is presented.
Meeting of January 28, 1957
PROGNOSIS IN ARTERIAL INSUFFICIENCY
ASSOCIATED WITH CLAUDICATION
AND ULCERATION
HERBERT J. ROBB, M.D., JOHN W. BOWDEN,
M.D., and RUDOLPH CASTELLANI, M.D.
In patients with symptomatic peripheral oc-
clusive disease who have segmental arterial blocks,
many good results have recently been obtained
by arterial gratfing procedures. With a view to
the future evaluation of this type of treatment,
we decided to study a group of individuals with
peripheral arterial insufficiency on whom lumbar
sympathectomy alone had been performed. An
attempt was also made to determine the factors
which influence the prognosis of patients with
arterial insufficiency.
In all, 140 male patients, seen at the Dearborn
Veterans Administration Hospital, were studied.
The average follow-up period was three years.
The 140 patients were grouped according to
the indication for surgery, which was ulceration
(or gangrene) in fifty-five patients and claudica-
tion alone in eighty-five cases. They were also
divided into diabetic and non-diabetic groups.
While there was no significant differences be-
tween the ulceration and claudication groups in
regard to the relief of night pain or claudication,
amputation and mortality rates were definitely
higher in the ulceration group.
The diabetic group did more poorly than the
(Turn to Page 735)
734
JMSMS
DETROIT SURGICAL ASSOCIATION
non-diabetic. However, a careful analysis of each
nf these groups revealed that the higher propor-
:ion of ulceration cases in the diabetic group was
responsible for the difference. Actually, non-dia-
netic patients with ulceration did just as poorly as
diabetic patients with ulceration and diabetic pa-
tients with claudication did just as well as non-
diabetic patients with claudication.
Walking ability, the distance travelled before
daudication occurred, was usually not improved
after sympathectomy.
It is concluded that all patients with sympto-
matic peripheral occlusive disease should be
studied by arteriography in order to select those
with segmental arterial blocks. Arterial grafting,
which now seems to offer better results, may well
prove to be the treatment of choice in this type of
patient.
THE RESULTS OF GRAFTING SURGERY
OF PERIPHERAL OCCLUSIVE DISEASE
D. EMERICK SZILAGYI
(Read by title )
SURGICAL ASPECTS OF CORPUS
LUTEUM CYSTS OF THE OVARY
CARL COFFELT and C. S. STEVENSON
(Read by title)
Meeting of February 25, 1957
THE STAPES MOBILIZATION
OPERATION FOR OTOSCLEROSIS
JAMES E. CROUSHORE, M.D.
It has been known for more than a century
that osteogenesis in the region of the oval window
results in fixation of the stapes and produces deaf-
ness. In otosclerosis, when there is good cochlear
reserve, improvement in hearing can be expected
either when the stapedial footplate is remobilized,
Dr when a surgically created fenestra is made into
the perilymphatic space. It remained for Lempert
to develop a practical one-stage operation for
fenestrating the lateral wall of the horizontal
semicircular canal. Lempert’s technique today
gives improvement in hearing to the practical un-
aided level in about 75 per cent of the ears oper-
ated on the ideal candidate.
The history of efforts to mobilize the stapes
parallels the development of ossicular surgery,
which reached a rather high level of technical
achievement about the end of the 19th century
and the beginning of the 20th century. In most
instances, stapes mobilization was incidentally em-
ployed in the process of eliminating infection and
diseased ossicles and gave way to stapedectomy,
which eventually was abandoned as a futile pro-
cedure to improve or restore hearing.
In 1946, Lempert presented a technique for dis-
engaging the tympanic membrane from its an-
nular attachment, permitting exposure of the
middle ear structure for tympano-sympathectomy.
This approach is useful for securing middle ear
biopsies, cutting adhesions and visualization of the
middle ear structures. It was employed by Rosen
to test for the mobility of the stapes to determine
suitability for fenestration surgery. During the
testing for ankylosis, he found the stapes was in-
advertently remobilized in a few instances, with
consequent improvement in hearing. This ex-
perience led to the suggestion of employing this
approach for surgical treatment of otosclerosis.
June, 1957
Since the fenestration operation is designed to
by-pass sound waves around the fixed ossicular
chain directly to the newly created fenestra in
the horizontal canal, the pathologic lesion is not
disturbed. The stapes mobilization approach, how-
ever, directly attacks the pathologic lesion at the
oval window. Under ideal conditions, the mobili-
zation operation completely respects the integrity
of the tympanic membrane-ossicular chain vi-
bratory mechanism, so that the mechanical ad-
vantage of this impedance matching mechanism
is not lost. In most instances, when a good result
is obtained, the hearing will return to a higher
level after mobilization than after fenestration.
Since the mobilization operation is less de-
bilitating to the patient, it has a wider variety of
applications. When hearing loss in one ear is
minimal, but handicapping in the other, binaural
hearing may be obtained with little morbidity. If
one ear has been fenestrated successfully, the
patient may be more inclined to undergo the
smaller operation on the opposite ear. In ad-
vanced mixed deafness, enough improvement may
be obtained to render a hearing aid more efficient.
Individuals who have a moderate hearing loss,
but are not handicapped for ordinary social con-
versation, yet need better hearing for their occu-
pation, such as school teachers, store clerks, sec-
retaries, et cetera, would be justified in submit-
ting to the mobilization operation, but would
hesitate to undergo the more debilitating fenes-
tration operation.
The operation is done under local anesthesia.
Excellent lighting must be available. Magnifica-
tion must be employed, using magnification vary-
ing from 3 to 15 times the actual size. After the
tympanic membrane is elevated from the tympanic
sulcus in the posterior half, the membrane is then
reflected forward, exposing the middle ear struc-
tures. The stapes is mobilized by a combination
of ipanipulations. The commonest cause of fail-
ure is the breaking of the crura. This can be
735
DETROIT SURGICAL ASSOCIATION
avoided in most instances by prying the footplate
of the stapes loose, rather than trying to loosen
it by backward pressure on the head and neck
of the stapes. A vibrating mechanism attached to
the handpiece of a dental drill is of value in some
cases.
Various methods are employed in the operating
room for testing the hearing before and after
mobilization. In most instances, the operator can
obtain fairly accurate information as to whether
or not the stapes has been mobilized.
Although there is very little debility associated
with this operative procedure, the procedure, tech-
nically, is very difficult and should not be at-
tempted until one has first performed the oper-
ation repeatedly on the cadaver. Complications
can occur, but these can be kept to a minimum
with improved technique. The complications re-
ported in the literature are incudo-stapedial dis-
location, crural injuries, hemorrhage, bony spi-
cules or bone dust permitted to remain in the
middle ear, tympanic membrane perforations, fa-
cial paralysis, and postoperative infection.
In well-selected candidates, one can reasonably
expect about 40 per cent of the individuals oper-
ated on to obtain good practical hearing.
RESULTS OF GRAFTING THERAPY
IN PERIPHERAL ARTERIAL
OCCLUSIVE DISEASE
R. T. McDonald and D. E. SZILAGYI
The report deals with the results observed in
168 cases of peripheral occlusive arterial disease
operated on between January 1, 1953 and
December 31, 1957. Operative indications in this
series included intermittent claudication severe
enough to interfere with the patient’s mode of life,
rest pain, impending gangrene, and a remediable
lesion as visualized by arteriograms. The surgical
technique in aorto-iliac disease was resection, in
the femoral areas resection, exclusion and by-
passes. Forty of the lesions were aortoiliac, thirty-
three iliac and ninety-five femoro-popliteal; all
operations were followed by serial postoperative
aortograms. Of the forty aorto-iliac lesions, thirty-
seven (92 per cent) showed early and thirty-six
(90 per cent) showed late success. The rate of
early and late good results among the other cases
was as follows: Iliac operations 75 per cent and 72
per cent, femoro-popliteal operations 77 per cent
and 46 per cent. In the entire group of 168 cases,
there was an immediate success rate of 81 per cent
and a late success rate of 60 per cent.
In looking for the causes of late failures, the
most common factor leading to the obliteration
of a previously patent graft was found to be the
progression of the original occlusive disease
process. Technical operative details did not play
an important role. Deterioration of the homo-
736
grafts was a rare cause for the loss of a previously
good result but degenerative changes were ob-
served fairly commonly (in about 17 per cent of
the cases) ; these may lead to later occlusion.
RADIO-ISOTOPE AMINO ACID
METABOLISM OF THE PANCREAS
ROBERT D. WEBER, M.D., MELVIN SIKOV, PH.D.,
and ROBERT M. WHITROCK, M.D.
The effect of secretin and parasympathomi-
metic stimulation of the pancreas in healthy dogs
is shown by measuring the increased uptake of
a radioactive amino acid (L-Methionine S-35) in-
jected intravenously.
In acute experiments, the common bile duct
was transected and cannulated to collect bile,
while an isolated duodenal loop was likewise
cannulated to collected pancreatic secretions. Dur-
ing a one-hour collection period and compared
with a control series, the radioactive methionine
was shown to increase in pancreatic secretions
and in the pancreatic tissue itself. Secretin pro-
duced only a slight increase in these values but
parasympathetic type stimulation (Urecholine in-
jection) increased the uptake of pancreatic tissue
five-fold and increased the amount in pancreatic
secretion almost twenty-fold.
EFFECT OF ADMINISTRATION OF
METABOLIC MATERIAL EFFECTIVE
FOR DISSOLVING CHOLESTEROL ON
THE HEPATIC BILE OF PATIENTS
CHARLES G. JOHNSTON and FUMIO MAKAYAMA
Human hepatic bile is saturated with cholesterol
and will hold no additional cholesterol. The bile
of the dog, cow, pig and sheep are not saturated
with cholesterol and will take up additional choles-
terol. Stones placed in the gall bladders of the
latter animal will be dissolved in a matter of a
few months. With the addition of a preparation
of ox bile salt-lecithin, animal bile can be made
much more effective in dissolving cholesterol or
human gallstones than normal animal bile. This
material can easily be introduced into the hepatic
bile of man in effective concentrations. Studies
on patients illustrating the effect of introducing
materials effective in dissolving cholesterol into
hepatic bile of patients is presented.
TUBERCULOSIS CASES IN DETROIT
In 1956 there were 2,586 new cases of tuberculosis
discovered in Detroit according to Health Department
records.
Of these new cases 1,618 were active tuberculosis;
172 active cases were found through the mobile chest
x-ray unit survey. — Detroit Medical News, May 13, 1957.
TMSMS
Philosophy and Facts
Do we want to keep our public trust — Michigan Medical
Service?
The pioneering spirit that permitted the establishment of
this program in 1939 is necessary today, if we are to meet
the demands of a changing economic, political and social
climate.
We have an alternative. We can place our heritage in the
hands of others — big government, big labor or big business.
What is your choice?
The basic philosophy of the medical profession is and has
been to provide everybody across the board with medical care
at a price he can afford to pay. The early thinking of the
founders of Michigan Medical Service formulated the prin-
ciple of the service plan and prescribed the utilization of
community rating based on integration rather than segrega-
tion of risk.
Time has passed and with it has come change.
Changes in medical science itself necessitate changes in
coverage by insurance and in cost of that coverage.
Changes in people’s demands and needs must be reflected
in the provisions of insurance policies. Experience has shown
that today there is both a demand and a need for coverage
other than that necessary for strictly catastrophic conditions.
Changes in political and social philosophies, particularly
as related to security of which health is a segment, require
alterations in the operations of insurance mechanisms.
The people are partners of the doctor in these plans and
health; not just the facilities for care, not just the quality of
care or the convenient availability of it, but with its costs
as well.
Because voluntary health insurance and prepaid medical
care are of such vital, direct and personal concern to such a
large percentage of our population, we are rapidly approach-
ing the day when these programs will be regulated by legis-
lation unless all of us — doctors, hospitals insurance and
service plans, people and all purveyors of health services
assume the responsibility of voluntary regulation and re-
straint. This is a stern reality.
The apparent need for evaluation and re-evaluation at
both local and state levels on a systematic, realistic and
fair basis cannot be ignored.
Our only answer is to meet economic and social change
with intelligent application of a combined economic and
scientific realism based on tested philosophy and accompa-
nied by sound fact.
It will take courage. Doctors have it.
should be accorded their just place in the partnership.
Everyone is personally and individually concerned with
President, Michigan State Medical Society
June, 1957
737
Editorial
YEAR OF DESTINY
The year 1940 was of great significance in medi-
cal socio-economics, especially for the people of
Michigan. That year saw the accomplishment of
prepaid medical care for our people. Michigan
Medical Service, our Blue Shield, became a fact.
The feasibility of guaranteeing, on the community
state-wide experience basis, the professional care
for our patients was an established demonstration.
The medical profession had recognized a com-
munity need which it alone could solve. The age
old custom of caring for patients who were des-
perately in need financially as well as medically,
left patients as well as doctors unhappy, collections
averaging 60 per cent of charges and much of the
doctor’s effort necessarily devoted to economic
stress. For years, appeals to the insurance indus-
try had been fruitless, appeals to our national
officers met with the rebuke — “Just practice medi-
cine— leave medico-economics to the insurance
companies.”
Ten years of study by ambitious pioneers of
medicine in Michigan, trial and error, rebuff from
some, encouragement from enough to assure a
worthwhile effort, enthusiasm for a worthy objec-
tive, and repeated return to the fray, gave us
Michigan Medical Service. Many of those un-
daunted dreamers are still in there fighting.
The year 1940 saw a division of the medical
men into two generations. Before that time, every
soul of them knew the pangs of unemployment
of their people, as well as of themselves. There
were no reserves of money to meet unexpected
catastrophe in the form of sudden hospitalization
or surgery. Hospitalization of a patient meant
arrangements with the whole family and friends
to establish credit. Too frequently, the patient
and his family had to go “on relief.”
Now what? Since 1939, the medical schools in
the United States have graduated 110,852 doctors
of medicine. The 1956 AM A Medical Directory
listed 219,288 doctors in the United States and
dependencies. Almost exactly half of the doctors
now active never saw practice before prepayment
— never had to watch for the first paying patient.
Calls, even at night, were never refused. Patient’s
738
needs were uppermost in the medical mind even
their patients’ economic security, involving great
effort, expense, devoted sacrifices of time and
discouragement from our own people. Medicine
showed the way to a much more satisfactory
managing and budgeting for health matters. Far-
sighted enthusiasts in our profession did a her-
culean work for our public and for ourselves.
Our Benefits?
The profession by its solution of a great eco-
nomic impasse for our patients, saved the private
practice of medicine to them and to ourselves.
The socio-economic evolution of the medical
world is the direct result. We changed our own
economic picture, almost eliminated the collection
feature, and assured prompt and direct payment
to the doctor beyond the wildest dreams of our
original workers. Now some of our doctors are
demanding revision of fees paid for many indi-
vidual items. The researchers who have been
working on fee schedules know there are inequali-
ties. They also know that historically there were
the same inequalities — one group earning more
than another — but that is a question that has
always been with us, a question that medical
societies never did settle and our service organiza-
tion should not be asked to solve. Blue Shield in
Michigan has not raised rates since the inception
of the $5,000 income limit contract, but piecemeal
it has increased services and fees until now we
are paying 21 per cent more for the average
service. In 1956, there were 91,000 such services
every month.
Has Michigan Medical Service given some
distinct socio-economic advantage to our doctors?
This question is only academic for the younger
generation — they never saw practice before pre-
payment. But for the older half of our members,
stop and think. Did you collect 60 per cent of
your charges? Perhaps, if you are a very unusual
man, at great effort you may have collected 75
per cent. Michigan Medical Service is not paying
you as much as you would like, but very probably
it is paying relatively more than you received
under the old regime.
How many would like to return to the 1930’s?
JMSMS
EDITORIAL
t probably will never happen, for before that
ibor, then government, will have encompassed us.
Tiat is labor’s ultimate goal, “Medical care for
.11 at no cost to the individual.” Labor is not
specially interested in the Doctor of Medicine.
ADVANCE OF CIVILIZATION
For generations, two or three things have been
iniversally pointed out as the great steps in the
idvancement of civilization. In prehistoric times,
he tribes, consisting of a few families, united for
:he hunt to provide food for all, not just for the
ucky huntsman. Probably there were very few
ictual families in those days as we now under-
tand the family.
Most food was eaten raw until someone dis-
:overed that fire from lightning would improve
he taste. The discovery of how to produce and
:ontrol fire was the first acknowledged advance -
nent in civilization. The earliest people were of
lecessity nomads, hunting for food. As a good
rnnting ground became exhausted, the tribe moved
aboriously from place to place.
The wheel was the next great advance, and
uccessively came the ability to work in iron (and
he other metals) — copper probably first.
In modern times came the discovery of the
:ombustion engine which really was a universal
nove forward. Our own generation has witnessed
he conquering and capture of the atom and its
remendous possibilities. Such, in brief, is the ac-
:epted history of the advance of civilization. We
ubmit one collossal accomplishment mentioned
>ut not stressed or listed. Without doubt, man’s
greatest discovery, and most important to him and
o the medical profession in his development, is
rEAMWORK — the ability and purpose to work
ogether by agreement.
A generation ago, 85 per cent of the Michigan
nen of medicine did a conspicuous and success-
ul herculean task, in spite of almost insuperable
idds, in spite of the expert who claimed medical
ervices were uninsurable, in spite of opposition
rom political and quasi socio-economic leaders
md national medical authorities, and in spite of
:xtremely vigorous opposition by some of our own
Michigan colleagues.
A medical generation ago, determination and
.bsolute teamwork accomplished a miracle. Now,
inother and greater problem faces the profession.
Ian we and will we continue to guarantee un-
lampered private practice of medicine to our pa-
tients— and maintain the privilege for ourselves?
Again one answer— all must work together as a
team. Problems are to be solved by the meeting
of minds, not forgetting the lessons of experience
— absolutely banning misunderstandings and
thoughtless insinuations. Man’s greatest discovery
was not the wheel, the internal combustion en-
gine, nor the atom. The greatest discovery is
teamwork by agreement — the fact that working
together to produce more of the good things of
life pays better than fighting with one another
over the division of what is already available and
risk losing what we have won at such great cost.
* * *
The American people have learned this lesson
of teamwork spectacularly. We recently saw an
article listing the twenty-five greatest corporations
in the United States. These are combinations of
many people, about two-thirds of which have in-
comes of less than $7,500 a year, who by com-
bining resources are giving employment to count-
less working persons and are paying vast amounts
in taxes to government. The number of stock-
holders in these great corporations exceeds the
number of employed workers by over 600,000.
Only six of that number have less stockholders
than employes. WHAT A LESSON IN UNITED
TEAMWORK!
A YEAR OF TRIAL
Officers, administrators and policy-making
groups responsible for Michigan’s Blue Shield will
never forget the year 1956 — a year of profound
influence; a year of history-making events and de-
cisions.
First came the hearings before the Governor’s
Commission, instructed to “determine the causes
of excessive cost and to find out how to render
more and better health care more efficiently and
at less cost.” There were weeks of almost daily
newspaper front-page stories — frequently unfriend-
ly publicity. It was primarily an investigation of
Michigan Hospital Service, but practically all the
testimony was directed at the medical profession
— its faults and failures; its role in putting pa-
tients into the hospital; the care ordered, and re-
leasing patients from the hospital. It is now
more than a year since the study began, and the
Commission has not yet reported — and that delay
is being blamed on the M.D.’s for asking for an
unprejudiced study.
Financially, the year was bad. Michigan Medi-
une, 1957
739
EDITORIAL
cal Service dipped into resources by more than
two and one-half million dollars. For the eight
years in which Michigan Medical Service of-
fered the $5,000 ceiling contract, the premium has
not changed. At almost every meeting, the Medi-
cal Advisory Committee and the Board have
boosted the allowance for individual items found
or thought to be out of line.
Secondly, the number of services for the year
increased by about 100,000, with an equal num-
ber of subscribers. Utilization increased more
than 10 per cent. We tried to believe the labor
lay-off on account of strikes was responsible, but
the first three months of 1957 showed no change.
During the year, management and the Board
completed studies and plans to extend our pre-
ferred services to include out-patient and office
surgery, laboratory tests, electrocardiograms, elec-
troencepholograms, tests for basal metabolism,
therapeutic and diagnostic x-ray and radiology,
consultation, physical medicine, about ten elabora-
tions in a package to be added to the basic con-
tract. Surveys show that great groups of sub-
scribers will never be satisfied unless we can guar-
antee there will be no extra bills, that the service
contracts, in fact, will be that.
Management and the Board have been con-
vinced that medical men rather than laymen
must be in direct contact with our doctors, who can
talk the same language. L. Fernald Foster, M.D.,
Secretary of the Michigan State Medical Society,
has been carrying all that load on a voluntary
basis. Nearly two years of negotiation culminated
at the close of 1956. Dr. Foster has been induced
to give up his private practice and has become the
Medical Executive Director of Michigan Medical
Service on a long-term contract. He is also the
new president.
Plans were also being made to bring the story
directly to the members of Michigan State Medi-
cal Society more forcibly than had been possible
before — hence the special session of the House
of Delegates held on April 27, 1957 the first in
more than twenty years.
Yes, it has been a year of trial. We believe
some very fundamental results are in the making,
in spite of months of anxiety. Many committees
have been cooperating and advising. The de-
cision has now been referred to the House of
Delegates and all the members.
Do we want to continue and expand prepay-
ment? If we do not, labor is ready to take over
740
and establish its own supervision and regulation.
Also, we must remember the late Senator Van-
denberg’s caution, “If your prepayment program
fails, socialized medicine will follow within a
year.”
A CHANGED WORLD
The social philosophy well understood by our
older generation was a world of postpayment.
Almost everything, including medical service, was
bought on time or credit. The income limit of
$2,500 per year covered 85 per cent of our fami-
lies. Insurance had experimented. About a dozen
companies, at most, offered health and accident
policies which, for a premium of $100.00 a year,
would pay the insured person $25.00 a week after
a certain waiting period and for a specified num-
ber of weeks.
The medical profession, in establishing the pre-
payment philosophy and taking advantage of a
war economy (World War II) which is still with
us, has changed the habits of our people into
a prepayment concept in the medical and health
field, where well over 75 per cent of people now
carry some form of health insurance, and extend-
ing quite generally into business — “cash and car-
ry”; financing most fair-sized purchases through
acceptance corporations; establishing a credit to
cover expected “needs,” including literally thou-
sands of cooperative groups for consistent sav-
ing; and established borrowing resources. Now,
after only seventeen years, the world of health
care is metamorphosed — almost completely
changed to a prepaid economy, without worry,
but confident of care when serious illness comes.
We may be proud — we are proud — that we
have pointed the way to voluntary insurance
which has entered the field after being “shown”
and that our public, which is no longer satisfied
with the protection against health calamities now
in effect, is demanding much more extensive serv-
ice.
This changing world has overtaken us. In the
tragic years of the 1930’s medical visionaries, med-
ical statesmen, refusing to accept defeat, estab-
lished a world leadership grafted upon our sacred
“calling” of care and protection to our patients.
Another generation of doctors is now taking over.
A new and much more demanding world is now
living in most prosperous times, accustomed to
and wanting the impossible. Again the medical
profession must assume leadership. We have the
JMSMS
EDITORIAL
‘know-how.” and our committees and technicians
ire prepared. Our Blue Shield can again pre-
erve the American way of life in the medical
ield and forestall the pressure groups in and out
)f government who would like to follow Bismarck’s
jreat coup — grab power through the most logical
means (the health of the people).
The next move must be made by the medical
profession. Do we value our traditional unen-
cumbered freedom? We know the demands and
needs of our public. We know the answers. Are
we yet willing to work together as one entity,
one closely knit cohesive band of dedicated sol-
diers— a working team for the common good? Or
will splinter groups refuse for their own selfish
reasons and again jeopardize the entire program
■ — the good of ALL the people, not just the medi-
cal professional groups?
* * *
Had government during those same trying years
also gone on a prepayment basis instead of trying
to “spend us into prosperity,” what a different
world !
DOCTOR, WAS THAT ORDER NECESSARY?
The Editor is constrained to report a circum-
stance, which is presented for our readers to give
the answer.
Within the past three weeks, five different Doc-
tors of Medicine have cited a condition and asked
what is to be done. One man was on a hospital
record committee and reported records he has
seen. Others were staff or medical society officers,
and one was a surgeon. This is the story:
There are a few doctors who always order a
new patient into the hospital before calling on
him; always have a routine half page or more of
tests made, including complete blood study, gastro-
intestinal and x-ray series, electrocardiogram,
electroencephalogram, basal metabolism tests, and
so on, to an unnecessary cost of a $100-$ 150.
The surgeon suggested that it would pay the
State Medical Society and Blue Shield to hire a
high-class advertising man to teach our own mem-
bers how to order laboratory and such work for
our patients. The morning he talked to the editor,
he had just had assigned to him a new house
physician in training for surgery. He read the
orders the new man had written — half a page of
everything, not a one of which cost less than $5.
and altogether amounting to more than $100.
The surgeon crosed out all but three, which he
considered essential.
The surgeon reports that this fault is not con-
fined to young house physicians or candidates for
certificate of surgery. Altogether too many re-
ferred cases on almost every call have much too
many unimportant and needless orders.
He suggests a large placard over each record
desk reading: “DOCTOR, WAS THAT ORDER
NECESSARY?”
HOSPITAL BEDS AND COSTS
Hospital costs, Blue Cross (not Blue Shield)
premium rates, have been increased four times
in the past five years, and another boost is sched-
uled for this summer — co-incident with Michigan
Medical Service’s first increase since establishing
the $5,000 income ceiling contract.
Over 80 per cent of Hospital costs are wages
and salaries. Other costs, such as supplies and
replacements, have undergone moderate changes,
but the labor world in general is now about to
start its tenth round of bargaining. Hospital wages
and salaries always have been low and are still
far below the general labor standard. Every
economist seems to look to the medical profession
to hold this line. Under the present hospital
standards and policies, we must look for a con-
tinuing correspondence with labor in general.
But there is a situation which might help.
Many believe our hospital construction plan needs
modifying. For many years, we have been build-
ing super hospitals with the ultimate in facilities,
accommodations and services, believing that a
patient ill enough for hospitalization is entitled
to “tops.” For the acutely ill (surgical and medi-
cal), there is no argument, but after a few days
in most instances, nursing or custodial care are
all that is necessary for several days, or even
weeks and months in chronic cases. Such patients
do not require super accommodations costing $30
to $45 a day. It would seem the time has arrived
to build good convenient structures pointed to
this concept of care, single rooms, two beds, and
small wards with feeding facilities and practical
nursing. These buildings could have arrangements
with the general hospital so that emergencies could
be transferred temporarily. However, they should
be under independent management to hold costs
down.
Blue Cross could cooperate and pay $5, $8 or
June, 1957
741
EDITORIAL
$10, thus reducing the now constantly increasing
trend. Such structures would find another usage.
Most of our modern homes are small, with ab-
solutely no convenience for convalescent care or
even custodial care. Many older people, partially
helpless, cancer or paralytic patients could also
use these accommodations. They could even re-
lieve a present hospital abuse by providing vaca-
tions to many of our harrassed people with prob-
lems of grandmothers or grandfathers during peri-
ods when other duties call.
We hope someone breaks the ice and provides
for one of these so ideally conceived places. The
State of Michigan has more than 500 so-called
nursing or rest homes which, in many instances,
are unworthy of the name.
Detroit is developing a new medical center
encompassing four hospitals, Harper, old Grace,
Women’s and Children’s. What a wonderful op-
portunity to pioneer in a sadly needed type of
quasi-medical service.
One of the hospitals in Battle Creek has an-
nounced extensive improvements with some new
beds. Such plans are undoubtedly in the making
in several places. More super hospital beds are
expensive. Providing the suggested type of con-
valescent bed would release about an equal num-
ber of the more expensive beds at a mere fraction
of their cost, also could tend to lessen Blue Cross
costs.
WHO OWNS AMERICA?
General Motors is one of the world’s greatest
and most powerful corporations, doing approxi-
mately $12 billion worth of business each year,
of which more than 50 per cent goes to its 21,000
suppliers. It employs 599,000 persons and pays
them $96.63 per week, yearly average. General
Motors has 656,000 shareholders who, by cooper-
ative effort and pooling of money interests, give
constant and remunerative employment to five
men for every six of themselves. For every $1,000,
these stockholders have invested, they, through
their cooperative effort, have received $50 in div-
idend income, but have paid $175 in taxes — -in-
come sales or excise. Such is the power of united
effort. By themselves, these people would have
failed utterly to approach this accomplishment.
Such is the stuff of which our American way
of life was built. Only by constant watchfulness
and “meeting of minds” has General Motors de-
veloped. Our State Medical Society may wel
consider its past and future. General Motor:
started slowly and built. Michigan State Medica
Society, in the 1930’s, found a group of condition:
which threatened our way of life. Cohesive anc
concerted effort met the challenge and in sc
doing built Michigan Medical Service, a greal
corporation consisting of six participators out ol
every seven of our members. That corporatior
was founded to meet the calamitous needs of oui
patients and incidentally to forward our own
ideals. Success in both followed.
New economic conditions, new ambitions tc
rule, new methods of attaining political or eco-
nomic power are demanding another period ol
self-searching by the 6,000 or more doctors whose
very livelihood is at stake. The ideals must be
arrived at democratically, but once adopted, this
time there must be no “free riders.” There must
be seven out of every seven who combine to assure
our subscribers that promises will be fulfilled.
CORRECTION
In The Journal for March, 1957, the Report of
the MSMS Rheumatic Fever Control Committee on
page 375, is a tabulation in which the first column
with the heading “Center**” was dropped down one
line, thus placing the named Centers one line below
where they actually should be.
Editor
MSMS ANNUAL MEETING
September 25-26-27, 1957
Civic Auditorium, Pantlind Hotel
Grand Rapids
Make your hotel reservation now. <—
742
TMSMS
Michigan State Medical Society
The Ninety-second Annual Session
D. Bruce Wiley, M.D.
Utica
Council Chairman
Arch Walls, M.D.
Detroit
President
K. H. Johnson, M.D
Lansing
Speaker
L. Fernald Foster, M.D.
Bay City
Secretary
official call
The Michigan State Medical Society will
convene in Annual Session in Grand Rapids,
Michigan, September 23-24-25-26-27, 1957.
The provisions of the Constitution and By-
Laws and the Official Program will govern
the deliberations.
Arch Walls, M.D.
President
D. Bruce Wiley, M.D.
Council Chairman
K. H. Johnson, M.D.
Speaker
J. J. Lightbody, M.D.
Vice Speaker
Attest :
L. Fernald Foster, M.D.
Secretary
J. J. Lightbody, M.D.
Detroit
Vice Speaker
TWO-DAY SESSION OF HOUSE OF DELEGATES
September 23-24, 1957
The 1957 House of Delegates of the Michigan State
ledical Society will hold a two-day session beginning
londay, September 23, at 10:00 a.m. The business of
le House of Delegates will be transacted in the Ball
oom of the Pantlind Hotel, Grand Rapids.
The House will meet also on Monday, September 23,
t 2:00 p.m. and at 8:00 p.m. and on Tuesday, Sep-
:mber 24, at 9:30 a.m. and at 8:00 p.m.
The intervals between meetings of the House of Dele-
une, 1 95 7
gates have been spaced to permit the Reference Commit-
tees ample time to transact all business referred to them.
SEATING OF DELEGATES
“Any Delegate-Elect not present to be seated at the
hour of call of the first meeting may be replaced by the
accredited Alternate next on the list as certified by the
Secretary of the component County Society involved.” —
MSMS By-Laws, Chapter 8. Section 6.
743
OUTLINE OF 1957 ASSEMBLY AND SECTION SPEAKERS
92ND ANNUAL SESSION MSMS
Grand Rapids, September 25-26-27, 1957
Time
Wednesday
September 25, 1957
Thursday
September 26, 1957
Friday
September 27, 1957
AM.
9:00- 9:30
Obstetrics
Carl T. Javert, M.D.
New York
Surgery
Theodore O. Winship, M.D.
Washington, D. C.
General Practice
E. Keith Hammond, M.D.
Paoli, Ind.
9:30-10:00
Gynecology
Herbert E. Schmitz, M.D.
Chicago
Surgery
Oscar T. Clagett, M.D.
Rochester. Minn.
Pathology
David C. Dahlin, M.D.
Rochester, Minn.
10:00-11:00
INTERMISSION TO VIEW
EXHIBITS
INTERMISSION TO VIEW
EXHIBITS
INTERMISSION TO VIEW
EXHIBITS
11:00-11:30
Pediatrics
Edward Press, M.D.
New York
Otolaryngology
Oscar J. Becker, M.D.
Chicago
Dermatology & Syphilology
Charles R. Rein, M.D.
New York
11:30-12:00
U rology
Edwin L. Prien, M.D.
Brookline, Mass.
Public Health & Preventive Medicine
John D. Porterfield, M.D.
Washington, D. C.
Dermatology
James W. Burks, M.D.
New Orleans, La.
P.M.
12:00- 1:00
DISCUSSION CONFERENCE
DISCUSSION CONFERENCE
DISCUSSION CONFERENCE
2:00- 2:30
Pediatrics
Douglas T. Davidson, Jr., M.D.
Boston
Beaumont Lecture
Raymond J. Jackman, M.D.
Rochester, Minn.
Nervous & Mental Diseases
Adelaid M. Johnson, M.D.
Rochester, Minn,
and
Leo H. Bartemeier, M.D.
Baltimore, Md.
2:30- 3:00
Biddle Lecture
Walter P. Reuther
Detroit
Ophthalmology
Peter C;. Kronfeld, M.D.
Chicago
3:00- 4:00
INTERMISSION TO VIEW
EXHIBITS
INTERMISSION TO VIEW
EXHIBITS
3:00-3:30
FINAL INTERMISSION
TO VIEW EXHIBITS
4:00- 4:30
Obstetrics
Paul A. Bowers, M.D.
Philadelphia
Occupational Health
Frank J. Ayd, Jr., M.D.
Baltimore
3:30:4:00
Medicine
Walter L. Palmer, M.D.
Chicago
4:30- 5:00
Radiology
Max Cutler, M.D.
Beverly Hills, Caif.
Surgery
Ormand C. Julian, M.D.
Chicago
4:00-6:00
Medicine Panel
(Including Medical Section Meeting)
What’s New in Heart Disease
Robert L. Novy, M.D.
Detroit, Moderator
Samuel Bellet, M.D.
Philadelphia
Richard J. Bing, M.D.
Birmingham, Ala.
Hans H. Hecht, M.D.
Salt Lake City, Utah
Robert J. Schneck, M.D.
Detroit
5:00- 6:00
FIVE SECTION MEETINGS
SIX SECTION MEETINGS
Occupational Health
Frank J. Ayd, Jr., M.D.
Baltimore
T. I. Boileau, M.D.
Detroit
Gastroenterology-Proctology Panel
Raymond J. Jackman, M.D.
Rochester, Minn
Leo S. Figiel, M.D.
Detroit
Don W. McLean, M.D.
Detroit
C. Allen Payne, M.D.
Grand Rapids
Gerald A. Wilson, M.D.
Detroit
Obstetrics-Gynecology
Herbert E. Schmitz, M.D.
Chicago
Pediatrics
Stuart M. Finch, M.D.
Ann Arbor
FIVE SECTION MEETINGS
Ophthalmology
Peter C. Kronfeld, M.D.
Chicago
Medicine
(See Program immediately above)
Radiology
Max Cutler, M.D.
Beverly Hills, Calif.
Public Health & Preventive Medicine
John D. Porterfield, M.D.
Washington, D. C.
Der mat ology-Sy philology
James W. Burks, M.D.
New Orleans, La.
Urology
Edwin L. Prien. M.D.
Brookline, Mass.
Surgery
Oscar T. Clagett, M.D.
Rochester, Minn.
Ormand C. Julian, M.D.
Chicago
Theodore O. Winship, M.D.
Washington, D. C.
Pathology
David C. Dahlin. M.D.
Rochester, Minn.
Nervous & Mental Diseases Panel
Adelaid M. Johnson, M.D.
Rochester, Minn.
General Practice
Benjamin Jeffries, M.D.
Detroit
Leo H. Bartemeier, M.D.
Baltimore, Md.
Anesthesiology
(To be selected)
Otolaryngology
Oscar J. Becker, M.D.
Chicago
7:00 p.m.
Officers Night
Banquet
10:30 p.m. to 1:30 a.m.
State Society Night
MSMS Entertainment
END OF ANNUAL SESSION
744
TMSMS
Michigan State Medical Society
The Ninety-second Annual Session
PANTLIND HOTEL, GRAND RAPIDS
SEPTEMBER 25-26-27, 1957
INFORMATION
• GRAND RAPIDS WILL BE HOST TO MSMS IN
SEPTEMBER, 1957
• MSMS HOUSE OF DELEGATES convenes Mon-
day, September 23, at 10:00 a.m., Ball Room,
Pantlind Hotel. It will hold three meetings on Mon-
day and two meetings on Tuesday, September 24.
• THE PROGRAM OF THE ASSEMBLY for the
92nd Annual Session of the Michigan State Medical
Society lists guest speakers from all parts of the
United States. They are the usual stars in the med-
ical world who always grace the podium at the an-
nual conventions of the Michigan State Medical So-
ciety; they insure a valuable concentrated refresher
course in all phases of medicine and surgery for
the busy practitioners of Michigan, of neighboring
states and the Province of Ontario, on September
25-26-27.
• REGISTRATION, Tuesday afternoon through Fri-
day afternoon, September 24-27, Civic Auditorium.
Advance registration — on Tuesday and early Wednes-
day morning — will save your time. Present your
State Medical Society, American Medical or Cana-
dian Medical Association membership card to ex-
pedite registration.
• NO REGISTRATION FEE FOR STATE MEDICAL
SOCIETY AND CMA MEMBERS.
Doctors of Medicine, who are not members of their
state medical society or of the Canadian Medical
Association, will be accorded the privileges of the
MSMS Annual Session upon payment of a $25.00
registration fee.
• REGISTER AS SOON AS YOU ARRIVE. AD-
MISSION BY BADGE ONLY.
• ALL SUBJECTS at the MSMS Annual Session are
applicable to clinical medicine. They stress diagnosis
and treatment, usable in everyday practice.
• POSTGRADUATE CREDITS given to every MSMS
member who attends MSMS Annual Session.
• SIX ASSEMBLIES — 16 Section Meetings — Three
Discussion Conferences, all on September 25-26-27.
» A DISCUSSION CONFERENCE— featuring the
guest speakers of each day — will be held daily from
12:00 noon to 1:00 p.m. in the Black and Silver
Ball Room of the Civic Auditorium. Audience partici-
pation invited.
» SECTION MEETINGS at 5:00 to 6:00 p.m. will
follow the daily Assemblies.
» PAPERS WILL BEGIN AND END ON TIME. The
MSMS scientific meeting always features by-the-clock
promptness and regularity.
• TECHNICAL AND SCIENTIFIC EXHIBITS will
contain much of interest and value. Two daily in-
termissions to view the exhibits have been arranged.
• C. ALLEN PAYNE, M.D., GRAND RAPIDS, is
Chairman of the Committee on Arrangements for the
1957 Annual Session.
• BANQUET, WEDNESDAY, SEPTEMBER 25.
The Officers Night Banquet — to- which all
MSMS members and their ladies are cordially
invited — will be held in the Ball Room of the
Pantlind Hotel, Grand Rapids. Reception, 7:00
p.m.; banquet, 8:00 p.m. Sponsored by the
Michigan State Medical Society and its Wom-
an’s Auxiliary.
THREE DISCUSSION CONFERENCES
A. C. Furstenberg, M.D.
Ann Arbor
Leader on Wednesday,
September 25, 1957
Perry C. Gittins, M.D.
Detroit
Leader on Friday,
September 27, 1957
C. Allen Payne, M.D.
Grand Rapids
Leader on Thursday,
September 26, 1957
Three quiz periods will be
held, Wednesday-Thurs-
day-Friday, September 25-
26-27, in the Black and
Silver Ballroom of the
Civic Auditorium, Grand
Rapids, 12:00 noon to
1:00 p.m., with all the
guest speakers of the day
on the platform.
An opportunity to ask
questions concerning the
presentations of the guest
essayists, or to discuss an
interesting case with them,
is provided at these daily
Discussion Conferences.
• CABARET-STYLE DANCE AND ENTERTAIN-
MENT, with the compliments of the Michigan State
Medical Society, will be held in the Ball Room of the
Pantlind Hotel on Thursday evening, September 26.
All who register will receive a card of admission and
they and their ladies are cordially invited to attend.
• THE WOMAN’S AUXILIARY to the Michigan
State Medical Society will present an attractive social
and business program at the Pantlind Hotel, Grand
Rapids. The wife of every MSMS member is cor-
dially invited to attend.
• THE MICHIGAN STATE MEDICAL ASSIST-
ANTS SOCIETY will hold its meeting at the Hotel
Manger Rowe, Grand Rapids, on Wednesday and
Thursday, September 25-26.
• MEMBERS OF MICHIGAN MEDICAL SERVICE
will meet in annual session, Tuesday, September 24,
at 2:00 p.m. This meeting will follow the annual
MMS luncheon to be held in the Ball Room, Pantlind
Hotel.
SCIENTIFIC ASSEMBLY
Wednesday-Thursday-Friday
September 25-26-27, 1957
June, 1957 745
SAVE AN ORDER FOR THE EXHIBITORS AT THE
MICHIGAN STATE MEDICAL SOCIETY ANNUAL SESSION
Michigan State Medical Society
The Ninety-second Annual Session
PANTLIND HOTEL, GRAND RAPIDS, SEPTEMBER 23-24, 1957
HOUSE OF DELEGATES— ORDER OF BUSINESS*
MONDAY, SEPTEMBER 23
Ball Room, Pantlind Hotel, Grand Rapids
10:00 a.m. — First meeting
1. Call to Order by Speaker
2. Report of Committee on Credentials
3. Roll Call
4. Welcome
(a) Hon. Paul G. Goebel, Grand Rapids. Mayor,
City of Grand Rapids
(b) Hon. Gerald R. Ford, Jr., Grand Rapids,
Congressman, Fifth District of Michigan
5. Appointment of Reference Committees
(a) On Officers’ Reports
(b) On Reports of The Council
(c) On Reports of Standing Committees
(d) On Reports of Special Committees
(e) On Constitution and By-Laws
(f) On Resolutions
(g) On Special Memberships
(h) On Rules and Order of Business
(i) On Legislation and Public Relations
(j) On Hygiene and Public Health
(k) On Medical Service and Prepayment In-
surance
(l) On Miscellaneous Business
(m) On Executive Session
(n) On National Defense and Disaster Planning
6. Speaker’s Remarks — K. H. Johnson, M.D.,
Lansing
7. President’s Remarks — Arch Walls, M.D., Detroit
8. President-Elect’s Remarks — G. W. Slagle, M.D.,
Grand Rapids
9. Annual and Supplemental Reports of The Coun-
cil— D. Bruce Wiley, M.D., Utica, Chairman of
The Council
10. Report of Delegates to American Medical Asso-
ciation— W. A. Hyland, M.D., Grand Rapids,
Chairman
11. Brief of Annual Report of Woman’s Auxiliary —
Mrs. A. C. Stander, Saginaw, President
12. Brief of Annual Report of Michigan State Med-
ical Assistants Society — Miss Doris larrad,
Lansing
13. Brief of Annual Report of Michigan Medical
Service —
(See printed report)
14. Selection of Michigan’s Foremost Family Physi-
cian
Fifty-year Awards
*See the Constitution, Articles IV, VII and XII, and
the By-Laws, Chapter 8 on “House of Delegates.”
746
MONDAY, SEPTEMBER 23
Ball Room, Pantlind Hotel, Grand Rapids
2:00 p.m. — Second meeting
15. Supplemental Report of Committee on Credentials
16. Roll Call
17. Resolutions**
18. Reports of MSMS Standing Committees
A. Committee on Postgraduate Medical Educa-
tion
B. Preventive Medicine Committee
(1) Committee on Rheumatic Fever Control
(2) Cancer Control Committee
(3) Maternal Health Committee
(4) Venereal Disease Control Committee
(5) Tuberculosis Control Committee
(6) Industrial Health Committee
(7) Mental Health Committee
(8) Child Welfare Committee (and Subcom-
mittees)
(9) Iodized Salt Committee
(10) Geriatrics Committee (and Subcommit-
tees)
C. Public Relations Committee (and Subcom-
mittees)
D. Ethics Committee
E. Legislative Committee
19. Reports of Special Committees
A. Beaumont Memorial Committee
B. Scientific Radio Committee
C. Advisory Committee to Woman’s Auxiliary
D. Advisorv Committee to Michigan State Med-
ical Assistants Society
E. Committee to Study MSMS Financial Struc-
ture (a committee of the House of Delegates)
Reports of the Committees of The Council, in-
cluding Committee on Scientific Work, are in-
cluded in Annual Report of The Council.
MONDAY, SEPTEMBER 23
Ball Room, Pantlind Hotel, Grand Rapids
8:00 p.m. — Third Meeting
20. Supplementary Report of Committee on Creden-
tials
21. Roll Call
22. Unfinished Business
23. New Business
24. Reports of Reference Committees
(a) On Officers’ Reports
(b) On Reports of The Council
(c) On Reports of Standing Committees
(d) On Reports of Special Committees
**A11 resolutions, special reports, and new business
shall be presented in writing in triplicate (By-Laws,
Chapter 8, Section 10-m).
JMSMS
THE NINETY-SECOND ANNUAL SESSION
(e) On Constitution and By-Laws
(f) On Resolutions
(g) On Special Memberships
(h) On Rules and Order of Business
(i ) On Legislation and Public Relations
(j ) On Hygiene and Public Health
(k) On Medical Service and Prepayment In-
surance
(1 ) On Miscellaneous Business
(m) On Executive Session
(n) On National Defense and Disaster Planning
TUESDAY, SEPTEMBER 24
Ball Room, Pantlind Hotel, Grand Rapids
9:30 a.m. — Fourth Meeting
25. Supplementary Report of Committee on Creden-
tials
26. Roll Call
27. Unfinished Business
28. New Business
29. Supplementary Reports of Reference Committees
TUESDAY, SEPTEMBER 24
Ball Room, Pantlind Hotel, Grand Rapids
8:00 p.m. — Fifth Meeting
30. Supplementary Report of Committee on Creden-
tials
31. Roll Call
32. Unfinished Business
33. Supplemental Report of The Council
34. Supplementary Reports of Reference Committees
35. Elections
(a) Councilors:
7th District — H. B. Zemmer, M.D., Lapeer
- — Incumbent
8th District — L. C. Harvie, M.D., Saginaw
— Incumbent
9th District — G. B. Saltonstall, M.D.,
Charlevoix — Incumbent
10th District — W. S. Stinson, M.D., Bay
City — Incumbent
(b) Delegates to American Medical Association
W. A. Hyland, M.D., Grand Rapids — In-
bent
J. S. DeTar, M.D., Milan — Incumbent
C. I. Owen, M.D., Detroit — Incumbent
(c) Alternate Delegates to American Medical
Association
W. W. Babcock, M.D., Detroit — Incumbent
E. F. Sladek, M.D., Traverse City — Incum-
bent
O. J. Johnson, M.D., Bay City — Incumbent
(d) President-Elect
(e) Speaker of the House of Delegates
(f) Vice-Speaker of the House of Delegates
36. Adjournment
ADVANCE REGISTRATION OF DELEGATES
Sunday, September 22, 1957
8:00 to 10:00 p.m.
Lobby of Pantlind Hotel
ANNUAL SESSION APPOINTMENTS
Chairman of Arrangements
C. Allan Payne, M.D., Grand Rapids
House of Delegates Press Relations Committee
K. H. Johnson, M.D., Lansing, Chairman
L. Fernald Foster, M.D., Detroit
J. J. Lightbody, M.D., Detroit
D. W. Thorup, M.D., Benton Harbor
C. L. Weston, M.D., Owosso
Scientific Press Relations Committee
P. W. Kniskern, M.D., Grand Rapids, Chairman
H. G. Benjamin, M.D., Grand Rapids
F. C. Brace, M.D., Grand Rapids
A. B. Gwinn, M.D., Hastings
HOTEL RESERVATIONS
MICHIGAN STATE MEDICAL SOCIETY
92nd Annual Session
Grand Rapids, September 25-26-27, 1957
The reservation blank below is for your convenience
in making your hotel reservations in Grand Rapids.
Please send your application to the Committee on Hotels
for MSMS Convention, Pantlind Hotel, Grand Rapids,
Michigan. Mailing your application now will be of
material assistance in securing hotel accommodations.
As very few singles are available, registrants are
requested to co-operate with the Committee on Hotels
by sharing a room with another registrant, when con-
venient.
Committee on Hotels,
Michigan State Medical Society
c/o Pantlind Hotel
Grand Rapids, Michigan
Please make hotel reservation (s) as indicated below:
Single Room(s) persons
Double Room(s) for persons
_ Twin-Bedded Room(s) for persons
Arriving September hour A.M P.M.
Leaving hour A.M P.M.
Hotel of First Choice: :
Second Choice:
Names and addresses of all applicants including per-
sons making reservation:
Name Address City State
Date Signature
Address City
June, 1957
747
MSMS HOUSE OF DELEGATES, 1957
Delegates and Alternates
(Names of Alternates appear in italics)
OFFICERS
K. H. Johnson, M.D., 1116 Mich Natl. Tower, Lansing
5 peaker
J. J. Lightbody, M.D., 501 David Whitney Bldg., Detroit
Vice Speaker
L. Fernald Foster, M.D., 441 E. Jefferson, Detroit
Secretary
W. S. Jones. M.D., 1146 Tenth Avenue, Menominee
Immediate Past President
ALLEGAN
L. F. Brown, M.D., 133 E. Allegan, Otsego
E. B. Johnson, M.D., 412 Water St., Allegan
ALPENA-ALCONA-PRESQUE ISLE
E. S. Parmenter, M.D., P.O. Box 192, Alpena
J. E. Spens, M.D., 125 N. Second Ave., Alpena
BARRY
A. B. Gwinn, M.D., City Bank Bldg., Hastings
J. A. Millard, M.D., 303 Broadway, Middleville
BAY-ARENAC-IOSCO
O. J. Johnson, M.D., 207 N. Walnut. Bay City
D. A. Bowman, M.D., 101 W. John, Bay City
W. G. Gamble, M.D., Mercy Hospital, Bay City
S. A. Cosens, M.D., 101 W. John St., Bay City
BERRIEN
Noel J. Hershey, M.D., 122 Grant St., Niles
D. W. Thorup, M.D., 610 Fidelity Bldg., Benton Harbor
H. J. Klos, M.D., 2121 Niles St., St. Joseph
F. H. Lindenfeld , M.D., 8 N. St. Joseph, Niles
BRANCH
R. J. Fraser, M.D., 22 W. Pearl St., Coldwater
R. M. Leitch, M.D., 304 N. Broadway, Union City
CALHOUN
James W. Hubly, M.D., 25 W. Michigan Ave., Battle
Creek
Harvey C. Hansen, M.D., 65 W. Michigan Ave., Battle
Creek
George T. Kelleher, M.D., 65 W. Michigan Ave., Battle
Creek
Robert E. Fisher, M.D., 1501 W. Michigan Ave., Battle
Creek
CASS
S. L. Loupee, M.D., 110 W. Division St., Dowagiac
U. M. Adams, M.D., Marcellus
CHIPPEWA-MACKINAC
W. F. Mertaugh. M.D., Central Savings Bank Bldg.,
Sault Ste. Marie
E. S. Rhind, M.D., 300 Court St., Sault Ste. Marie
CLINTON
Franklin W. Smith, M.D., 105 S. Ottawa St., St. Johns
James M. Grost, M.D., 303 E. Walker St., St. Johns
DELTA-SCHOOLCRAFT
James R. Dehlin, M.D., 8 S. Eleventh St., Gladstone
James H. Fyvie, M.D., 202 S. Cedar, Manistique
DICKINSON-IRON
D. R. Smith, M.D., 105 W. A. St., Iron Mountain
E. R. Addison, M.D., 412 Superior St., Crystal Falls
EATON
B. P. Brown. M.D., 339 S. Cochran, Charlotte
R. E. Landick, M.D., 111 S. Cochran, Charlotte
GENESEE
J. E. Livesay, M.D., 621 Mott Foundation Bldg., Flint
F. D. Johnson, M.D., 312 Paterson Bldg., Flint
C. W. Colwell, M.D., 706 Citizens Bank Bldg., Flint
F. W. Baske, M.D., 923 Maxine St., Flint
G. E. Anthony, M.D., 1015 Detroit St., Flint
Kendall Hooper, M.D., 714 Beech St., Flint
J. E. Wentworth, M.D., 1651 Chevrolet Ave., Flint
L. G. Bateman, M.D., 1928 Lewis St., Flint
John C. Benson, M.D., 402 W. Second St., Flint
W. F. Buchanan, M.D., 104 W. Caroline St., Fenton
GOGEBIC
J. E. McEnroe, M.D., Newport Hospital, Ironwood
A. C. Gorilla, M.D., Ironwood
GRAND-TRAVERSE-LEELANAU-BENZIE
D. G. Pike, M.D., 876 E. Front St., Traverse City
C. E. Lemen, M.D., 216l/z E. Front St., Traverse City
GRATIOT-ISABELLA-CLARE
E. S. Oldham, M.D., Breckenridge
(No alternate elected to date.)
HILLSDALE
A. W. Strom, M.D, Hillsdale
L. W. Day, M.D., Jonesville
HOUGHTON-BARAGA-KEWEENAW
P. S. Sloan, M.D., 609 Sheldon Ave., Houghton
L. C. Aldrich, M.D., 301 Quincy St., Hancock
HURON
C. W. Oakes, M.D., Harbor Beach
C. A. Scheurer, M.D., Pigeon
INGHAM
K. H. Johnson, M.D., 1116 Michigan National Tower,
Lansing
H. W. Harris, M.D., 609 N. Washington, Lansing
J. M. Wellman, M.D., 301 Seymour, Lansing
F. L. Troost, M.D., 4341 W. Delhi, Holt
L. A. Drolett, M.D., 3526 West Saginaw, Lansing
Milton Shaw, M.D., 320 Townsend, Lansing
K. W. Toothaker, M.D., 930 N. Washington, Lansing
R. E. Kalmbach, M.D., 301 Seymour, Lansing
IONIA-MONTCALM
R. E. Rice, M.D.. Greenville
]. L. Tromp, M.D., Lake Odessa
JACKSON
W. A. Wickham, M.D., 420 W. Michigan, Jackson
H. W. Porter, M.D., 505 Wildwood, Jackson
C. R. Lenz, M.D., 405 First St., Jackson
Jack P. Bentley, M.D., 404 MacNeal, Jackson
KALAMAZOO
Wm. A. Scott, M.D., 208 Bronson Medical Center, Kal-
amazoo
Sherman E. Andrews, M.D., 224 E. Cedar, Kalamazoo
Frederick C. Ryan, M.D., 507 S. Burdick, Kalamazoo
Martin D. Verhage, M.D., 228 W. Cedar, Kalamazoo
Robert R. Dew , M.D., 312 Bronson Medical Center,
Kalamazoo
James G. Malone, M.D.. 420 John St., Kalamazoo
748
JMSMS
MSMS HOUSE OF DELEGATES, 1957
ENT
M. Burroughs, Jr., M.D., 11 S. Wilson, Grandville
R. Brink, M.D., 110-116 E. Fulton, Grand Rapids
S. Alfenito, M.D., 26 Sheldon S.E., Grand Rapids
. A. Rasmussen, M.D., 1810 Wealthy S.E., Grand
Rapids
r. C. Beets, M.D., 124 E. Fulton, Grand Rapids
T. Boet, M.D., 2339 Wyoming S.W., Grand Rapids
. W. DeBoer, M.D., 26 Sheldon S.E., Grand Rapids
. R. Vanden Berg, M.D., 26 Sheldon S.E., Grand
Rapids
i. L. Kessler, M.D., 1610 Robinson Rd. S.E., Grand
Rapids
. F. Failing, Sr., M.D., 110-116 E. Fulton, Grand
Rapids
. J. Hoffs, M.D., 26 Sheldon S.E., Grand Rapids
!. C. Boelkins, M.D., 125-7 Fountain S.E., Grand
Rapids
r. A. Notierr, M.D., 26 Sheldon S.E., Grand Rapids
. R. VanZwalenburg, M.D., 833 Lake Dr. S.E., Grand
Rapids
APEER
i. J. O’Brien, M.D., Nepessing St., Lapeer
'homas K. Buchanan, M.D., Imlay City
ENAWEE
r. C. Wilson, M.D., 108 N. Jackson St., Clinton
A H. Hewes, M.D., 146 E. Maumee, Adrian
IVINGSTON
[. C. Hill, M.D., 116 N. Michigan, Howell
. E. May, M.D., 203 N. Court St., Howell
UCE
•. C. Adams, M.D., Newberry State Hospital, Newberry
Vo alternate elected to date)
IACOMB
ydney Scher, M.D., 132 Cass Ave., Mt. Clemens
dward G. Siegfried, M.D., 91 Cass Ave., Mt. Clemens
ames W. Jewell, M.D., 18215 Utica Road, Roseville
renry C. Wellard, M.D., New Baltimore
IANISTEE
obert R. Garneau, M.D., Mercy Community Hospital,
Manistee
. B. Miller, M.D., 425 River St., Manistee
[ARQUETTE- ALGER
. S. Narotzky, M.D., Miracle Circle, Ishpeming
R. Acocks, M.D., Morgan Heights San., Marquette
[ASON
[. G. Bacon, M.D., Scottville
. B. Boldyreff , M.D., Custer
IECOSTA-OSCEOLA-LAKE
aul Ivkovich, M.D., 1 1 1 S. Chestnut, Reed City
dward H. Kowaleski, M.D., Remus
[ENOMINEE
R. Heidenreich, M.D., Daggett
r. R. Brukardt, M.D., 534 1st Street. Menominee
IIDLAND
iarold L. Gordon, M.D., 1423 Clover Lane, Midland
fartin J. Ittner, M.D., 217 N. Saginaw, Midland
IONROE
. Newton Kelso, M.D., 127 East Front St., Monroe
. A. Frary, M.D., 423 East Elm Ave., Monroe
IUSKEGON
. W. Scholle, M.D., 2500 Peck St.. Muskegon Heights
'. R. Boyd, M.D., 1735 Peck St., Muskegon
M. Busard, M.D , 503 Liberty Life Bldg., Muskegon
A H. Tyler, M.D., 1435 Peck St., Muskegon
LINE, 1957
NEWAYGO
J. Paul Klein, M.D., 16 West Sheridan St., Fremont
Robert E. Paxton, M.D., 40 West Sheridan, Fremont
NORTH CENTRAL
E. H. Rodda, M.D., 308 Michigan Ave., Grayling
George L. Schaiberger, M.D., 707 W. Hought, West
Branch
NORTH MICHIGAN
J. R. Rodger, M.D., Bellaire
G. A. Drake, M.D., Petoskey
OAKLAND
P. E. Sutton, M.D., 629 Washington Square Bldg.,
Royal Oak
H. A. Furlong, M.D., 940 Riker Bldg., Pontiac
E. B. Cudney, M.D., Pontiac Motor Div., Pontiac
W. J. Zimmerman, M.D., 258 Washington Square Bldg.,
Royal Oak
E. W. Bauer, M.D., 23055 John R., Hazel Park
John M. Markley, M.D., 849 W. Huron, Pontiac
C. G. Burke, M.D., 1022 Riker Bldg., Pontiac
Norman F. Gehringer, M.D., 880 Woodward, Pontiac
Felix J. Kemp, M.D., 880 Woodward, Pontiac
F. M. Adams , M.D., 600 N. Woodward, Birmingham
Paul T. Lahti, M.D., 325 Washington Square Bldg.,
Royal Oak
R. W. Bullard, M.D., Jr., 20 S. Main St., Clarkston
OCEANA
W. G. Robinson, M.D., 219 State Street, Hart
(No alternate elected to date)
ONTONAGON
W. F. Strong, M.D., Ontonagon
C. R. Lahti, M.D., Ontonagon
OTTAWA
Otto VanderVelde, M.D., 35 W. 8th St., Holland
K. N. Wells, M.D., 119 W. Savidge St., Spring Lake
SAGINAW
E. C. Galsterer, M.D., 124 S. Jefferson, Saginaw
J. P. Markey, M.D., 808 N. Michigan, Saginaw
A. C. Stander, M.D., 1411 Court St., Saginaw
A. K. Cameron, M.D., 409 1st Savings Loan Bldg.,
Saginaw
F. E. Luger, M.D., 303 N. Jefferson, Saginaw
H. T. Caumartin, M.D., 404 S. Warren, Saginaw
SANILAC
K. T. McGunegle, M.D., Sandusky
R. J. Winfield, M.D., Marlette
SHIAWASSEE
Claude L. Weston, M.D., Matthews Bldg., Owosso
John E. Harroun, M.D., Matthews Bldg., Owosso
ST. CLAIR
Joseph F. Beer, M.D., 104 North Riverside, St. Clair
Anthony C. Gholz, M.D., 208 Sperry Bldg., Port Huron
ST. JOSEPH
S. A. Fiegel, M.D., 111 S. Monroe, Sturgis
R. J. Fortner, M.D. , 137 Portage, Three Rivers
TUSCOLA
L. L. Savage, M.D., Caro
E. N. Elmendorf, M.D., Vassar
VAN BUREN
F. J. Loomis, M.D., Paw Paw
/. A. Kleber, M.D., 311/2 Center St., South Haven
749
MSMS HOUSE OF DELEGATES, 1957
WASHTENAW
V. M. Zerbi, M.D., 315 N. Adams, Ypsilanti
Gerhard H. Bauer, M.D., 505 First National Bldg., Ann
Arbor
Harold F. Falls, M.D., 408 First National Bldg., Ann
Arbor
George R. Sayre, M.D., 220 Pearl St., Ypsilanti
Clarence E. Crook, M.D., 2112 Wellington Road, Ann
Arbor
Theodore G. Kabza, M.D., 2310 Fernwood, Ann Arbor
John W. Smilie, M.D., 2615 Overidge Dr., Ann Arbor
Paul J. Wicht, M.D., 1385 W. Michigan Avenue, Ypsi-
lanti
WAYNE
Louis J. Bailey, M.D., 620 Vinewood Ave., Birmingham
C. I. Owen, M.D., 4160 John R. St., Detroit
Francis P. Rhoades, M.D., 970 Maccabees Bldg., Detroit
James J. Lightbody, M.D., 501 David Whitney Bldg.,
Detroit
Robert L. Novy, M.D., 858 Fisher Bldg., Detroit
Eugene A. Osius, M.D., 901 David Whitney Bldg.,
Detroit
Milton A. Darling, M.D., 673 Fisher Bldg., Detroit
J. E. Webster, M.D., 840 David Whitney Bldg., Detroit
Joseph G. Molner, M.D., 334 Bates, Detroit
James B. Blodgett, M.D., 606 Kales Bldg., Detroit
Gaylord S. Bates. M.D., 861 Monroe Blvd., Dearborn
Luther R. Leader, M.D., 1129 David Whitney Bldg.,
Detroit
Edwin H. Fenton, M.D., 15125 Grand River Ave.,
Detroit
William S. Reveno, M.D., 958 Fisher Bldg., Detroit
David I. Sugar, M.D., 13120 Broadstreet, Detroit
Warren B. Babcock, M.D., 868 Fisher Bldg., Detroit
Wm. S. Carpenter, M.D., 1317 David Whitney Bldg.,
Detroit
Max L. Lichter, M.D., 2900 Oakwood Blvd., Melvindale
Charles W. Sellers, M.D., 2314 W. Grand Blvd., Detroit
Milton R. Weed, M.D., 1997 E. Grand Blvd., Detroit
Albert D. Ruedemann, Sr., M.D., 1633 David Whitney
Bldg., Detroit
Wm. L. Brosius, M.D., Harper Hospital, Detroit
Earl G. Krieg, M.D., 1842 David Whitney Bldg., De-
troit
Alvin E. Price, M.D., 313 David Whitney Bldg., Detroit
Russell F. Fenton, M.D., 15125 Grand River Ave.,
Detroit
Clyde K. Hasley, M.D., 1429 David Whitney Bldg.,
Detroit
John G. Bielawski. M.D.. 922 Maccabees Bldg., Detroit
Louis Jaffe. M.D., 1002 David Whitney Bldg., Detroit
Roger Walker, M.D.. 1255 David Whitney Bldg., Detroit
Claire L. Straith, M.D., 2605 W. Grand Blvd., Detroit
Joseph A. Kasper, M.D.. Bon Secour Hospital, Grosse
Pointe
Saul R. Rosenzweig, M.D., 2114 David Broderick Tow-
er, Detroit
Ralph R. Cooper, M.D., 1515 David Whitney Bldg.,
Detroit
S. E. Gould, M.D., Wayne County General Hospital,
Eloise
Ralph H. Pino. M.D., 208 David Whitney Bldg., De-
troit
Raphael Altman, M.D., 1052 Maccabees Bldg., Detroit
Edward H. Lauppe, M.D., 1650 David Whitney Bldg.,
Detroit
Harry F. Dibble, M.D., 1313 David Whitney Bldg.,
Detroit
Clarence L. Candler, M.D., 20040 Mack Ave., Grosse
Pointe Woods
Laurence S. Fallis, M.D., Henry Ford Hospital, Detroit
James E. Croushore, M.D., 573 Fisher Bldg., Detroit
James D. Fryfogle, M.D., 655 Fisher Bldg., Detroit
750
Meyer Teitelbaum, M.D., 405 Kales Bldg., Detroit
Harold B. Fenech, M.D., 324 Professional Bldg., Detroi:
Perry C. Gittins, M.D., 732 Maccabees Bldg., Detroit
Elmer C. Texter, M.D., 7457 Gratiot Ave., Detroit
Russell T. Costello, M.D., 630 Fisher Bldg., Detroit
Donald G. Young, M.D., 1151 Taylor Ave., Detroit
Sidney Adler, M.D., 755 Fisher Bldg., Detroit
Hugh W. Henderson, M.D., 308 Professional Bldg.
Detroit
Alice E. Palmer, M.D., 3919 John R. St., Detroit
William L. Sherman, M.D., 10 Peterboro, Detroit
George S. Fisher, M.D., 1709 David Whitney Bldg..
Detroit
Remus G. Robinson, M.D., 3751 31st St., Detroit
Joseph A. Witter, M.D., 344 Glendale, Detroit
Carl ]. Sprunk, M.D., 2900 Oakwood Blvd., Melvindale
Robert K. Whiteley, M.D., 541-3 David Whitney Bldg.,
Detroit
Leslie T. Henderson, M.D., 14814 E. Warren, Detroit
Joseph Hickey, M.D., 6004 W. Fort St., Detroit
Donald A. Young, M.D., 14807 W. McNichols Rd.,
Detroit
Hugh M. Fuller, M.D., 1257 David Whitney Bldg.,
Detroit
Ruben Meyer, M.D., 18254 Livernois , Detroit
Sidney E. Chapin, M.D., 10149 Michigan Ave., Dear-
born
Earl F. Lutz, M.D., 13-204 General Motors Bldg., Detroit
Milton J. Rueger, M.D., 708 Kales Bldg., Detroit
John J. Dudek, M.D., 16401 Grand River, Detroit
E. Clarkson Long, M.D., 2626 Rochester, Detroit
Lyle W. Korum, M.D., 18585 E. Warren, Detroit
Clarke M. McColl, M.D., Henry Ford Hospital, Detroit
John G. Slevin, M.D., 1304 David Broderick Tower,
Detroit
Melvin S. Dennis, M.D., 751 S. Military Ave., Dearborn
Henry L. Smith, M.D., 16401 Grand River, Detroit
Glenn L. Coan, M.D., 2336 Van Alstyne Blvd., Wyan-
dotte
A. Z. Rogers, M.D., 20451 Mack Ave., Grosse Pointe
Woods
Howard C. Rees, M.D., 15700 Mack Ave., Detroit
Sampson S. Wittenberg, M.D., 934 Maccabees Bldg.,
Detroit
John W. Sigler, M.D., Henry Ford Hospital, Detroit
Robert C. Lytle, M.D., 411 Professional Bldg., Detroit
Earle A. Irvin, M.D., Ford Motor Co., 3000 Schaefer
Rd., Dearborn
Harry Y. Kasabach, M.D., 952 David Whitney Bldg.,
Detroit
Arthur B. Levant, M.D., 15715 E. Warren, Detroit
Edgar R. Sherrin, M.D., 17555 James Couzens High-
way, Detroit
Brenton M. Hamil, M.D., Henry Ford Hospital, Detroit
John P. McGuire, M.D., 815 Kales Bldg., Detroit
Earl E. Weston, M.D., 18101 James Couzens Highway,
Detroit
Clarence D. Moll, M.D., 10 Peterboro, Detroit
Ross M. Knox, M.D., 9 Salliotte, Ecorse
Edgar G. Cochrane, M.D., 12805 Hamilton, Detroit
Everal M. Wakeman, M.D., 22276 Garrison, Dearborn
A. H. Hirschfeld, M.D., 829 Fisher Bldg., Detroit
Karl G. Pinckard, M.D., 932 Mason St., Dearborn
Victor E. Nelson, M.D., 7345 Fenkell, Detroit
William P. Curtiss, M.D., 3181 E. Jefferson, Detroit
John W. Rebuck, M.D., Henry Ford Hospital, Detroit
Crosby D. Eaton, M.D., 462 Fisher Bldg., Detroit
Victor A. Kelmenson, M.D., 7356 Twelfth St., Detroit
WEXFORD-MISSAUKEE
Robert V. Daugherty, M.D., 302 E. Chapin, Cadillac
Maxwell D. Bentley, M.D., 120/2 E. Cass, Cadillac
JMSMS
HOUSE OF DELEGATES— 1957
REFERENCE COMMITTEES AND CREDENTIALS COMMITTEE
(All meetings of Reference Committee will be held in the
Pantlind Hotel, Grand Rapids)
CREDENTIALS COMMITTEE
N. J. Hershey, M.D., Chairman, 122 Grant St., Niles
Paul Ivkovich, M.D., 111 S. Chestnut, Reed City
K. T. McGunegle, M.D., Sandusky
N. W. Scholle, M.D., 2500 Peck St., Muskegon Heights
REFERENCE COMMITTEES
Officers Reports
3. W. Sellers, M.D., Chairman, 2314- W. Grand Blvd.,
Detroit
Harold L. Gordon, M.D., 1423 Clover Lane, Midland
S. Narotzky, M.D., Miracle Circle, Ishpeming
H. W. Porter, M.D., 505 Wildwood, Jackson
R.. E. Rice, M.D., Greenville
Reports of The Council
H. A. Furlong, M.D., Chairman, 940 Riker Bldg.,
Pontiac
fames B. Blodgett, M.D., 606 Kales Bldg., Detroit
f. R. Brink, M.D., 110-116 E. Fulton, Grand Rapids
Ralph H. Pino, M.D., 208 David Whitney Bldg., Detroit
W. G. Robinson, M.D., 219 State Street, Hart
f. R. Rodger, M.D., Bellaire
F. L. Troost, M.D., 4341 W. Delhi, Holt
Reports of Standing Committees
Edwin H. Fenton, M.D., Chairman, 15125 Grand River
Ave., Detroit
F. S. Alfenito. M.D., 26 Sheldon S.E., Grand Rapids
R.obert V. Daugherty, M.D.. 302 E. Chapin, Cadillac
Earl G. M. Krieg, M.D., 1842 David Whitney Bldg.,
Detroit
V. M. Zerbi, M.D., 315 N. Adams, Ypsilanti
Reports of Special Committees
Louis J. Bailey, M.D., Chairman, 620 Vinewood Ave.,
Birmingham
sherman E. Andrews, M.D., 224 E. Cedar, Kalamazoo
5. A. Fiegel, M.D.. Ill S. Monroe, Sturgis
fames D. Fryfogle, M.D., 655 Fisher Bldg., Detroit
E. H. Rodda, M.D., 308 Michigan Ave., Grayling
D. W. Thorup, M.D., 610 Fidelity Bldg., Benton Harbor
Constitution and By-Laws
5. S. Parmenter, M.D., Chairman, P.O. Box 192, Alpena
R J. Fraser, M.D., 22 W. Pearl St., Coldwater
v L. Loupee, M.D., 110 W. Division St, Dowagiac
Resolutions
f. M. Wellman, M.D., Chairman, 301 Seymour, Lansing
Warren B. Babcock, M.D., 868 Fisher Bldg.. Detroit
Gerhard H. Bauer, M.D., 505 First National Bldg., Ann
Arbor
R.obert R. Garneau, M.D.. Mercy Community Hospital,
Manistee
Luther R. Leader, M.D., 1129 David Whitney Bldg.,
Detroit
L. I. Owen, M.D., 4160 John R. St., Detroit
Dtto van der Velde, M.D., 35 W. 8th St., Holland
Rules and Order of Business
Perry C. Gittins, M.D., Chairman, 732 Maccabees Bldg.,
Detroit
L. L. Savage, M.D.. Caro
A. C. Stander, M.D.. 1411 Court St., Saginaw
Legislation and Public Relations
William S. Reveno, M.D., Chairman, 958 Fisher Bldg.,
Detroit
D. R. Boyd, M.D., 1735 Peck St., Muskegon
A. B. Gwinn, M.D., City Bank Bldg., Hastings
Harvey C. Hansen, M.D., 65 W. Michigan Ave., Battle
Creek
Claude L. Weston, M.D., Matthews Bldg., Owosso
Hygiene and Public Health
J. G. Molner, M.D., Chairman, 334 Bates, Detroit
James W. Hubly, M.D., 25 W. Michigan Ave., Battle
Creek
C. W. Oakes, M.D., Harbor Beach
P. S. Sloan, M.D., 609 Sheldon Ave., Houghton
Medical Service and Prepayment Insurance
Max L. Lichter, M.D., Chairman, 2900 Oakwood Blvd.,
Melvindale
Laurence S. Fallis, M.D., Henry Ford Hospital, Detroit
H. C. Hill, M.D., 116 N. Michigan, Howell
R. L. Novy, M.D., 858 Fisher Bldg., Detroit
D. G. Pike, M.D., 876 E. Front St., Traverse City
Sydney Scher, M.D., 132 Cass Ave., Mt. Clemens
W. F. Strong, M.D., Ontonagon
Miscellaneous Business
W. F. Mertaugh, M.D., Chairman, Central Savings Bank
Bldg., Sault Ste. Marie
James E. Croushore, M.D.. 573 Fisher Bldg., Detroit
J. Paul Klein, M.D., 16 West Sheridan St., Fremont
F. J. Loomis, M.D., Paw Paw
Franklin W. Smith, M.D., 105 S. Ottawa St., St. Johns
Special Memberships
Wm. L. Brosius, M.D., Chairman, Harper Flospital,
Detrot
E. C. Galsterer, M.D., 124 S. Jefferson, Saginaw
D. J. O’Brien, M.D., Nepessing St., Lapeer
P. E. Sutton, M.D., 629 Washington Square Bldg., Royal
Oak
G. C. Wilson, M.D., 108 N. Jackson St., Clinton
National Defense and Disaster Planning
W. C. Beets, M.D., Chairman, 124 E. Fulton, Grand
Rapids
H. G. Bacon, M.D., Scottville
John M. Markley, M.D., 849 W. Huron. Pontiac
Edward G. Siegfried, M.D., 91 Cass Ave., Mt. Clemens
Executive Session
J. E. Livesay, M.D., Chairman, 621 Mott Foundation
Bldg., Flint
B. P. Brown, M.D., 339 S. Cochran, Charlotte
J. E. McEnroe, M.D., Newport Hospital, Ironwood
D. R. Smith, M.D., 105 W. A. St., Iron Mountain
MSMS House of Delegates
Special Session of April 27, 1957
TABLE OF CONTENTS
I. Call to order and introduction of the subject matter.
Speaker K. H. Johnson, M.D 753
II. How we got where we are (the history and philosophy of Michigan Medical Service).
MSMS Secretary L. Fernald Foster, M.D 754
III. Various attempts to solve the problem (service, indemnity, closed panel, etc.) 755
Panel — Arch Walls, M.D., Chairman 755
D. W. Thorup, M.D 756
M. L. Lichter, M.D 759
IV. Where we are now — the end result of taking each of the roads described.
J. C. Ketchum 763
V. What road do you want to follow?
MSMS President-Elect G. W. Slagle, M.D 765
VI. Questions and Answers 767
VII. Presentation of Resolutions and Motions 773
1. Resolution No. 1: Recognition of Pathology Under Medicare 773
2. Resolution No. 2: Recognition of Pathology in Blue Cross-Blue Shield 773
3. Resolution No. 3: Increased Benefits in Michigan Medical Service Contracts 774
4. Resolution No. 4: Limit Blue Shield Contracts to Those in Specified Income Limits 774
5. Motion No. 1 : Authorizing Survey to Determine Consumers’ Attitude on Services
and Payments 774
6. Resolution No. 5: Recognition of Internists 775
7. Resolution No. 6: Change Michigan Hospital Sendee — Michigan Medical Service
into Indemnity Plans 776
8. Motion No. 2: Encouraging Extended Coverage of Service Contracts 776
VIII. Summation: Your opportunity and responsibility to spread this information to all
MSMS members.
G. W. Slagle, M.D 776
IX. Adjournment 776
752 JMSMS
MSMS House of Delegates
Special Session, April 27, 1957
SATURDAY MORNING SESSION
April 27, 1957
The first meeting of a special called session of the
louse of Delegates of the Michigan State Medical So-
iety, held at 441 East Jefferson Street, Detroit, Michi-
an, on Saturday, April 27, 1957, convened at 10:25
.m., K. H. Johnson, M.D., Speaker of the House, pre-
iding.
I. INTRODUCTION
By Speaker K. H. Johnson, M.D.
Members of the House of Delegates, Alternates, Coun-
y Society Presidents and Secretaries, Members of The
louncil, Officers of the State Society, Officers of Michi-
an Medical Service, Members of the Press, Guests,
,adies and Gentlemen:
This special session of the House of Delegates is, in my
find, another milestone in the history of forward prog-
;ss of the Michigan State Medical Society. Those
f us whose duty it is to sit month after month listening,
eighing, considering and disposing of the mass of in-
)rmation that comes before The Council and its Ex-
:utive Committee are keenly aware of the fierce pres-
ires from many directions which are exerting their in-
uence upon the profession of medicine and the public
seeks to serve. It is highly commendable that a com-
littee of The Council saw fit to request that The Coun-
1 call this special session and that The Council, by
nanimous vote, requested that the meeting be called.
It is essential that each member of this House be
loroughly familiar with the responsibilities that are his
; he votes for the principles by which this State Society
ad the profession of medicine shall be guided in the
ays and months and years ahead. It is no small re-
>onsibility and surmounts any individual gain or specific
roup satisfaction. It is my strong personal conviction
tat the future history of the profession of medicine is
ling to be written by this House of Delegates during
le next two years.
With this in mind. I call this special meeting to order.
May we have a report from the Credentials Commit-
e.
A. B. Gwinn, M.D. f Barryl : Mr. Speaker, in this
lecial session of the House of Delegates there are ninety
degates seated, and 50 per cent of these are not from
ly one county.
The Speaker: I therefore declare a quorum is
•esent, and we shall proceed with the business of the
iy-
I should like to explain to you that everyone in this
'om is welcome.
The purpose of this special session, as it was presented
the call, is to acquaint the members of the House and,
turn, all members of the State Society, with certain
ises facing the profession in regard to the future of
epaid health insurance in this State. This meeting was
quested by The Council, according to Section 4, Chap-
r VIII of the Bylaws, which reads as follows:
“The House of Delegates shall meet annually at the
Tie and place of the meeting of this State Society as a
hole, as when it meets in general session, and may hold
ch number of meetings as the House may determine
its business require, recessing from day to day as may
: necessary to complete its business, and specifying its
vn time for the holding of its meetings.
jne, 1957
“The House of Delegates may also be called into ses-
sion at any time by the Speaker upon a two-thirds vote
of The Council or on petition of 25 per cent of the
delegates. The purpose of such special session shall be
stated in the notice to call.”
I would like to extend my personal thanks and, I am
sure, the thanks of the members of the House of Dele-
gates, for the very excellent work of the administrative
staff, the members of the panel, the Councilors and the
officers of this Society in their efforts to present to you
a concise bit of information which you will find in the
brochure that has been handed to you. Purposely there
are wide margins on the pages so that you may make
side notes as we go along.
I think they have done an excellent job, and I also
would like to thank the Credentials Committee for its
work in getting here early today and organizing the set-
up. A great deal of very sincere energy and effort has
gone into the matter.
We have made every effort to handle things so that
there will be no missed opportunities. Loud speakers
will be at your service on the floor. The speakers will
use this rostrum. We have a stenotypist who is taking
down everything that is said, and we have a tape re-
corder that is taking down how it is said.
You will notice that the meeting is divided into, first,
an informational period. At this time we will have men
who will present the history and philosophy of prepaid
medical insurance in this State, and we will have an-
other group who will present the various attempts that
have been made to solve our problem. Then we will
have some statements of facts from an insurance stand-
point as to where we are today and what the future
holds, providing we choose this or that direction.
Following this informational, we will have a question
and answer period. Large question cards will be passed
out to members of the House. Please bear with me when
I say that only members of the House may use these
cards, but of course if there is some person in the
audience who would like to ask a question through a
delegate it is perfectly proper for him to do so.
Will you write your question on the card legibly. You
may ask your question of a specific member of the panel,
or you may simply ask it in a general way. You may
or may not sign your name, as you wish. Please write
your questions as the program proceeds. We are trying
not to keep you here all night, and I am sure that if
questions come to your mind and you jot them down at
the time, it will facilitate somewhat the speed of the
program.
Immediately following the question and answer period
there will be an opportunity for motions and resolutions
to be presented. I believe it is perfectly obvious to
everyone here that for this House in a special session, to
take definitive action that is binding on the entire mem-
bership of the State of Michigan would be a very great
mistake. Therefore, it will be the duty of the Speaker to
evaluate as to whether or not a motion or resolution
that is submitted is something that can be acted upon
today.
I hope you will bear with me in the decisions I may
make. You will recall that this is the first special ses-
sion of the House of Delegates since 1939, and I might
make some mistakes because I have very little precedent
to follow. I will do my best to rule fairly; but may I
repeat that, basically speaking, it will be up to the
Speaker to decide whether or not a motion or resolution
that is submitted is germane to the topic today.
There is in our Bylaws a definite statement that reso-
753
SPECIAL SESSION— MSMS HOUSE OF DELEGATES
lutions will be referred to a reference committee; but
motions will have to be evaluated. If action seems wise
today, then action will be taken and there will be dis-
cussion. However, any resolution or any motion that I
do not consider germane to what we are talking about
today will be referred to the appropriate reference com-
mittee. When I say “appropriate” it simply means that
the time for the appointment of reference committees for
the meeting of the House of Delegates in September is
not presently at hand. That appointment will be made
very soon, but it has not been made as yet.
I would also like to inform you that your Speaker has
been completely aware of the resolution that was passed
in the House of Delegates in regard to a permanent
Advisory Committee for the Study of Fees. Gentlemen,
it has been a very real task to select that Committee but
it will be appointed not later than May 15; there was
no direction by the House of Delegates in the resolution
as to who should constitute the Committee, how many
should be on the Committee, how it should be handled,
or when it should report, and it has been left up to the
Speaker to make those decisions.
There is only one more thing to say, then, and it is
this: It is not necessary for you to move for another
session of this House of Delegates, since it is already set
for September. That is automatic. However, if you
should decide that you wish another special session of
this House, then of course before we adjourn today it
will be necessary to so move.
I would like to introduce to you Dr. L. Fernald Fos-
ter, Secretary of the Michigan State Medical Society,
whose presentation will be, “How We Got Where We
Are.”
II. HOW WE GOT WHERE WE ARE
By Secretary L. Fernald Foster, M.D.
I have been assigned by The Council the subject,
“How We Got Where We Are.” Probably the first
statement to be made in that connection is a statement
as to where we are. I think that can be simply said,
that we are still in the position of practicing medicine
as a free enterprise, as we have all known it, and that
that is where we are; but the title as assigned, “How
We Got Where We Are,” involves a consideration of
certain factors that were operative in the last eighteen
or twenty years to have preserved the status quo in
which we find ourselves.
It was apparent, in the late ’20s, that the costs of
medical care were rising rapidly, and an appreciation of
this was had probably as early as any by the State
Medical Society. The rapidly increasing tempo of med-
ical science had been adding considerably to the costs of
medical care, and your State Medical Society through
its Council and Executive Committee began early to
conduct research studies in the costs of medical care.
These research studies involved, as some of you will
remember, the sending of a delegation to Europe to
study the plans on the continent and in England, and
other studies, to the end that early in the consideration
of this problem a device based on the insurance prin-
ciple was developed — a device which many of you have
probably forgotten, a device known as Mutual Health
Service, a voluntary plan quite like the Michigan Med-
ical Service, but a plan which was never put into
operation because of certain economic conditions existing
at the time.
However, in the early ’30s there developed in this
country a new social and political philosophy; and as I
look about this room I see many men here who were
active in the research studies and in the activities lead-
ing to the devices developed since.
Also, in this group I see many men to whom the
early history of the present device under which we have
operated is simply a matter of hearsay, and so this
presentation has been ordered by The Council simply to
refresh the memory of those who had an active part in
754
its development, and at the same time to bring to those
to whom this is not firsthand information, the facts of
what happened.
If you will remember, with the development of the
new social and political philosophy in the early ’30s, a
philosophy based on paternalism and a philosophy that
lent itself readily to the institution of a new type of
medical practice that would fit into that new political
and social philosophy.
It was perfectly evident at the time that unless some-
thing could be developed by the medical profession to
preserve the private practice of medicine with all those
attributes that we have pointed to so much, that of
wholesome competition and unrestricted initiative, and
a patient-physician relationship, and others — and so The
Council set about developing some such procedure.
Obviously, they turned to the logical source of such
a development, which was the insurance industry. The
insurance industry flatly refused to have any part of
such a development because of the lack of actuarial data
and statistical information that was necessary in order
to develop plans, contracts, fees, and so on.
So, it left your Council with but two alternatives.
One was to endeavor by their own techniques to develop
some sort of a device, or to succumb to the then actively
developing programs in the Congress. The Council
chose to lose, if they had to lose, by at least trying,
rather than to lose by default; and so they set about
developing what is now Michigan Medical Service.
They had only two commodities with which to work
in the development of this device. One was the par-
ticipation of nearly 90 per cent of the doctors of
Michigan, and the second one was a will and a deter-
mination to solve this rapidly growing economic problem.
And so, by a most cumbersome and inefficient trial
and error technique, but the only one at their disposal,
they came forth with what is now Michigan Medical
Service. Some of you will recall the fact that in the
early stages, by the deficiencies in such a technique of
trial and error, they found themselves many times in
bad shape because it was purely guesswork.
As time went on, and as statistical information and
actuarial data were compiled, it became sounder, and
was on a sound actuarial basis. Incidentally, in this
connection, let me say that it was the actuarial statistics
developed by Michigan Medical Service that subsequent-
ly were utilized by the commercial companies in entering
the field and making the contribution that they have
since made. They have frankly made the statement that
when they did enter the field, they entered it because
they had then acquired actuarial data which were de-
veloped definitely by the Michigan State Medical So-
ciety in its program.
Now, we believe that Michigan Medical Service is
certainly not perfect. We believe that for seventeen
years it has served (as some of us said so many times)
to save the medical profession from the institution of a
governmental program of compulsion as compared to a
voluntary program that is more democratic.
The most important thing that it has done, I be-
lieve, is to have served the public better. What it did
for the medical profession, I would feel, might better
be considered as a secondary result. But for seventeen
years it has served a purpose.
Probably the device in its present form is not now
adequate to serve the purpose of the problems that are
arising due to our changing economic climate. That, I
believe, is probably why today you have been called
into session to determine what, if any, changes should be
made in this device or whatever device is utilized to
solve the problems of 1957.
There are, however, certain points that I should like
to mention in this sketchy presentation. One is the fact
that, first of all, Michigan Medical Service is not an
insurance company. It was developed on the basis that
if the medical profession were to indulge in this activity,
it should stay within its prerogatives, and for that reason
it was developed on the theory of a service plan.
JMSMS
SPECIAL SESSION— MSMS HOUSE OF DELEGATES
As you know, only the medical profession is in a
>sition to render service. A commercial insurance com-
iny can't give service ; all they can give is dollars. All
at the medical profession can give in any program is
rvice. They haven’t funds to give money. And therein
;s the difference between a service plan and an jn-
irance company.
The question has been raised many times that if the
resent device operated by the State Medical Society
ere to become an insurance company, then the medical
rofession might well ask itself if it was exercising its
rerogative to be in the insurance business.
The medical profession from time to time has decried
le fact that corporations practice medicine, and one
ight imagine that the insurance companies might well
,y: If they become an insurance company, what right
ive we as doctors of medicine to be operating an in-
irance company any more than a corporation has to
; operative in the field of medical care?
Michigan Blue Shield is now constituted as the Michi-
in State Medical Society. Its corporation is the House
Delegates elected democratically by the component
lunty societies. The corporate body elects the directors,
) per cent of whom are practicing doctors of medicine,
hey determine the policies based on their knowledge of
'ivate practice as we understand it and have under-
ood it.
The development of Michigan Medical Service over
e last seventeen years has served the purpose of giving
e people a better service at a price they could afford to
ty, and at the same time preserving the private prac-
:e of medicine as a free enterprise.
Had The Council failed in 1939 when this was de-
iloped, those of you who have come into the practice
medicine since that time might never have known
hat the private practice of medicine was, as those of
i knew it who have been practicing for some time,
ou probably would have been practicing under some
heme of compulsion that would have kept from you
e knowledge of what private practice is as you know
today.
We believe that the development of Michigan Medical
:rvice, as has been so often stated, has not only pre-
■nted the medical profession from having been invaded
r governmental agencies, but there are other groups
id other forces at work particularly now. Aside from
at of governmental intervention, we have the pressure
commercial companies, we have the individual pres-
re groups, and of course we have the constant threat
governmental intervention.
It isn't government alone. It does not make too much
fference, I believe, whether it is the government or
ivate agencies or pressure groups. If any of them suc-
ed in directing the practice of medicine, then we will
ive lost a heritage that we believe has been preserved
r us and that has brought us to where we are at the
■esent time.
1 would like to close these remarks, which are just a
etchy review to most of you. about how we got where
2 are, which is simply a condition of status quo from
ir private practices.
The one element is the device we are here to discuss
day, Michigan Medical Service. I think we should
ar in mind also that the responsibility of the State
edical Society or Michigan Medical Service is to pre-
rve, first of all, the over-all practice of medicine for
erybody. I think we must realize that there is only one
inner under which we all. as specialists, as staffs, as
unty medical societies and as rugged individuals can
lly, and that is under the banner given you by your
actor of Medicine degree and the fundamental units
organized medicine.
I think your Council believes that its first respon-
fility is to preserve the over-all practice of medicine,
id that then the problems arising from groups within
e profession have to be handled as equitably as pos-
>le within the realm of being realistic in what we do,
id at the same time keeping the plan actuarially sound.
ine, 1957
The significant factor most often overlooked in this
program is its acceptance by the people of Michigan
and the country. Without doubt the representatives of
Michigan Medical Service have done an excellent job
in presenting the Blue Shield plan, but it is not because
of the supersalesmanship of these representatives that the
Blue Shield plans have grown so vigorously. It is be-
cause the people have wanted the service, and the pro-
tection this plan affords them.
This is a partnership proposition entered into between
the patient and his doctor. Nothing must be done which
will disturb or negate the relationship, because the suc-
cess of the entire voluntary movement is based upon it.
The interposition of any party between the patient and
the doctor is an anathema to both, for socio-economic
and scientific reasons.
Evidently to date the service afforded the patient by
the doctor has been very acceptable to the patient, or he
would not have continued his support of the program.
We who have the responsibility for the administration of
the program have the task of giving all the patients
what they want and are willing to pay for within the
philosophies of the plan.
We are not responsible for acceeding to the wishes of
pressure groups, nor of solving solely by this machinery
all of the social and medical problems involved in the
care and treatment of the healthy and the sick. To at-
tempt to do this would be to accept a responsibility not
intended by the Michigan Medical Service charter, nor
possible within the scope of its financial assets.
The Speaker: Thank you, Dr. Foster.
The next portion of the informational part of this
meeting will be a discussion of various attempts that
have been made to solve the problem. For this part of
the presentation, Dr. Arch Walls, President of the
Michigan State Medical Society, Dr. Donald W. Thorup
of Benton Harbor, delegate from Berrien County Med-
ical Society, and Dr. Max L. Lichter of Melvindale, a
delegate from the Wayne County Medical Society, will
be called upon at this time.
III. VARIOUS ATTEMPTS TO SOLVE
THE PROBLEM
Panel Discussion by
Drs. Walls, Thorup and Lichter
President Arch Walls: The purpose of this panel
this morning is to bring you merely factual information.
These two members, Dr. Thorup and Dr. Lichter, are
from a committee that was appointed by your State
Society to study and review what other plans have been
in existence and what they are doing throughout the
United States. They have done a very exhaustive study,
and we hope by their presentations this morning that
they will be able to give you some factual information
that you will be able to condense and form some
opinions on as to what we are going to do in the
future.
The plans outlined here were selected to represent
various programs in the area of prepaid medical care.
There are, of course, a great number of plans and ap-
proaches in existence, far too many to be detailed here.
For the present purposes it was felt that prototypes of
the various approaches would serve to indicate what
has developed.
The presentation is based upon the following classifica-
tion :
1. Plans controlled by medical societies:
(a) Blue Shield (1)
(b) Windsor (Ontario) Medical Service (2)
2. Plans not controlled by medical societies:
(a) Indemnity
(1) Commercial insurance (3)
(2) Deductible and co-insurance (4)
755
SPECIAL SESSION— MSMS HOUSE OF DELEGATES
(b) Group or closed panel
(1) Health Plan of the Kaiser Foundation
(5)
(2) Health Insurance Plan of New York
(HIP) (6)
(3) Community Health Association (CHA)
(7)
Each plan is outlined under the following headings:
1. What the plan covers.
2. How physician functions under plan.
(a) Organizational structure.
(b) How physician is paid.
(c) How physician works under plan.
Rather than take further time, I will call on Dr.
Donald Thorup to give you his presentation of the facts
and information that he has.
* ■*■ *
D. W. Thorup, M.D. | Berrien]: There has been
distributed to you gentlemen a glossary of terms which
we felt might be beneficial to you in discussing or think-
ing about the various plans that are going to be pre-
sented. As Dr. Walls has said, we cannot begin to
present anywhere near all of the prepaid plans that are
in existence. Consequently, we have selected a few that
we thought were examples of the various types, and we
are presenting those plans in some detail.
This glossary of terms we will run through briefly.
Most of these terms are probably familiar to you.
Participating Doctor. — A doctor of medicine who has
signed an agreement with Michigan Blue Shield to ac-
cept as full payment for his services to Blue Shield mem-
bers the fees as established in the Blue Shield Schedule
of Benefits when the member’s family income is within
the limits of his Blue Shield contract. Currently there
are two income limit contracts and two schedules of
benefits — $2,500 family income and $5,000 family in-
come ceilings.
Participating Hospital. — One that has a contract with
Blue Cross to provide Blue Cross members with all
available services covered in their Blue Cross contracts,
and to look only to Blue Cross for payment of these
services. Blue Cross in turn agrees to reimburse the
hospital for all such services received by Blue Cross
members, according to the payment formula established
by the Blue Cross Board of Trustees. This is a legal
agreement validated by both hospitals and Blue Cross.
Blue Cross Participating Agreement. — The document
which contains signatures of the hospitals and Blue
Cross, specifying the conditions under which a hospital
is a “participating” hospital, and binding the hospital
and Blue Cross to these conditions. These are signed
by the doctor and the hospital agreeing to provide these
hospital services.
Medicare is not particularly germane to our immedi-
ate problem, and is not going to be discussed in detail.
It is a program through which dependents of U. S.
servicemen and servicewomen are entitled to certain
benefits. The program is administered by Blue Cross-
Blue Shield acting as agents in this State.
Service Benefits. — This is a term that you hear a
great deal about. Service benefits are hospital, medical
and surgical services provided by the Blue Cross and
Blue Shield certificates as needed. Payments for these
services are made directly to the doctors and hospitals.
Insured Plans. — We refer here to programs of hospital-
ization, medical and surgical coverage offered by com-
mercial insurance companies that are usually and in
fact almost always on an indemnity basis.
Loss Ratio. — This is the ratio of claims paid to total
income. At present the Blue Shield loss ratio is about
98 per cent.
Fee Schedules. — Also referred to as the Schedule of
Benefits, the Fee Schedule provides payments for services
on a level with what the medical profession regards as
the average fee for the average case for persons within
the prescribed income brackets. These schedules were
developed, as you know, by committees of the Michigan
756
State Medical Society from information secured fron
you, the doctors of the State.
Non-Group Contracts. — These are certificates offerei |
for individual participation in Blue Shield and Blui
Cross.
Group Contract. — A certificate offered to groups o
five or more people. The membership fees are paic
collectively through one remitting agent.
Group Conversion. — The certificate offered to indi
viduals when they leave the group through which the}
have been covered. The benefits are less broad for thi:
type of service and the rates are somewhat higher.
Indemnity. — The term “indemnity,” which we wil
use several times today, is specific cash payments paic
for benefits. These are usually paid directly to the in-
sured, unless he assigns them to the hospital or phy-
sician.
Catastrophic Illness Coverage. — A kind of modifiec
“major medical” offered widely by commercial com-
panies to provide coverage for catastrophic illnesses,
such as poliomyelitis, leukemia, diphtheria, and so on
Major Medical. — These are programs that are pro-
vided for unusually long or complicated cases. They
usually contain so-called deductible or co-insurance fea-
tures; that is, after the basic coverage has been ex-
hausted there is a benefit covered by the patient, and
then subsequently benefits are paid by the member and
the plan together. They share in payment on a pre-
determined percentage basis.
Several terms which you will hear later on when
Dr. Lichter discusses them is the HIP. Health Insur-
ance Plan of Greater New York: the CHA, Community
Health Association, which is being spearheaded here in
Detroit by certain union officials; the Kaiser, or Kaisei
Foundation Health Plan; the Veterans Home Town
Program, with which many of you are familiar, and
the Windsor Medical Services plan, which I will discuss
in some detail.
The terms “experience rating versus community rat-
ing” are extremely important terms in our discussion.
“Experience rating” is a term used to describe the meth-
od by which many commercial companies arrive at rates
for their remuneration. They determine the rate for
each individual group on the basis of utilization of
benefits and fees paid out for these benefits. The result
is that so-called “cream” business, that is, large groups,
particularly those with a high percentage of young
employees or single male employees, the type who least
need and use medical care, are likely to have a very low
rate.
I might point out that these commercial carriers are
not interested in providing services for groups and so-
called associations. They are not particularly interested
in the Farm Bureau, or the medical society, or lawyers’
groups, or nursing groups, and so on — certain poor risk
groups that they are not interested in carrying coverage
on.
Small groups and those with a predominance of older
employees who tend to use and need more medical care
would have an extremely high rate. For them, the rate
is often beyond their ability to pay.
It boils down to the fact that experience rating is
good business for the insurance companies, but bad
business from a community health protection standpoint
and, in the long run. for the doctor. It would leave
the patients, to whom he will be providing the most
care, without a prepayment program. Under this ex-
perience rating concept the rate would be too high for
them to afford, and actually inflict a penalty on poor
health.
On the other hand, community rating, as practiced
by Blue Shield, is a sound social concept. The Blue
Shield rate is determined by the average utilization
of all groups, large and small, and thus represents a
reflection of the utilization of the community as a whole.
In essence, the extremely good risk groups do carry
some of the load of the very poor risk groups, but it
levels out to the average for the entire community.
JMSMS
SPECIAL SESSION— MSMS HOUSE OF DELEGATES
This provides protection at equal cost for all segments
}f the community on a fair and practical basis. It is
lot only good business for the doctor in the long run —
t is the cornerstone of the basic Blue Shield philosophy
if providing the most benefits at the lowest cost to the
nost number of people in the community.
Now, please turn to some of these specific plans,
rhis material is in the booklet that was handed to you,
ir at least a good deal of it will be found there.
The first of the plans is the one with which you are
nost familiar, our own Blue Shield Plan selected as
m example of a nonprofit, medical-society-controlled
ervice benefit plan.
1. Our Plan covers:
(a) In-hospital surgical care.
(b) In-hospital medical care.
(c) In-patient x-rays by schedule. $15 on basic
contracts.
(d) Anesthesia by physician — payment by time.
(e) Emergency first aid treatment and x-ray.
(f) Limited office surgical care.
(g) Maternity — delivery only — flat fee.
(h) X-rays and EKG’s as in-patients. Supple-
mental to basic by rider, unlimited as to
number and in accord with fee schedule.
(i) Hospitalization through Michigan Blue
Cross.
2. Physicians’ function with Plan:
(a) Plan controlled by Michigan State Medical
Society.
( 1 ) Members of the House of Delegates
of the Michigan State Medical So-
ciety are the members of the corpo-
ration.
(2) 33-member Board of Directors — 2/s
must be M.D.’s. Six from Michigan
Hospital Association, balance repre-
sents the public.
(3) All Board members are elected by
members of the corporation, by the
House of Delegates of the State So-
ciety.
(b) Physicians are paid by Plan on a fee for
service basis.
( 1 ) Two schedules of benefits offered to
the public — both of which were de-
veloped by the Michigan State Med-
ical Society and adopted by the Plan
Board of Directors. (Fees paid to
general practitioners and specialists
are the same.) They are considered
as average fees for average cases.
(a) $2,500 Family Income Limit
Plan. ($2,000 Single)
(b) $5,000 Family Income Limit
Plan. ($3,750 Single)
( 2 ) Participating physicians guarantee
that fees for contract benefits paid by
Plan are full payment for persons
with incomes less than the income
limit stated in their contracts.
(3) Plan uses advisory boards from coun-
ty medical societies to recommend
individual fees for specific cases
which fall out of the category of
routine. (Those are also passed upon
by the Medical Advisory Board and
the Board of Directors.)
(c) The physician works as a private practi-
tioner on a fee for service basis. He re-
serves the right to select the patients he
wishes to care for. His participation with
the Plan is optional. He may resign as an
individual from participation with the plan
without penalty.
(d) Plan pays physician directly in all cases.
fuNE, 1957
3. Plan’s current cost to patient:*
(a) Group $2,500 Family Plan for medical and
surgical care is $3.25 per month.
(b) Group $5,000 Family Plan for medical and
surgical care is $4.50 per month.
(c) Plan employes principle of community rat-
ing.
( 1 ) All groups with same coverage get
same rates regardless of utilization
of individual group.
( 2 ) All groups, regardless of type of em-
ployment, or nature of work or age
grouping or race, are all charged
the same rates for like contracts.
(3) Subscriber group contracts do not
exclude pre-existing or chronic con-
ditions.
(4) Deductibles and/or co-insurance are
not written-in features of the Plan’s
contracts.
(5) Conversion privileges to individual
status are available to group sub-
scribers when employment is termi-
nated.
(6) Provision is made to cover retired
workers for same benefits and same
rates as active group when formal
retired group program exists.
Those are the developments of the Blue Shield Plan
as it exists today. As pointed out, there is no penalty
for nonparticipation. This Blue Shield Plan probably
merits some comparison with some of the other Blue
Shield plans. There are in existence Blue Shield plans
controlled by medical societies which do not pay directly
to nonparticipating physicians. In certain plans pay-
ment for nonparticipating physicians is made directly to
the subscriber.
There are Blue Shield plans controlled by medical
societies that are indemnity plans. They make payments
on an indemnity basis solely. Their benefits, by the
way, compare about equally with a good commercial in-
surance company. Any indemnity benefits from any
source may be service benefits if a group of doctors elects
to have them be service benefits. That is, if a county
medical society in Indiana, for example, decides that
the indemnity payment paid by Indiana Blue Shield is
satisfactory, and if they are willing to accept it as a
service benefit, then those indemnity benefits may in
turn be the same as service benefits.
Similarly, a group of doctors can get together and
decide to accept the benefits paid by a commercial in-
surance company; if they do, they then may serve as
service benefits. That is not the customary procedure,
of course.
There has been considerable discussion of more com-
prehensive service, and studies are being made of ways
in which more comprehensive service can be provided
by Blue Shield. It can be done within certain limits.
It will cost more. The cost probably would be 30 to
35 per cent more than the cost for the $5,000 income
limit medical-surgical contract. By “more comprehen-
sive benefits” I mean outpatient surgery, anesthesia,
pathological services, therapeutic radiology, physical
therapy, and a series of diagnostic procedures including
x-rays, EKG’s and metabolism tests.
The figure that I have given you is not an exact one.
It is an approximation, and the actuaries are specific
that they cannot be held exactly to that figure, but that
is their approximation of the additional cost of those
services.
As has been pointed out, Michigan Medical Service
contract has unique features which set it apart from
those held by commercial carriers’ experience rating
and community rating contracts.
*X-ray, EKG and 245-day Medical Rider available
at additional subscription fee.
757
SPECIAL SESSION— MSMS HOUSE OF DELEGATES
The second of the prototypes or services that I want
to discuss is the Windsor Medical Service Plan. This
Plan has been in existence since 1937, when it was
established by the physicians of the Essex and Kent
County Medical Societies.
1. Windsor Medical Service covers:
(a) Hospitalization through Ontario Blue Cross.
(b) In-hospital surgical care.
(c) Office surgical care.
(d) Maternity care ($50 delivery plus pre- and
post-care, at so much per visit).
(e) Medical anesthesia — payment by time.
(f ) X-ray — diagnostic and therapeutic — no max-
imum.
(g) BMR. EKG, refractions, annual medical
examination as outpatient.
(h) In-hospital medical — no limit on number
of visits except as determined on each indi-
vidual case by medical director.
(i ) Consultation, with prior authorization by
Plan.
(j ) Shock treatments.
(k) Diagnostic hospital admissions.
(1 ) Home and office calls.
(m) Waiting periods for T&A’s, hernias, gyn.,
O.B. and refractions.
2. Physicians’ function with Plan:
(a) Controlled by Essex and Kent County Med-
ical Societies.
(b) Board of Directors consists of ten members
— seven M.D.’s and three lay people.
(c) Free choice of physician and fee for serv-
ice based upon a schedule.
(d) Plan pays about 90 per cent of schedule,
when pro ratio of income is adjusted to
services.
(e) Plan fee schedule is about 89 per cent of
Michigan Blue Shield $5,000 Plan.
(f) Specialists are paid higher fees for con-
sultation than G.P.’s.
(g) Non-participating physicians are not paid
by Plan. Payments made to subscribers.
(h) Medical director adjudicates all disputes be-
tween subscribers and Plan and doctors
and Plan — decision is usually final — can ap-
peal to special committee who reports to
the Board.
(i ) Medical director reserves right to deter-
mine adequate amount of medical care, and
Plan pays accordingly. Doctor can’t charge
extra to patient if Plan reduces allowances
if patient is under income.
(j ) The Plan’s board and committees police
itself. Reports are that it effectively re-
duces over-utilization and helps to stabi-
lize rates to subscribers.
(k) Plan may cancel participation of M.D.
(1 ) Plan is full service for families under
$6,500 incomes — usually accepted for ev-
eryone.
(m) 35 to 40 per cent of Plan benefits are
rendered outside hospital.
3. Plan’s cost to patient:
(a) Group plan for a family — $7.90 per month.
(b) Individual plan for a family — $8.50 per
month.
(c) Plan employs principle of community rating.
(d) Plan does not use deductibles or co-insur-
ance.
Among the features of the Windsor Plan, as you will
note, is the feature that the amount of allowable services
is restricted by the Plan’s medical director or com-
mittee. They refer to this practice as “taxing.” Doctors
report their services in much the same manner as
through Michigan Medical Service. A schedule of fees
758
is administered and placed in the doctor’s account for
“allowable” services. The medical director has relatively
great latitude in determining which services are allow-
able. For example, it is within his scope to reduce the
number of medical attendance calls for which benefit
will be allowed if, in his opinion, the doctor reports an
inordinate number of such calls in relation to the dis-
ability and in relation to general standards of care
in the area. As pointed out above, the medical director’s
decision in these instances is generally final. The items
are then placed in the doctor’s account as a charge
against the total fund each month. At the end of each
month the corporation subtracts its overhead ratio,
generally in the vicinity of 10 per cent, from total
charges against the plan from doctors’ accounts. If
doctors’ accounts exceed the revenue, as is generally
the case, a pro rata percentage is established, and this
percentage is paid each doctor against his account in
full and final settlement. We are given to understand
that in practice the doctor receives about 90 per cent
of his account. Nonparticipating doctors receive fees
which are approximately 90 per cent of the schedule
and are at liberty to charge the patient an additional
amount.
Specialists are paid higher amounts for consultation
than general practitioners. In Canada there is gov-
ernment certification of specialists, making them a very
distinct class and making this differentiation more
feasible than it would appear to be the situation in
Michigan. This distinction is readily accepted.
The Windsor Plan is one of the most comprehensive
programs of its type in existence today. It appears to
enjoy a high degree of subscriber satisfaction. Control
of the Plan seems to lie in the right of the corporation
to determine which services will be allowed, and in their
right to settle with doctors according to the sums
available in the funds on a monthly basis.
The fee schedule of the Windsor Plan: A few ex-
amples are given. An office visit to the general prac-
titioner is $3 for the first visit and $2 for the second.
The office visit to a specialist in internal medicine is $7.
The fee for an appendectomy is $100; the O.B. fee is
$50. and pre- and post-natal care is provided on an
office visit basis of $3 and $2.
Finally, commercial insurance contracts, with which
you are familiar and on which we need not spend much
time :
1. Insurance covers:
(a) Hospital insurance, usually on basis of fixed
amounts for room and extra services.
(b) In-hospital medical care per schedules.
(c) Office and hospital surgical care (including
O.B., delivery only) per schedules.
(d) Emergency accident care (includes out-
patient) .
(e) Home and office calls — with and without
deductibles.
(f) Outpatient diagnostic services on a deduct-
ible basis or maximum per year allowances.
(No schedule on x-rays).
(g) Dread disease riders up to $5,000 or $10,-
000.
(h) Major medical coverage — usually inclusive
of all charges for hospital, medical, drugs
and appliances with deductibles and co-
insurance. (No schedule of fees.)
2. Physician’s function with carrier:
(a) Physicians are totally unassociated with
insurance plans and have no voice in policy
decisions covering payments for medical
care.
(b) Insurance plans controlled by stockholders
and lay corporation boards of directors.
(c) Physician is paid on fee for service from the
insured member. Insured member looks to
insurance company for claim. Payment, un-
JMSMS
SPECIAL SESSION— MSMS HOUSE OF DELEGATES
less assigned to doctor, is made to patient.
(d) Each insurance company has a wide variety
of fee schedules which it sells to insurance
consumer. Usually, the one selected is de-
termined by its price to the insured. Fee
schedules range from $100 schedules to
$150, $200, $225, $250, $300, $350, $400
so on.
(e) Insurance plans do not seek fee recommen-
dations from the Michigan State Medical
Society nor do they have county society
fee adjudication boards to assist them in the
determination of fees for unusual and com-
plicated procedures.
(g) Physician reserves the right to choose his
patients.
(h) Insurance plans generally will get together
any kind of a plan desired by a group —
but on an indemnity basis and scaled to fit
a predetermined premium charge.
3. Cost of insurance plans to patients:
(a) Cost varies with level of benefits selected
by insured.
(b) Cost of group contracts is determined by
group utilization since insurance plans use
the principle of risk selection and experience
rating.
(c) Cost of group contracts is also influenced
by type of employment and age grouping.
(d) Usually, conversion from a group status to
an individual status upon termination of
employment is not offered.
(e) Seldom offers same coverage at same rates
to retired workers as are available to active
employees.
(f) Many groups of employees are considered
undesirable by insurance companies and
are dropped or never written by them.
President Walls: Thank you, Dr. Thorup.
Dr. Max Lichter, the next man on the panel, will
ilk to you in regard to some of the other plans that
re in existence throughout the country, such as the
iaiser Plan, the HIP, and a few of the others that
re in some of the smaller areas.
* * *
Max L. Lichter, M.D. (Wayne) : This method of
resentation which Dr. Thorup and I are following was
esigned to acquaint you with what is going on in
irious parts of the country, to provide you with a back-
round which will prove valuable in your own con-
derations of the momentous problems facing the pro-
ission, at least in Michigan. The plans that I am
Ding to discuss represent a departure from the type
lat have been given to you by Dr. Thorup.
The General Electric Comprehensive Medical Expense
rogram is an insured program but, as you will note
hen we detail it, it represents a rather radical depar-
ire for an insured program, and also has in it certain
atures which could prove quite attractive to both
ie physicians and patients.
The Plan went into effect on October 1, 1955, despite
msiderable resistance on the part of union leaders in
lis industry, which represents about the third largest
nployer of people in the Unted States.
Despite the resistance of the leadership of these work-
's, 94 per cent of the employees signed up with the
Ian originally, and when the rolls were opened on
ctober 1, 1956, a total of 99 per cent of the employees
General Electric accepted this Plan.
1. What Plan covers:
(a) It is part of an insurance program pro-
viding life insurance, accidental death or
dismemberment insurance for employees,
weekly sickness and accident insurance for
employees, comprehensive medical expense
for employees and dependents, and mater-
nity benefits for female employees and
dependent wives.
(b) There are two classes of expenses:
(1) Type A covers hospital room and
board, special hospital services re-
quired for medical or surgical care ;
operating room, drugs, dressings and
blood transfusions; anesthetics surg-
ical fees; diagnostic x-rays; infant
care.
The Plan has a deductible feature which is put in
for obvious reasons. Two obvious reasons come to mind.
One is that it is a device to reduce the premium, and
secondly it may be regarded as a device to prevent
overutilization.
Under Type A, the first $25 of expense is paid by the
employee. The next $225 is paid by the Plan. Then
the co-insurance feature begins to operate, and the em-
ployee pays 15 per cent with the Plan paying 85 per
cent.
(2) Type B. Outpatient feature of Plan.
Covers services of physicians, includ-
ing specialists, other than for surg-
ery ; diagnostic laboratory work not
covered under Type A ; x-ray and
radium treatment not covered under
Type A. Oxygen and administration
thereof not covered under Type A.
Blood transfusions not covered under
Type A. Services of most registered
graduate nurses; drugs and medi-
cines requiring prescription ; rental
of such equipment as iron lung;
artificial limbs.
In any one calendar year the first $50 is paid by
the employee. That is per individual, not per family
or per contract ; it is the first $50 for any one person.
Above that, the Plan is strictly co-insurance, with the
employee paying 25 per cent and the Plan paying 75
per cent.
(3) Combined maximum benefits for
Type A and Type B expenses for
each covered individual — $15,000 in
total with maximum of $7,500 in
any one calendar year.
(4) Benefits determined separately for
each individual. Employee pays no
more than first $50 for any combi-
nation of both Type A and Type B
expenses for any one covered person
during any one calendar year.
(5) Benefits for semi-private hospital ac-
commodations are provided without
dollar limit.
(6) Maternity benefit (in lieu of ALL
OTHER benefits):
Normal delivery — $150. This is not
necessarily a fee to the doctor;
this is regarded as an indemnity
payment to the patient in lieu of
all other benefits.
Caesarean — $225
Miscarriage — up to $75
For severe complications of preg-
nancy or resulting from childbirth,
Plan pays 75 per cent of amount
exceeding $150 (paid by em-
ployee) up to $5,000 for any one
pregnancy.
(7) Psychiatric treatment out of hospital
will be paid by Plan up to 50 per
cent. If in hospital, benefits will be
paid on basis of Type A and Type B.
2. How physician functions under Plan:
(a) Organizational structure
( 1 ) Through Metropolitan Life Insur-
SPECIAL SESSION— MSMS HOUSE OF DELEGATES
ance Company. In effect until Oc-
tober 1, 1960.
(2) Care is furnished through regular
private practice channels. Patient
has complete free choice.
(b) How physician is paid
( 1 ) Physician is paid his usual fee for
service rendered, subject to deduct-
ible and co-insurance provisions of
Type A, Type B, and maternity
benefits coverage.
(2) Physician collects employee’s por-
tion of fee directly, and Plan’s por-
tion from the insurance carrier.
(3) There is no fee schedule. Benefits
are based upon fees which are
“reasonable, necessary and custo-
mary.”
(c) How he works under Plan
( 1 ) Physician’s cooperation is essential to
success of Plan. Must guard against
taking unfair advantage of the in-
surance program. As Elmer Hess
has said, “Insurance per se . . . does
not create new wealth and ... is no
justification for increasing an other-
wise reasonable fee for a professional
service.”
( 2 ) Physician renders his service upon
usual basis of private practice.
Necessary consultations are per-
mitted. Surgical assistants are paid.
Services can be rendered in the hos-
pital, in the office, at home — wher-
ever physician feels the patient will
receive best care.
3. How much employee pays:
(a) Is based upon whole Insurance Plan. He
buys one package.
( 1 ) For employee alone, 0.9 per cent of
normal annual straight-time earn-
ings.
( 2 ) Comprehensive medical expense in-
surance and maternity benefits for
dependents, additional 2 per cent of
normal annual straight-time earnings.
(3) Example: Employee earns $6,000
per year straight-time wages. Cost
of Plan: Individual employee, $54.
Employee and dependents, $174.
This is for entire package.
(4) Balance of cost paid by General
Electric.
(They pay, I am told, at least 50 per cent, and I have
heard the figure of two-thirds.)
As I said earlier, this is an attractive plan, one which
requires the cooperation of physicians. In Berkshire
County, Massachusetts, where there are a fair number
of General Electric employees, the County Medical So-
ciety has taken it upon themselves to establish a com-
mittee to police the operation of the Plan.
As you may know, just last month the Wisconsin Blue
Shield Plan offered three contracts which in principle
are similar to the program that General Electric is using.
These three programs were based upon the experience
obtained in Racine, Wisconsin. We can’t tell you too
much about it because there has not been an opportunity
to investigate the program initiated by Wisconsin, but it
certainly is one that deserves a lot of consideration.
The next plan that I think is of interest to you is the
one that is sponsored by the Kaiser Foundation.
1. What Plan covers:
(a) Diagnosis and treatment (surgical and med-
ical) in hospital and home and office, by
specialists, with no limits on number of
visits, physical check-ups, pediatric care,
eye examination for glasses.
760
(b) Dependents pay half of x-ray and laboratory
fee in most contracts.
(c) Tonsillectomy $15 extra for subscriber to
$35 extra for dependents.
(d) 111 days’ hospitalization for subscriber; 60
days for dependent, with additional 51 days
at half private rate.
(e) $1 for each office visit (except in some
contracts where for an additional premium
this charge is prepaid). $3.50 and $5 house
call charge, depending on time of day.
(These charges of $3.50 and $5 for a house call were
put in mainly to provide additional revenue for the
group that operates the medical aspects of this Plan. It
provides no deterrent aspect, and when this was dis-
cussed with the Kaiser people their studies indicated that
the $1 had no particular effect on the utilization in-
cidence.)
(f) Obstetrics $60 for subscribers; $95 for de-
pendent after ten months’ membership.
(g) Pre-existing conditions covered at half
private rate in most groups. (This is just
for the subscriber. By “subscriber” here I
mean the man who is a member of a par-
ticular group.)
(h) Drugs and appliances not furnished. (They
can be purchased either at the clinics or
hospitals that have been set up, and the
cost is about 10 per cent less than one
would pay in the drug store of his own
choice.)
(i) Free choice of physician within group. (If
the patient is not satisfied with the physi-
cian to whom he was assigned, he can
choose another physician within the group;
this, however, has led to some embarrassing
situations to both the physician and pa-
tient.)
(j) Special provision for care outside service
area, in which the Plan pays up to $250 for
expenses incurred. (In order to beat that
cash outlay they have been known to send
airplanes to pick up patients and bring
them to their own hospital. )
2. How physician functions under Plan:
(a) Organization Structure
(The organizational structure is rather
complicated and difficult to understand.
Apparently it has undergone some changes
in the past few years.)
(1) Kaiser Foundation. Is a nonprofit
organization, interested in many
areas of philanthropy.
(2) Kaiser Health Plan (is regional).
Three regions, one in the Northwest,
the Portland-Vancouver area; one in
the San Francisco Bay area, and the
third in the Los Angeles area. Plan
in these regions contracts with doc-
tors and hospitals for services on be-
half of its subscribers.
(3) Kaiser Foundation Hospitals own all
hospitals and clinic buildings and
rent space to doctors. (These were
turned over to this new organization
several years ago.)
(4) Permanente Medical Group in Bay
area has 300 physicians (determined
on basis of one physician per 1,000
patients), about 70 of whom are
partners and balance are salaried.
(Apparently the Health Plan does not interfere with
the group in the type of medical care rendered. They
merely contract for service; but as nearly as we can
determine, there is no intrusion of the Plan into the
professional aspects of medicine. The third party rela-
JMSMS
SPECIAL SESSION— MSMS HOUSE OF DELEGATES
:ionship here is off to one side, and is purely a financial
>ne.)
(b) How physician is paid
( 1 ) Group is paid a capitation fee by
Plan. Extra charges to member as
well as fees from private patients ac-
crue to Permanente Group.
(2) Physician is employed initially on a
salary basis.
For example, it is easy to get internists. They will
hire them for a lesser salary than they might hire sur-
geons. If they hire a thoracic surgeon, and if they are
hard to come by, he might be engaged at an initial
salary of $1,500 a month. Their current salary for new
internists is $900 a month, and for surgeons $1,000 a
month.
After three years of satisfactory service, the physician
may become a participant in the group. As a participant
he is entitled to a certain portion of any profit or excess
over operation that the entire group accumulates. After
a two-year period he may purchase a partnership in the
group. That runs somewhere around $7,000 or $8,000.
The income of the partner depends upon his seniority
and also upon the degree of responsibility he has in the
group. All department heads, for example, are not paid
the same salary, but as a partner they share alike and to
a greater extent than participants in the profits.
(c) How physician works
(1) Group divided into specialty services
in each facility, each headed by a
chief. There is intra- and inter-serv-
ice consultation, and this is encour-
aged. Practically no general practi-
tioners are employed.
As far as I could determine, in the Bay area they
employ two general practitioners who are in the Depart-
ment of Medicine. The rest of the operation is strictly
by specialists who are either Board certified or Board
eligible.
(2) They work 5 Vi days a week or, as
they put it, eleven halves in a week.
They see patients in their own serv-
ice by appointment. All administra-
tive details are handled by ancillary
assistants.
(3) House calls, night and emergency
service are rotated among the junior
members.
(4) Vacation periods, educational privi-
leges, etc. depend upon the physi-
cian’s status with the group.
3. How much it costs the patient:
(a) This depends upon the class of coverage.
The examples are based on family unit.
Group — Same benefit for subscriber and de-
pendents, $14 per month. Group — Sub-
scriber benefit and usual dependent, $11.4-0
per month. Non-group (equivalent to usual
dependent benefit and for subscriber and
dependents), $11.80 per month.
(b) Groups pay $2 registration fee
(c) Non-group (family) pay $4 registration fee
and $3.50 medical, review fee.
(d) Approximately 600,000 members.
The Speaker: May I ask the members of the House
to write out your questions, and either send them to the
front of the room or hold them up so they may be col-
lected. We have asked the Vice Speaker, Dr. Lightbody,
if he will take these questions and combine them so that
when we come to the question and answer period this
afternoon there won’t be a lot of overlapping. As soon
as you have written your questions, hold them up so
that they may be collected, or bring them to the front
of the room.
M. L. Lichter, M.D.: The next plan of interest is
the Health Insurance Plan, HIP.
June, 1957
1. What Plan covers:
(a) Complete care including home, office and
hospital by general practitioners and spe-
cialists.
(b) Outpatient diagnostic and laboratory pro-
cedures.
(c) Eye examinations, visiting nurse service,
periodic health examinations, immuniza-
tions.
(d) House calls at patient’s request between 10
p.m. and 7 a.m. at extra charge of $2.
This is only extra.
(e) Free choice of group and then of physician
within group.
2. How physician functions under Plan:
(a) Organizational structure
(1) A central “headquarters” which col-
lects dues, disburses to physician
groups; sets standards for initiation
of groups and maintenance of stand-
ards of medical care ; develops ap-
propriate statistics; develops system
of patient records and maintains
their completion and collection; in-
itiates subscriber as well as physician
educational programs relative to the
plan; conducts surveys concerning
utilization and quality of medical
care furnished members; administers
a pension fund set up for physicians.
(In this respect the central head-
quarters intrudes itself between the
physician and patient.)
(2) Physicians form autonomous medical
groups and approach plan for par-
ticipation. Must conform both in
composition and physical facilities to
criteria laid down by plan. Groups
are partnerships with additional phy-
sicians on a salary basis. Limited in-
frequently used specialties paid on a
fee basis through a special fund con-
tributed to by all groups. Groups
must finance own building and
equipment. Criteria, in addition to
basic, further depend upon number
of persons group contemplates caring
for. All groups are responsible to
central office through a 15-member
medical control board, a policy-
establishing mechanism. (The groups
do not have any interrelationship
other than as spokes of a wheel
radiating toward the central head-
quarters, which is the hub.)
(b) How physician is paid
( 1 ) Group receives annual per capita fee
of $31.20 (at present) for each
member who elects to use group.
(This is not only for each member
but also for each member of the
family.)
(2) After administrative and operating
expenses are paid, as well as salaries,
collected funds are apportioned to
group partners on basis of respon-
sibility, training and seniority.
(c) How physician works under Plan
( 1 ) Almost all physicians work in Center
part-time. (One exception in the
group sponsored by the hospital in
New York.) Most have own private
office for private practice, but even
here many will see HIP members.
Only one group is composed entirely
of full-time physicians, as it is asso-
ciated with a hospital.
(2) As far as possible, each patient is
761
SPECIAL SESSION— MSMS HOUSE OF DELEGATES
first seen by a general practitioner
(who represents about 40 per cent of
the 1,100 men in the plan), who
serves as the personal physician and
who acts as the referral agent and
is responsible for follow-up of treat-
ment as well as the patient’s com-
pliance with consultative referrals.
(3) House calls rotated through partners
of group with main responsibility
falling on general practitioners.
(4) Patients are seen by appointment
with physician of choice. New pa-
tients are assigned on rotation. Pro-
vision for emergencies and drop-ins.
(5) Non-members seen at Center with
fees based upon a schedule and ac-
cruing to group. Part-time physi-
cians (even partners) conduct pri-
vate practice in own separate office.
(6) Hospital care is given at hospital of
which physician is a staff member or
where he has privileges.
(7) Group contracts with central office
to furnish agreed medical services to
members.
3. How much Plan costs patient:
(a) Standard plan, designed for individuals
with base salary of not more than $6,000
or families with income of not more than
$7,500, has monthly cost of $3.56 for in-
dividual; $7.56 for couple, and $10.68 for
family. At least one-half must be paid by
employers.
(b) Subscriber earning more than in standard
plan pays 20 per cent more.
(c) Usual enrollment is group of 10 or more
subscribers, though recently individual en-
rollment in apartments or housing projects
has been undertaken.
(d) All subscribers must carry own hospital in-
surance and it must be Associated Hospital
Service of New York (Blue Cross).
The next plan is the Community Health Association,
or CHA. Unfortunately, we have had to be quite vague
in our presentation, because while we have heard much
of what they are going to do, we have not been aware
of any plan in which they outline precisely what is to be
offered, and how.
All information relative to this plan should be re-
garded as hearsay, although much probably represents
what will prove to be definitive.
1. What the Plan covers:
(a) Apparently the coverage will be compre-
hensive in home, office and hospital with
diagnostic and laboratory service. There is
no information concerning exclusions.
There is no information concerning extras.
There is no information concerning status
of dependent coverage.
(b) Apparently plan is based upon combination
of features of HIP and Kaiser Plan. At
present it is said that CHA does not con-
template building own hospitals. (The
present plan is that physician members of
their organization will utilize the hospitals
in which they now have membership or
privileges.)
(c) Apparently premium will include hospital-
ization. It may be that CHA will then
negotiate for hospitalization directly with
hospitals (though on what basis is presently
not known) or will purchase hospitalization
from Blue Cross.
(d) It is said that, in beginning, CHA will
start on a small-scale experimental basis.
One local union (for example) will be of-
fered the plan. Within this group there will
be further offered to the individual union
member the choice of accepting CHA or
continuing his present plan (or any modi-
fication thereof). It is said that this type
of choice will always be a policy of the
LTAW-CIO. It is said that CHA eventually
wishes to offer its plan to any member of
the community.
2. How physicians function under Plan:
(a) Organizational structure
( 1 ) CHA will have a board of directors
who will decide and control every
aspect of the plan.
(2) There will be a CHA medical direc-
tor, responsible solely to the board.
His responsibilities have not been an-
nounced.
(3) Apparently there will be “built-in
mechanisms to make possible the
rendering of high quality medical
care.” (We put that in the form of
a quote because those are words that
Walter Reuther used.) It may be
that this will be accomplished
(policy-wise) by the establishment of
a medical advisory committee (to
the board) built around a university
medical center. This committee,
having no executive function, pur-
portedly would be sensitive to trouble
spots, advise on standards and poli-
cies, have no vested interest, and
would eliminate local politics. It
would screen all physicians having
an integral role in the program.
(4) Groups of physicians would be estab-
lished to provide services of plan.
There is no information concerning
criteria for establishment of groups,
financing of group facilities and
equipment, or minimum number of
members a group must care for.
However, it has been suggested to
the Board that it is dangerous to
permit groups to have total autono-
my. Hence, the group medical di-
rector, its executive officer, should
have the title of associate medical
director of the plan.
3. How the physician is paid:
(a) No official pronouncement has been made.
Best information at present is that all phy-
sicians will be on a salary, to be paid di-
rectly by the CHA. (We have also heard
that a capitation system is contemplated,
but we don’t know which.)
(b) No information is available from any
source concerning care of nonmember (or
private patients) and fees so derived.
4. How physician works :
(a) No details are available. It is presumed
that the 4-0-hour week will provide the
basis for working hours. (We make that
presumption because it is a presumption of
the union regarding working hours.)
(b) All of the standard reasons for attracting
physicians to this type of group practice
have been mentioned at one time or an-
other.
(c) Apparently the general practitioner will be
“the cornerstone” of medical care, as advo-
cated by HIP.
(d) All physicians, presently having hospital
staff appointments or privileges, will be ex-
pected to maintain them and utilize them
762’
JMSMS
SPECIAL SESSION— MSMS HOUSE OF DELEGATES
for the members of the plan. Hospitals,
apparently, will be expected to see that
staff membership or privileges are not
jeopardized by the physician’s participation
in a group under the CHA plan.
(e) No information is available concerning the
actual functioning of physicians within the
plan or the groups. It would seem, how-
ever, that “the quality of medical care”
furnished by each physician will be subject
to constant scrutiny as well as periodic
evaluation. What this is intended to mean
is not clear as yet.
5. How much it will cost patient:
(a) There is no information, or even faint hint,
on this subject. It is thought, however,
that costs will be competitive with existing
plans of Blue Cross-Blue Shield and com-
mercial insurance.
You realize, of course, that there are other plans we
could have discussed — The Ross-Hoos plan — what the
physicians did in San Pedro, California, when faced with
the impact of the Kaiser Plan— how the Palo Alto
Clinic operates, and so on. We could have discussed the
very fine approach taken by the San Joachim Medical
Society doctors in California, but I feel we have be-
labored you long enough, and at least we have (I hope)
achieved our purpose of providing you with some back-
ground.
We could have discussed the differences and relation-
ships of these various plans to each other, but I am sure
with the material presented to you you can do this for
yourselves.
President Walls : I think a great deal of credit
should be given to these men and their committee for
the amount of factual information they have presented
to you this morning. I hope the information they have
given you will form a background on which you can talk
more freely and ask more intelligently the questions and
discuss more intelligently this afternoon the problems
that we have and that are going to face us.
The Speaker: I would only like to emphasize what
Dr. Walls has said. Certainly, you gentlemen of the
House would be completely blase if you did not appre-
ciate the tremendous amount of work which has gone
into the preparation of this presentation at this special
session of the House of Delegates.
We in the State of Michigan are very fortunate to
have a man who has made a study of insurance for a
great many years. I wonder if you also know that be-
side being Executive Vice President of the Michigan
Medical Service, Mr. Ketchum is a former member of
the Advisory Group to the Hoover Commission on Pre-
paid Medical Insurance. He is also one of the two lay
members of the AMA Advisory Committee to the Coun-
cil on Prepaid Medical Insurance.
IV. WHERE WE ARE NOW
Address by Jay C. Ketchum
Michigan Medical Service (Blue Shield) now provides
coverage for medical-surgical expense, according to its
various contracts, to almost one-half of the people of
Michigan, some 3)4 million. The benefits of coverage
have been (with some exceptions) limited to hospitalized
cases.
There has been voiced an increasing desire for exten-
sion of coverage into the diagnostic services without the
requirement for hospitalization. Demands for extension
of benefits to other than hospitalized cases are heard,
not only from large numbers of subscribers but from
many physicians as well.
Certainly, restricting payments to services rendered to
in-hospital bed patients does affect medical practice, par-
ticularly as to minor surgical and diagnostic procedures.
Coverage for long periods of hospitalized illness, includ-
June, 1957
ing convalescence, has been requested. In the main, but
by no means exclusively, there have been requests for
adjustment of our service income ceilings to more near-
ly reflect present economic conditions, voiced by the
representatives of large organizations of our subscribers.
A spokesman for Labor, Dr. Morris Brand, last De-
cember in the AFL-CIO News stated Labor’s aim in
the field of prepayment for health care.
Dr. Brand stated that since Congress has not enacted
legislation to set up a national insurance program —
which most labor unions favor — unions have had to find
other sources of health insurance coverage for their
members, mainly Blue Cross-Blue Shield and commercial
carriers.
However, Dr. Brand continued, since home and office
care are rarely offered in these plans, some labor groups
have established direct service medical centers where
services are actually provided rather than cash indem-
nities to cover part of the costs. The latter type of plan
has proven more popular with members because there
are no barriers to the service, preventive services are
usually included in the benefits, and there are no hidden
bills cropping up after the services are rendered.
In general, Dr. Brand feels that “The extent to
which commonly available insurance programs meet a
family’s health needs is not too impressive to Labor.”
He says that indemnity payments are “not a satisfactory
method of paying for services and are a base upon
which some physicians too frequently add substantial
charges. Also, the emphasis on hospital and surgical
coverage, as in the case of most plans without substan-
tial outpatient benefits, is frequently a cause for un-
necessary hospitalization. Also, as a result of inadequate
concern for operating efficiency in hospitals and an un-
willingness to enforce legitimate controls, there are un-
justified premium increases.”
According to Dr. Brand, these are Labor’s goals for
better health plans:
“1 — Complete prepayment for medical care without
co-insurance and deductible features and hidden added
costs.
“2 — Comprehensive benefits — only if the range of
health services is complete will the individual’s health
needs be effectively and economically met.
“3 — Rational organization of medical services — on the
basis of group practice, and
“4 — Control of the quality of medical services which
must be built into medical care plans.”
Mr. Walter Reuther, in his President’s report to the
UAW 16th Constitutional Convention, April, 1957,
confirmed Dr. Brand’s statement.
Efforts to develop a $6,000 family income ceiling
service contract have consumed so much time and, in
relation to the fees proposed therefor, would require
subscriber rates of such amount, that we are led to be-
lieve the results would not be acceptable to the in-
terested subscriber groups.
The minimum benefits needed right now to satisfy the
market seem to be approximately as follows:
Surgical services, in or out of the hospital.
Obstetrical services, in or out of the hospital.
Medical (non-surgical) services in the hospital.
Anesthesia services, in all surgical cases.
Diagnostic radiology, in or out of the hospital.
Therapeutic radiology, in or out of the hospital.
Physical therapy, in or out of the hospital.
EKG. BMR, EEG, EG, in or out of the hospital.
Pathological tissue examinations, in or out of the hos-
pital.
These services to be limited only by the applicable
scheduled fees.
Coverage for the services of consultants and surgical
assistants is also desirable but presents difficult problems.
Extensions of benefits to those services performed out-
side of the hospital present unique problems in that
certain elements of control of utilization inherent in the
hospitalized case are not present outside. Conventional
insurance methods toward control, such as deductibles
763
SPECIAL SESSION — MSMS HOUSE OF DELEGATES
and co-insurance, might provide a degree of control and
reduction of subscriber dues.
These methods, however, appear to be unacceptable
in health care prepayment to the representatives speak-
ing for many of our subscribers.
It is extremely difficult, if not impossible, to determine
at what point a particular deductible amount or co-in-
surance percentage becomes not just inhibitive as to
elective use, but, in effect, prohibitive as to utilization of
needed services. These representatives insist that con-
trol of utilization must be assumed by the profession and
the hospitals.
Deductible and co-insurance would undoubtedly re-
ceive much more acceptance if the maximums contem-
plated by our service schedules were certain of ac-
ceptance. It seems obvious that assurance of acceptance
of our schedules of fees can be given only if there is
some arrangement for some form of evaluation of charges
by the profession.
An experiment by Blue Shield in Wisconsin provides
for payment of physicians’ usual and reasonable charges.
Fee schedules as such have been completely abandoned
(in this experiment). However, the Medical Society has
assumed the full burden of evaluating charges, even to
entering into court cases as co-defendant with the patient
against what are considered unreasonable charges.
The scope and nature of benefits provided by Blue
Shield are not the only shortcomings complained of by
some of our subscribers. Mostly, these are regulations
of Blue Shield activity caused by its relationship to, and
the attitudes of, the medical profession.
There is, for example, the difficulty the subscriber
experiences in determining the participating or non-
participating status of a particular physician. It seems
unfair to our subscriber when we promise service bene-
fits and then seem to refuse to assist him in receiving
the benefits.
It is just as difficult to demonstrate to many of our
participating physicians that there is any justification for
participation when the non-participating physician con-
tributes nothing to the success of the Plan but enjoys
its advantages. It is equally difficult to explain our at-
titudes toward other practitioners, such as dental sur-
geons, chiropodists and osteopaths, who legally render
service covered by our contracts, who are willing to
abide by our terms of participation, but who are not
permitted that formal arrangement with Blue Shield.
The concept of providing prepayment for only the
very lowest income classes has been rejected by most of
the public. Many persons and groups of persons are
convinced of the propriety and value of prepayment re-
gardless of incomes, and are unable to understand why
the profession is wary of dealing with all members of a
group on a service basis.
The insurance companies in this field have under-
written coverages for large numbers of people. The
coverage, quite similar to Blue Shield as to type and
scope, is of course provided on the indemnification basis.
The acceptability, to many groups, of the indemnity in-
surance is primarily based on price competition.
It is standard practice in the health insurance indus-
try to promulgate rates for a particular group of as-
sureds in relation to the experience of that group. The
result of this practice is that, based on price competition,
much of the preferred (or so-called “cream”) business is
underwritten by insurance companies.
Michigan Medical Service, being committed to pro-
vide the greatest good to the greatest number at a fair
cost, utilizes what is commonly referred to as community
rating; that is, for identical coverage identical rates are
charged. This makes it possible for all, regardless of
age, composition of group, race, occupation, and so on,
or experience within a particular group, to enjoy pro-
tection at an average cost for all in the community in
which Blue Shield operates.
The practice of experience rating, carried to its ulti-
mate conclusion, can result in many of the people, the
764
preferred risks, being removed, for rating purposes, from
the total community (the total average). Thus, the re-
mainder, being not so preferred, must bear a higher
proportion of the total cost of coverages.
This higher proportion of cost will, as it increases,
become an effective prohibition to some, particularly the
aged and lower income classes. When these can no
longer afford to secure voluntary protection, they will
look elsewhere, perhaps to government, for a method.
That the traditional insurance approach, based on a
profit motive, has failed to restrain government inter-
vention, has been demonstrated in other lines of
coverage.
While not the only example, the necessity for states
to establish governmental controls, monopolistic funds,
openly competing state-operated underwriters and re-
straining laws in workmen’s compensation, is illustrative.
A comparatively new form of health care coverage,
the so-called “major medical” contract, is receiving con-
siderable acclaim in insurance circles as the answer to
Blue Cross-Blue Shield competition. This form provides,
subject to a deductible provision, from $100 to $500 but
sometimes as low as $25, and co-insurance above the
deductible at 20 or 25 per cent but sometimes as low as
10 per cent, on almost all types of care of a patient, in-
cluding hospitalization, physician, surgeon, drugs, ap-
pliances, convalescence, private duty nursing, and so on,
at home, doctor’s office, and so forth.
The only other limitation of any concern is related to
time, during a period of one, two, three years or even
longer, for a total aggregate cost, unallocated as to type
of $5,000, $10,000 or even $25,000. In one case we
know of, there is no time limit and no dollar limit.
This, at first glance, seems to have a great deal of
merit. However, students of the problems of the total
population concerned with the final effects on medicine
are aware of grave danger. Remember that the aggre-
gate maximum amounts are not allocated, and no limit
is placed on any one item. The individual charges by
individual doctors, hospitals, nurses, and so on, are ex-
pected to be reasonable.
It is unlikely that there will be many flagrant abuses
(although some have been reported) of the open-end
provisions as to fees or charges. The real danger in
“major medical” lies in the possibility or perhaps the
probability (already well documented) of a gradual but
nonetheless appreciable and consistent increase in charges
for each service, simply because of the existence of the
insurance.
Such increase, accumulated in the costs for each unit
of millions of services, can ultimately effectively raise
the cost of medical care to the point of creating the de-
mand for intervention, the very thing which the public
and medicine has hoped to avoid by reliance upon in-
surance and prepayment.
Demonstrating that some representatives of our largest
groups of subscribers are aware of the dangers, there is,
among many examples, the evaluation of “major med-
ical expense insurance” by Jerome Pollack of the UAW-
CIO, Department of Social Security. He says: “The
insurance is without valid controls to prevent an un-
warranted inflation in health service costs.” His entire
statement of conclusion is extremely informative and
should be referred to.
The closed panel practice prepayment schemes, of
which we have varying degrees of intelligence, consist
of mechanisms whereby groups of professional persons
are brought together under a single management to
provide services for certain eligible people or groups of
people. The arrangements between the management and
the professional personnel may vary from salaried to per
capita (or capitation) ; may be full- or part-time; equip-
ment and facilities may be furnished by management or
the professional individual. Control and status may be
determined by professional personnel, by management
and professional representation, or exclusively by man-
agement.
JMSMS
SPECIAL SESSION— MS MS HOUSE OF. DELEGATES
These groups may provide limited type and scope of
renefit or up to almost all inclusive services. They may
)r may not require some payment at time of service in
iddition to prepayment dues. Many plans of this nature
lave been explained to you in considerable detail al-
ready this morning.
Much can be said of the advantages and disad-
vantages of these schemes, both from the professional as
well as from the patients’ point of view. There can be
definite effects on the quality of medical care, on the
patient-physician relationship, and on the freedom of
physicians to practice good medicine.
Voicing my opinions in this matter would help you
but slightly, if at all. You have an adequate knowledge
of your own on which to base judgment, individually and
collectively. I might add that the increasing rate of
organization of this type of plan is, to my mind, an
indication of dissatisfaction with the currently available
plan.
There are plenty of examples of government provision
of personal medical care. The most recent and dramatic
example is Medicare, the program for provision of care
for dependents of servicemen. This program, admin-
istered in Michigan by Blue Cross and Blue Shield, was
adopted after long study by many interests, including
your American Medical Association.
It can be said that the program, as finally instituted,
was at best a compromise. Effective July 1, this year,
the government, by grants-in-aid to states, will assume
further obligations for medical care by virtue of the
Welfare Act of 1956, for four more categories of its
citizens. Under consideration in the present Congress is
a proposal for the government to provide certain health
care benefits to the beneficiaries of Old Age Survivors
Insurance.
The people have been told that voluntary methods can
provide the answers. The voluntary plans have shown
great ability so far, and have led the people to expect
more and better results. If the medical profession wants
Blue Shield as its method in preference to other alterna-
tive attempts, and if Blue Shield is inadequate for cur-
rent needs, then change or expansion must make it
adequate.
Blue Shield can do the job, but it can do only what
the profession wills it to do. It can be only what medi-
cine and the public want it to be. Blue Shield in
Michigan is a joint responsibility of medicine and the
public, and will work as well as and only as well as that
cooperation will permit.
Certainly the public has the responsibility to voluntary
prepayment plans in that they themselves do not demand
more than they are entitled to or need. Michigan Medi-
cal Service is medicine’s responsibility in Michigan.
Medicine obtained the franchise, organized, and operates
Michigan Medical Service.
Only if the medical profession is convinced of the
value of the service benefit approach under the aegis
pf medicine on a fee-for-service basis, with free choice
of physician — only if the profession is convinced that
this is the most acceptable device — only if the profes-
sion is convinced of the value of our voluntary, work-
able plan as an alternative to the various other schemes
in existence and potential — only if the profession is
willing to do what is necessary to make its plan work —
should you continue to sponsor and concern yourselves
with Michigan Medical Service.
If you are convinced of these things, then you must
take an active part, acquire the necessary knowledge
of the program, make decisions, and be willing to sup-
port them with a unified effort in co-operation with the
public.
It is not sufficient that the profession express itself
critically and with many voices. We will be unable to
completely satisfy fifty-five county medical societies and
eighteen or nineteen different specialty groups with
oftentimes somewhat divergent, if not opposing, views.
The profession must communicate with all segments, all
June, 1957
the many specialty groups, all the components, all the
individual physicians.
It must consider all the different interests, and evalu-
ate all the special problems. It must agree, compro-
mise and reach decision. It must then direct and sup-
port united action in behalf of all the profession.
The only banner about which all of medicine can
rally is that of its parent society — first, the AM A; sec-
ond, the state societies; third, the county societies, and
then the specialty groups.
Dr. Austin Smith, Editor of the Journal of the AMA,
at Lansing on March 6 of this year made a strong plea
for all doctors and all segments of medicine to resolve
their differences and join hands in a united effort to pre-
vent the catastrophe that has overwhelmed the public
and the profession in many other countries.
Dr. Dwight Murray, in his Presidential Address to
the AMA at Seattle last fall, warned: “No nation can
merely reap the benefits of freedom; it must also sow
the seeds of freedom. In medicine the situation is the
same. If an apathetic profession takes its freedom for
granted, it will be the beginning of the end. . . .
“The day has come, gentlemen, when we can no
longer look upon medical economics and social changes
merely as issues to be considered during our limited
leisure hours. . . . We must now pay daily attention
to these matters. . . . They must be a vital part of our
life.”
The Speaker: Thank you, Mr. Ketchum.
Without further ado, we shall recess the morning
session. We shall reconvene immediately at 1:30 p.m.
(The meeting was recessed at 12:30 p.m.)
SATURDAY AFTERNOON SESSION
April 27, 1957
The meeting reconvened at 1:45 p.m., K. H. Johnson,
M.D., Speaker of the House of Delegates, presiding.
The Speaker: Is the Credentials Committee ready
to report?
A. B. Gwinn, M.D.: Mr. Speaker, there are 108
delegates seated at this session, 50 per cent of whom
are not from any one county. This constitutes a quorum.
The Speaker: I therefore declare this second session
of this special meeting in order.
I would like to announce that there is a total regis-
tration of 173, broken down as follows: 111 delegates
and alternate delegates, twenty out of twenty-six mem-
bers of The Council, and thirty-two county society offi-
cers and guests. All county medical societies are repre-
sented by delegates with the exception of six.
The next presentation will be by Dr. George W. Slagle,
President-elect of the Michigan State Medical Society.
His subject will be, “What Road Do You Want to Fol-
low?”
V. WHAT ROAD DO YOU WANT TO
FOLLOW?
By G. W. Slagle, M.D.
Time passes slowly, steadily and inexorably. The
previous speakers have brought us along this trail of
voluntary prepayment health insurance from the time it
was a gleam in its daddy’s eyes, through its fetal life,
birth, childhood, adolescence and maturity. We have
heard the story of Blue Shield, of private carriers, of
closed panel plans, and of projected union plans. The
facts of life, in so far as these problems are concerned,
have been placed before you.
This leads us to a forking in the road. Which road
do we want to follow? Do we want to adjust our think-
ing and planning of Blue Shield to present-day needs
and make it even more successful than in the past, or
do we want to disregard the warning clouds on the
horizon and lose our plan — the doctor’s plan — by
default?
765
SPECIAL SESSION— MSMS HOUSE OF DELEGATES
As has been stated many times today, Michigan Medi-
cal Service is the fiscal agent for the Michigan State
Medical Society. You as delegates are its “stock-
holders” and elect its Board of Directors. Each of us
through you, as our delegates, has a personal interest
and responsibility in the future of our Blue Shield.
Now. if you will permit me to assume that the huge
majority of the members of the Michigan State Medi-
cal Society (which I believe to be true) want Michi-
gan Medical Service to be continued and to be broad-
ened in scope and coverage, then I would like to pre-
sent to you the thinking of many of your confreres and
duly elected representatives.
Improved Lines of Communication. — It is readily
agreed by those close to the problem that the lagging
enthusiasm on the part of many physicians in Blue
Shield involves a breakdown in communication. The
rapid growth of the Blue Shield plans has created a
problem in maintaining a constant flow of information
to the participating doctor.
At this point I might ask the question, “Why the
lack of 100 per cent active physician participation?”
A combination of factors has probably been responsible.
For example, general prosperity has eliminated the need
for assurance of his fees, and in some physicians’ think-
ing it has eliminated even the need for prepaid health
insurance. The false notion that a third party is dic-
tating his fees is probably another factor.
Through the years the plans have risen to the de-
mands of the public and, without adequate explanation
to the participating physician, have given the appear-
ance of encroachment on his individuality and the free
practice of medicine.
We must let it be known that Blue Shield earnestly
and sincerely wants, needs and welcomes constructive
criticism and suggestions from physicians, and that no
suggestion nor criticism is too trivial or irrelevant to
receive careful attention. Through these methods, in
a spirit of good will and determination, we doctors
will assure a continuation of the improvement and suc-
cess of Blue Shield under the aegis of the profession.
It has been suggested that our professional relations
force be further enlarged to comprise groups of partici-
pating physicians to combat lack of information among
our colleagues in the informal atmosphere of our hospi-
tal lounges. In this regard each of us, after this par-
ticular meeting, can play a tremendously valuable part.
Through improved dissemination of information and
an awakened interest of the profession in Blue Shield,
we feel that all problems can be met and solved as each
physician exercices his fair share of influence in the de-
termination of policies that will best serve his patients.
Liberalization of Contracts. — There can be no argu-
ment that the ideal contract would give complete cov-
erage of the individual “from womb to tomb” for a
single subscription fee. Contrary to the belief of some
individuals and groups, this contract carries a “cost
tag.” There is no such thing as “free” coverage; it costs,
and someone has to meet that expense.
However, as has been outlined to you, plans for great-
er coverage for the subscriber are in the hopper and
are being developed and will be made available at a
cost that is actuarily sound and within the limits of
ability of the subscriber to afford. It is imperative that
this be done if we are to discharge our duty to our
subscribers, the public.
Supervisory Control of Patients, Hospitals and Doctors.
■ — For any plan to be successful, it has become apparent
that faulty or improper utilization or extra cost to the
carrier or subscriber must be kept at a minimum. We
feel that this is not a one-way avenue — that it is not
the infrequent doctor who is solely at fault or that it
is his sole responsibility.
The subscriber must be shown that his requests for
unnecessary care, or services not covered in his con-
tract, will eventually result in increased premium rates
and, if sufficiently great, might spell the demise of all
voluntary health insurance.
In addition, the hospitals must assume their right-
ful duty in controlling excessive and prolonged medica-
tion, so-called extras and undue overstay.
Where and how we doctors fit into this program is the
problem. Some years ago it was recommended by the
Michigan State Medical Society that review committees
be appointed by each individual hospital staff in an
attempt to find a solution to the problem we faced at
that time. Some are still functioning, but I daresay most
have been inactive for some time.
Whether or not something along this line is the
answer to the proper supervisory control of our present
and contemplated Blue Shield coverage or that some
other method should be devised, must rest with the
individual hospital staff, county society and/or this
House of Delegates.
Certainly, suggestions and recommendations that may
come from resolutions and discussions in reference com-
mittee will be eagerly awaited, and we hope that this
problem will be given serious consideration.
What Should the Profession’s Action and Philosophy
Be? — The following remarks that I will make are the
result of the thinking of many individuals and com-
mutes who have studied this problem over many
months, and are not solely original with me. They
will apply not only to the matter of prepayment health
service but also to the role that government and/or
other pressure groups may seek to play. In the past,
in 1939 and 1940, we were faced with a frontal at-
tack and we knew, to a large degree, what we were
up against; but now most of it is a flank attack, the
endeavor to get a “foot in the doorway.”
Replace Apathy with an Active, United Profession. —
Today there is a greater need for a united, forceful and
informed profession than ever before. The basic reason
for this special meeting of the House of Delegates is
to give you the information as to all the facets of pre-
payment of health care as of this moment. Through
you primarily, and with the help of others, it is hoped
that each individual member of the Michigan State
Medical Society will be better informed so that after
due deliberation considered decisions may be made.
Once those decisions are made by the majority, then
it is incumbent upon each of us to make it as nearly
unanimous as humanly possible.
The road of apathy and disunity can lead only to
disorder and possible disintegration, and we must sound
a warning to all our colleagues who don’t care or who
are pulling in the opposite direction.
As I said before, we must become a fighting UNIT
to keep the “doctor’s plan” truly an ALL doctors’
plan, to make it the best, and to give service to our
subscribers so that the public will prefer the doctor’s
plan to panel practice, organizational practice, govern-
mental practice or any other scheme involving third-
party control.
Free Choice of Doctors. — The patients’ right of free
choice of physicians has been said many times before
by many people, but to us it should never become a trite
saying. We must continually prove to our patients
that this right is an important one. one that under any
of the methods stated before could easily be lost through
directive of an intervening third party.
Oh yes, some plans maintain that when the individual
joins their group they have freely chosen their physician,
even though it is actually a group of salaried doctors.
Ridiculous!
Free Conduct in Medical Treatment. — As President
Dwight H. Murray of the American Medical Association
has so succinctly stated. “Another freedom closely tied
to freedom of choice is freedom in the conduct of
medical treatment.”
There should never be a third party telling you and
me how we should treat and care for our patients.
It is well known that closed panel plans claim to run
more cheaply than Blue Shield plans. This is mainly
because, by directives, the amount and type of labora-
tory examinations can be limited, the amount of time
766
TMSMS
SPECIAL SESSION— MSMS HOUSE OF DELEGATES
spent with the patient can be designated and the treat-
ment streamlined. It may be cheaper, but it’s “short-
change medicine.”
The dangers of shifting responsibilities for medical
care from the patient and doctor to a third party are
obvious. The caliber of medical care cannot be as high
as that which you and I give the patient. Initiative suc-
cumbs to dictation and the doctor becomes a “clock
watcher.”
Free choice of physician and free conduct of care
engenders a mutual confidence and trust between the
patient and the doctor that is so necessary for the
well-being of the individual. Remove this bond, and
the practice of medicine as you and I have known it
— that priceless heritage passed on to us through the
ages — is lost, and once lost can never be regained.
This philosophy of our profession is not new; it is
not something esoteric; it is an every-day working con-
cept that we all feel, share and believe in. It is the
driving force that enabled us to become doctors of
medicine, that carries us through our long hours of
work, our problems and tribulations and, above all,
that really endears us to our patients.
What Do the People Want? — Of great importance
also is the fact that any general service by professional
people which is to be sold must ( 1 ) be what the
public wants and/or needs; (2) be within reach of
the average man’s income.
I propose that we find out what the public really
wants, and that we get incontrovertible evidence to that
effect. This will help us greatly when we talk to
certain pressure groups who would have us believe that
the real wants of the people are the same as the
demands made by the leaders of pressure groups. I
question whether these pressure groups actually speak
the will of all of the people — or of a majority of the
people — who subscribe to Blue Shield.
In other words, I propose that we go to the people
through a survey or study that will give us part of the
knowledge we need upon which to predicate any changes
in our service, as well as the information necessary
to meet any false claims that may be made.
I propose, further, that this study or survey deter-
mine the extent and willingness of people to pay for
certain categories of medical and surgical service so that
we can better determine upon the most attractive, as
well as the most valuable, package to offer.
For example: Would the people prefer to have home
and office calls covered rather than x-rays? Would our
subscribers be more willing to pay for coverage of certain
diagnostic procedures than minor surgery? and so forth.
I do not mean that services offered through Blue
Shield should be limited to the most popular of the
services, for we would all agree that such would be
medically and scientifically unsound. Furthermore, Blue
Shield must represent ALL the profession, and if it
does not offer the broad variety of medical and surgical
services it cannot do that.
I merely indicate that with knowledge of what the
public really wants, with knowledge of what the people
are most willing to pay for, and with these knowledges
weighted by our own medical knowledge of what the
public needs and what is actuarily possible within the
limits of the public purse, we can arrive at the most
attractive offer consistent with the public interest, con-
sistent with our philosophy, and consistent with the
reasonable cost of our services.
Action, United. — The actions we must take to pre-
serve and implement these basic concepts must be ar-
rived at by you and our confreres back home after due
and careful deliberation. These must not be hasty deci-
sions but a result of clear thinking and interpretation
of the information given to you. The stand our united
Society takes can and will have far-reaching effect.
Let us work for what is best for all the people and
for the profession as a whole, and attempt to sublimate
June, 1957
any individual personal or selfish wish. Let us see the
forest and not the trees!
The Speaker: Thank you, Dr. Slagle.
Now I believe we are ready for the question and
answer period. I believe it would be proper if we limit
further questions to be submitted in the next five or six
minutes. If you have questions, will you please hold
them up; they will be collected and brought to the
front.
We are going to handle this on a panel basis. The
experts who have been giving you this information will
please come forward.
I shall read the questions as they are projected so
that they may be transmitted on the tape recorder.
VI. QUESTIONS AND ANSWERS
The Vice Speaker: There have been quite a few
duplications, and some of the questions were not too
relative to the point for discussion today.
We shall go ahead with the first question, directed to
Dr. Thorup:
“How is the doctor able to ascertain a member’s
family income? Often a subscriber has another source
of income in the community, and yet he has a $2J500
contract. Isn’t this the main deterrent for nonparticipa-
tion in Blue Shield?”
D. W. Thorup, M.D.: That is one of the sources
of irritation in the management of Blue Shield service.
I don’t know of any way to determine what the income
of the individual is, except to ask him. The knowledge
that we have of people of his similar employment status,
and incomes that they are obtaining, probably is of
value, but there is no way of knowing and there is no
procedure at present that gives you the income of
any subscriber.
The Vice Speaker: This question is directed to Dr.
Lichter:
“In discussing some of the plans regarding cost of
certain services, mention was made of the part of the
premium that was paid by the company. Does this
mean the cost printed in the book is the cost to the
subscriber, or to the subscriber and company?”
M. L. Lichter, M.D. : Those costs are the total costs
and represent the portion paid by the subscriber and
the company. The amount paid by the company is not
given in any of the figures. Usually it is one-half, and
in some negotiated contracts the company pays the whole
shot, but the cost given in the various material that
we had is the total cost to a subscriber for the plan.
The Vice Speaker: Is there anyone on the panel
who would like to volunteer to answer this question?
“Everyone is talking about the grass roots subscriber.
Has a survey ever been conducted to find out what the
grass roots M.D. wants in our Blue Shield Plan?”
G. W. Slagle, M.D.: In the proposed survey, it
primarily applies to the public. Also, in the discussion
(and this has definitely been preliminary prior to ap-
proval or disapproval by the House), the matter of
contacting the individual doctors has been thought of.
Certainly various resolutions discussed before the Con-
ference Committee in September will certainly have some
of that material at hand. It certainly would be a good
thing to consider in this survey.
The nearest thing to a survey like this having been
done was in the previous action of the committees setting
up the fees, and what each of us had a chance to vote
on the last time in 1951, in which the recent commit-
tee for the projected $6,000 policy had partly to do
with. To my knowledge that was considered somewhat
as a survey, but a specific written survey otherwise has
not been done.
767
SPECIAL SESSION— MSMS HOUSE OF DELEGATES
The Vice Speaker: This question is directed to
Dr. Lichter again:
“Can deductible and co-insurance be included in a
policy purporting to be a service policy?”
M. L. Lichter, M.D.: I think very definitely de-
ductible features and co-insurance features can be in-
corporated in a policy that is a service policy. As long
as the patient knows what his service is to be, and his
natural responsibility in connection with that service
is predictible, you have all the elements of a service
policy.
The Vice Speaker: If other members of the panel
who have participated in the discussion would like to
make any remarks relative to answering these questions
by the delegates, I wish they would volunteer at this
time.
The next question :
“During the period 1939 to the present. Blue Cross
costs have steadily increased with regular and correspond-
ing increases. During the same period Blue Shield fees
have been raised very little, and certainly not correspond-
ing to a realistic cost for services rendered. Why should
Blue Shield not use the same procedure for realistic
changes in fees and premiums kept up to date?”
Mr. Ketchum: When you put apples and cherries
together you get fruit salad. We are talking about
two entirely different things when we talk about Blue
Cross rates and Blue Shield rates, because the com-
modities and the services we are talking about are
entirely different things.
The point from which we take off, regardless of
what date you want to use — 1939 or 1950 or otherwise
- — hospital costs were on an entirely different basis from
the cost of almost any other service or commodity which
the people of this country availed themselves of. All
of you know, if you have been in the practice of medi-
cine for any length of time, that hospital labor com-
pared to all other forms of labor was terrifically under-
paid. Hospitals’ operating expenses are made up of
labor and supplies. Supplies to hospitals have in-
creased in cost about the same as supplies in any other
operation, industry or even personal and family.
Labor costs in hospitals have increased much more
than they have in any other service or operation because
of the very nature of the labor utilized by hospitals
in the past as compared to the nature of labor utilized
by hospitals now.
The difference in the work week is also a factor.
Hospitals used to use their employees 60 and 72 hours a
week. They now use them 44 hours, in some places
48 hours. Many hospitals are paying union scales for
their employees; at any rate, the cost of labor has almost
quadrupled in many categories.
You have recently seen the announcement of the
increased cost for nursing care. There was no compari-
son of the scales paid hospital labor in the past to
what is being paid now. Unfortunately we have not
seen the end of that increase in cost in the operation
of hospitals, at least in the labor costs of hospitals,
because hospitals have not yet caught up with the
going scales for labor in almost every other type of
endeavor.
Comparing hospital costs to doctors’ fees is just not
possible because of this difference. Also, there are many
other factors that have to be considered when you con-
sider the doctor’s income. Individual unit fees are not
the yardstick by which doctors’ incomes are measured.
There is only one yardstick by which doctors’ incomes
will be and can be adequately measured, and that is
total incomes for a period of work during a week, a
month or a year, which is comparable to another period
at some other point.
Doctors’ incomes, according to the only material avail-
able, have increased more in the total than have the
incomes of any other profession or trade increased in
768
the past several years, in spite of the fact that indi-
vidual unit fees for individual categories of services
may not have increased.
As I said, there are many factors contributing to
this. The facility and convenience with which a doctor
meets and deals with his patients is a factor. These
patients come to the hospital many more times now than
they did in the past. You meet them and treat them
there. This is one of the problems that insurance (
has caused as a problem in the utilization of hospital
facilities, but it is a benefit to the profession in that
you deal with your patients in the hospital. They come
to your offices more easily and more conveniently today
by car and highway than they did in the past, when
you went to them with a horse and buggy or maybe a
Model T Ford.
All of these questions have to do with the question
of comparable increases in incomes and costs. The
doctors’ incomes, as I said a few moments ago, have
increased beyond the increases enjoyed by any other
profession, trade or industry, and this can be proven
and is proven in the daily press almost every day these
days.
Peculiarly, in Michigan, having the third highest
percentage of enrollment in Blue Shield and in in-
surance in the United States, doctors’ incomes are
above those in any other state in the United States,
according to the recent survey of Medical Economics.
The Vice Speaker: This is another hot potato,
directed to Dr. Foster:
“What can be done to prevent overutilization of hos-
pital facilities by patients and physicians?”
Secretary Foster: Apparently this question is at
the root of all of our trouble, or most of it. You have
heard today, in all of the plans that were suggested,
that running through all of them were devices whereby
there were controls exercised, and it was repeated over
and over again that these controls had to be within
the profession.
The question is often asked, “Why doesn’t Blue Shield
exercise controls?” I don’t believe any of us would
welcome the exercising of controls by a fiscal agent,
Blue Shield. I believe we as a profession should stay
within our prerogative and do our own controlling.
I think that up to this time the only schemes that
have been suggested have been that they be done by
hospital staffs in the various communities, whereby
through smaller groups they can have these review
committees and can control, to a certain extent, the
utilization, because some of it is so obviously faulty that
it would not be a difficult job.
As long as no attempt is made — and as Dr. Slagle
said today that most of these committees instituted a
few years ago are probably inactive at the present time
— I think it boils down to the fact that overutilization
is a problem of the medical profession, and I don’t
believe we can delegate it to the fiscal agent, Blue
Shield, or that we can delegate it to anyone outside
of our own group. I don’t believe our members would
accept any type of control that came from without
the profession. Probably definitely that is the way it
should be.
The Vice Speaker: The next question:
“The United States Congress will soon pass legisla-
tion to give OSAI old age recipients hospital and
medical service at federal government expense under
Health , Education and Welfare (HEW). Do we have
plans to sell the government our voluntary health in-
surance contracts?”
Mr. Ketchum: The program which the Congress
is contemplating in connection with the recipients of
OASI for hospital care, (and incidentally at this point
it does not include medical care) is an entirely dif-
ferent problem. That is a provision for care of em-
JMSMS
SPECIAL SESSION— MSMS HOUSE OF DELEGATES
iloyed people or independent citizens. This is a special
:ategory of citizens.
The agent is receiving pensions or payments through
DASI, which I contemplated when I stated the failure
}f voluntary insurance to answer all of the problems in
he provision of health care.
The commercial insurance companies are certainly not
interested in this poor category of risk for commercial
insurance. Blue Cross and Blue Shield would love to
take on this job if we were not convinced through our
actuaries’ computations that taking on this job would
probably break us before we got very far into it. It
is a job that could well have been taken care of on a
voluntary basis.
Had we had the plans operating and without the inter-
ference of experience rated competition, perhaps we
could have taken care of it. We were not in time with
it, and in my estimation this bill will pass the Con-
gress, and the recipients under OASI will receive a
certain degree of hospital care at government expense.
Very much the same thing is happening in Canada
right now. Just this past week the Ontario government
decided to provide hospitalization at government ex-
pense for all of its citizens up to a certain level, and
there is a certain level of hospital care. The state-
ment was made at the time, and the releases last week
stated (and unfortunately I have only seen the press
releases and I don’t have the intelligence of the whole
situation) that commercial insurance in the hospitaliza-
tion field would be put out of business — that there
would be nothing for commercial insurance to do.
They hoped that Blue Cross, in providing the cover-
age over and above basic coverage, would be able to
provide something extra for the use of semi-private
beds and private beds certainly not for ward beds. So,
in Ontario, hospitalization as coverage as we have known
it is out of business.
This OASI thing is just another indication of what
can happen when certain categories of people are un-
able to buy voluntary protection.
I also mentioned this morning four other categories
of government wards which are going to receive medical
care as well as hospital care at the expense of govern-
ment, that is, the aged, the blind, disabled children,
and one other that I can’t think of (a minor cate-
gory). This is going to be a continuing thing until
voluntary means do provide for all of these categories
which are at least self-sustaining.
The Vice Speaker:
“What control does the medical profession have over
Blue Cross?”
Secretary Foster: I think the realistic answer
would be “None.” There are forty-one on the Blue
Cross Board of Directors; twenty-one are hospital ad-
ministrators or members of boards of trustees. There
are six doctors of medicine on that Board of forty-one,
and the remaining members are public representatives.
The direction of Blue Cross, I believe we can definitely
say, emanates from the hospitals.
The Vice Speaker:
“It is generally stated that the average family income
is above $4,000. Please state what percentage of Blue
Cross-Blue Shield subscribers have $2,500 conracts and
what percentage have $5,000 contracts. What is the
procedure used to determine and maintain the sub-
scriber’s current eligibility?”
Mr. Ketchum: Just so I won’t be proven a liar,
I am going to ask one of my staff to give me fairly
current percentage figures on this $2,500 as opposed
to $5,000.
Fifty-six per cent of our contract holders hold the
$5,000 income contract. Obviously, 44 per cent hold
the $2,500 contract. Seventy-four per cent of our con-
tracts are the medical-surgical contracts. Obviously,
then, 26 per cent are the surgical-only contracts.
June, 1957
The family incomes are just about $4,000, as this
question stated. I think our last figure was $3,860 or
so average family income in the State of Michigan.”
“What is the procedure used to determine and main-
tain the subscriber’s current eligibility?” I am not sure
I understand the question. If I make a wrong assump-
tion here, whoever asked this question I would hope
will clarify it.
The procedure we use in Michigan Medical Service
Service and Michigan Hospital Service is the mainte-
nance of a complete file of all subscribers by contract
number. When a request is made of us for verification
of the subscriber’s eligibility, this file is referred to and
his current paid-to-date is determined; her status as
to maternity benefits is determined if there has been
a waiting period on the contract.
It has not been common practice for Michigan Medi-
cal Service to verify coverage for doctors. We do it
in some cases. It has never been a great problem
because the request is made by the hospital. I think
there are thirty-three of the major hospitals that have
teletype equipment wired into this office. Inquiries are
made at a certain period by the hospital, each hospital
having an assigned period, and the information goes
back to the hospital that day as to whether or not that
patient seeking hospital entrance is eligible. The doc-
tors rely on that to determine whether or not the
subscriber is in a paid-up condition.
The Vice Speaker:
“Are osteopaths now participating physicians?”
I shall ask Dr. Walls to answer that. It could be
answered categorically “yes” or “no,” but I don’t think
he will do that.
President Walls : What do you mean by “yes” or
“no” ?
Osteopaths are nonparticipating as far as representa-
tion is concerned. They are being paid, however, by
Blue Shield, and their patients are being taken care of
by the Blue Cross.
There has been much discussion in the past, and we
hope to have some further information by September in
regard to what can be done with the osteopaths in re-
gard to participation in Blue Shield.
The Vice Speaker:
“When was the last increase in premiums for Blue
Shield ?”
Mr. Ketchum: There has been no increase in the
premium for the $5,000 surgical-medical contract or
surgical contract, as far as that is concerned, since its
inception in about 1949-1950. There was a 10 cent
increase in the subscriber rate per person in the $2,500
contract back in 1950. There have been increases in
the individual fees in the schedule under the $2,500
contract since its inception, which have totaled some-
thing like 23 or 24 per cent. There have been indi-
vidual adjustments in the doctors’ fees under the
$5,000 contract from time to time, as individually con-
sidered by the Medical Advisory Committee.
There has been a reduction in the operating over-
head of Michigan Medical Service of several per cent
in the last few years, which has made it possible for
us to pick up increased utilization and the adjustments
upward in the specific individual fees without an in-
crease in rates.
We are at the point right now where we are having
to consider the possibility of a rate increase for all
Blue Shield contracts.
The Vice Speaker:
“Has Blue Cross or Blue Shield attempted to conduct
a grass roots survey of policyholders concerning their
views on the services rendered and the costs of these
services, particularly to find out if the public wants
present policies liberalized?”
769
SPECIAL SESSION— MSMS HOUSE OF DELEGATES
G. W. Slagle, M.D.: The answer is yes. There is
one under way now by Blue Shield, attempting to do
this. The proponents of the proposal I submitted knew
this, and we hope to be able (if the proposal I suggested
is accepted) to utilize their findings along with independ-
ent findings of our own in this problem. I cannot
answer it as far as Blue Cross is concerned. It is a joint
survey.
The Vice Speaker: This is another hot potato:
“Did the announcement of the development of C,HA
have any influence on the decision of The Council to
call this special meeting?”
G. W. Slagle, M.D.: Basically, no. Committees
were functioning. First, eighteen months ago, at the
request of the Executive Director of Blue Shield, a
committee was appointed by The Council to take a
“big look” at Michigan Medical Service and what
could be done in the future — how it was to be done —
and it was a result of the findings of that committee,
originally chairmanned by Dr. Foster, and in the past
year chairmanned by myself, that led basically to this
meeting. Also, results of two other committees being
brought to light were factors that helped us.
The CHA proposition has been evolved while these
committees were studying it. I think I am correct that
Mr. Ketchum and others had their ears to the ground
and, knowing that we had to do something to improve
our service, drew the care and the over-all coverage.
So, this special meeting of the House of Delegates is a
result of the action of those committees, and only inci-
dentally was the idea of CHA used as a little bit of a
whip to stimulate us a little more.
The Vice Speaker:
“Many members of the Michigan State Medical So-
ciety believe that participating M.D.’s should accept
Michigan Medical Service fees and not be allowed to
make any additional charges. Why not eliminate all
additional charges as a good public relations gesture?”
Dr. Foster, woidd you take a whiff of that?
Secretary Foster: The Vice Speaker said, “You
have to pick on somebody,” and apparently I had the
handiest seat.
The answer I heard echoed all along the table was
“Yes,” but I think, after all, eliminating all additional
charges would certainly be good public relations, but
I don’t believe it is realistic.
The Vice Speaker:
“The twelve-hour limitation on treatment of injuries
seems to be a source of irritation to our members. Can
this limitation be eliminated?” Jay, that is for you.
Mr. Ketchum: If this is Michigan Medical Service
that you are talking about, it is twenty-four hours and
not twelve hours. This provision in our contract for
outpatient care of injuries was intended only as a first
aid measure. It was not intended to be full treatment
by any means. It was simply to get the people off the
street and to have their immediate needs taken care of.
The contract is rated for just that type of coverage.
You will also remember that there is no limit for
the treatment of traumatic injuries in connection with
an accident as far as fees are concerned, other than
the $15 provision for first aid.
The Vice Speaker: We have several questions here
that have been directed to Dr. Lichte'r, so I will ask him
to come up and read them and give the answers.
M. L. Lichter, M.D.:
“What specific methods have been tried or are pro-
posed to control doctors’ fees to a reasonable level, and
what ditto to control overutilization of services of a
doctor?”
The methods that have been tried are, first, the use
770
of substantial deductible and co-insurance features,
emphasize the word “substantial.” The same is trui
of the control of overutilization of services.
Another method that has been tried (notably in Wind
sor) is the use of rather stringent policing (witl
apologies to Dr. Foster’s esthetic sense) methods, where
by a physician can be removed from participation or thi
contract of a subscriber cancelled out.
Another method used in Windsor, as far as over
utilization or the control of doctors’ fees is concerned
has been to substantially reduce the fee that the physi
cian submits, and if there is overutilization the physi
cian's fee may be reduced because it might be felt tha
he encouraged this overutilization.
The next question deals with the same thing:
“Is there a built-in method of writing a policy to re
duce the incidence of improper practices which tend tc
be fostered by prepayment plans?”
There is no conceivable way of building into a plar
anything that will prevent sin. The only way you car
build anything into any plan is for the physicians anc
the patients to realize the value of the device and tc
cooperate with it, recognizing that anything they do to-
ward abusing it will result in the thing failing.
“Should hospitals be licensed by the state govern-
ment?”
I think we can all agree that the answer to that is a
flat “yes.”
“Can fee-for-service practice compete with closea
panel practice in cost?”
If we think of this strictly from a cost standpoint,
without any regard for the advantages of a fee-for-
service type of contract, I am afraid the answer would be
that we cannot compete on solely a cost basis, because
closed panel practices are predicated on building in
“efficiency” in the furnishing of medical care to pa-
tients. However, as you well know, this is not always
good for people. The difference in cost, however, would
not be so great as to make that difference a point of sub-
stantial objection.
“Is in-hospital medical and surgical care provided for
by HIP?”
Yes. That is the medical service aspect of their con-
tract ; but, if you will recall, the patient must provide his
own hospital insurance, and then through a specific car-
rier, the Blue Cross in New York City.
“D oes the Windsor Plan at $7.90 per month cover
hospitalization ?”
No. The subscriber must provide his own hospitaliza-
tion. The Windsor Plan merely provides medical serv-
ice. It is sponsored by the Essex County Medical So-
ciety and has nothing to do with hospital cost.
“In the General Electric Plan, is any life insurance
included?”
It is, only in the employee’s portion of the package.
There is no life insurance for dependents.
This next question, I think, is rather an important
one :
“ Could the relative value schedule of the California
Medical Association be used in the Michigan Medical
Service schedule of fees?”
As you know, the relative value schedule of the Cali-
fornia Medical Association was developed to determine
the relationship between various surgical, medical,
pathologic and radiologic procedures that are performed.
By determining this relative relationship, which is done
on a unit basis, and then using a factor, a dollar value
can be placed upon each service.
JMSMS
SPECIAL SESSION— M.SMS HOUSE OF DELEGATES
For example, an appendectomy is rated at 35 units,
'he unitage is on the basis of 100 being the highest. A
ysterectomy is rated at 60 units. If the average fee for
n appendectomy, let’s say, is $175, dividing that by 35
ives you a unit value of $5. Now you are in business,
nd you can start to compute the dollar value of these
ither procedures, which would make a hysterectomy, on
hat basis, $300.
If, on the other hand, the unit value is $4, then the
ippendectomy is $140 and the hysterectomy is $240.
One of the big problems (and perhaps dissatisfactions
vith many physicians) is their sense that fee schedules
nay not be adequate and may not reflect their own per-
onal schedules. By developing a relative value scale,
irst of all, the relationship of their own fees among
'arious procedures can be established.
The other thing that this type of thing would accom-
plish is taking into account the difference in average
ees in various parts of a given area. It might be very
veil if we considered the development of our own rela-
ive fee schedule.
One of the important points of having this type of fee
chedule, according to the California Medical Associa-
ion’s committee’s report, is that it then provides you
vith a yardstick for measuring the adequacy of the fee
chedule developed by a commercial carrier. Both phy-
icians and consumers are then able to determine wheth-
r they are purchasing or getting the thing that they
lave bought.
This relative fee schedule is used in one very attrac-
ive county medical society plan in California, wherein
>y its use the schedule has been raised to a level which
s quite satisfactory to 92 per cent of the membership
if that particular county medical society. I personally
eel it would be a very valuable thing if we in Michigan
leveloped a relative value schedule of this nature.
The Vice Speaker: We have had a number of
uestions about surveys of patients and surveys of doc-
ors, and so on, relative to types of policies the patients
pant, and patients the doctors would like to have.
I read this question once before; but because one of
ur members would like to say something about this, I
m going to read it again:
“Everyone is talking about the grass roots subscriber,
las a survey ever been conducted to find out what the
rass roots M.D. wants in our Blue Shield plan?”
Dr. Bob Novy, would you say a few words about that?
R. L. Novy, M.D. [Wayne]: I can’t resist the temp-
rtion of going off my subject just a little bit in refer-
nce to the last question of relative fee schedules.
To get the thing straight, if a relative fee schedule is
ot totally relative across the board, there is a relative
:e schedule for internal medicine; there is a relative fee
rhedule for allergy; there is a relative fee schedule for
rrgery, and you cannot compare them across the board,
’hey each have a different factor. You can when you
se that factor and convert it into cash, yes; but as the
dative fee schedule stands, you cannot use an office
all to determine how much an appendectomy is going
> pay.
In regard to this question: “Has a survey ever been
onducted to find out what the grass roots M.D. wants
i our Blue Shield Plan?” There has been. Unfortu-
ately, there was a certain amount of opposition at the
me this was put into effect, and also a very decided lag
i the time in which it was published. It has been pub-
shed. The Council on Medical Service undertook the
rrvey, and it was made throughout the United States
n a basis that was significant statistically, directed en-
rely to the doctor as to the type of program he would
e interested in, whether it would be service or whether
would be indemnity or whether it would be none, and
Iso a survey at the same time that if he did have a
:rvice plan, whether it would be unlimited sendee or
mited to what categories, $2,000, $4,000. $6,000,
7,000 or what.
une, 1957
That survey was returned. To answer the pertinent
question, about two-thirds of the doctors in the country
were in favor of service plans. That was a good size
proportion. Others had approval with qualifications.
Another outstanding thing in the survey showed that
the income limit was probably around $7,000 or there-
abouts as the doctors throughout the country made their
replies to that question.
I think that covers particularly the thing that is per-
tinent— in the first place, whether or not service plans
are acceptable throughout the country on the part of the
doctor. The answer, as indicated by that survey, is yes.
As indicated by the income limit that they considered,
it was variable, of course, but even more than we have
considered here in Michigan.
The Vice Speaker: There are several questions that
have been directed to Dr. Thorup, and I will ask him
to come up, read the questions, and answer them.
D. W. Thorup, M.D.:
“What major Blue Shield plan pays the professional
fee of the patient when the physician is nonparticipat-
ing?”
I think a little additional research is necessary to get
the answers. I don’t know that I have all of them yet.
There are gradations of that.
The answer to the question is that Northeastern New
York Medical Service, Incorporated; Colorado Medical
Service; District of Columbia Medical Service; United
Medical Service of New York; Wisconsin Associated
Service; Maine Medical Service; Maryland Medical
Service; Surgical Medical Care, Kansas City, pay only
90 per cent. Some of these pay less than the total
amount. Those are the plans which pay directly to the
patient when the physician is nonparticipating.
Several other plans — Montana, Arkansas, Utah, Min-
nesota, Massachusetts and North Dakota — pay the non-
participating doctors on a reduced amount. Massachu-
setts pays 50 per cent, but they pay it to the doctor — -
but only 50 per cent. Montana pays 85 per cent, and
the others pay proportions in between.
“What per cent of population does the Windsor Med-
ical Service cover?”
Approximately 80 per cent of the eligible people in
the area, as nearly as can be determined.
The Vice Speaker: Some of the questions that we
have had may have what would appear to be personal
problems, but I believe this one has more than that to
it:
“When the Michigan State Medical Society frowns
upon professional relations of its members with osteo-
paths, how can Blue Shield condone payment for x-ray
examination to osteopathic hospitals ordered by osteo-
paths, and refuse to allow a member of the Michigan
State Medical Society, in good standing, to be paid for
diagnostic x-ray work when that work constitutes his
only income?”
President Walls: I could probably spend the after-
noon talking about osteopaths, their relationship with
doctors, and what their relationship has been and what
it might be in the future.
I was on the national AMA committee, the Review
Board, to bring about an answer to what could be done
with the raising of the level of the osteopaths. At that
time we reviewed a great many of their schools, and
found that the first two years of their educational pro-
gram was on a par with the medical profession schools.
They were lacking in the education of the clinical years.
That is the problem which the AMA and each and
every individual state is trying to solve today.
When you realize that we have 1,600 osteopaths in the
State of Michigan, and that they are taking care of
over 20 per cent of the people — and we as M.D.’s are
interested and have a responsibility to give the public
771
SPECIAL SESSION— MSMS HOUSE OF DELEGATES
of Michigan the best medical care that is possible — I do
think and I charge each and every one of you to say
that we do have an interest in raising the level of the
osteopath, in his education and in the work he is doing,
and hoping to have some control over it.
Osteopaths are just as much interested in raising their
standards as we are in having them raise their standards.
I trust in the future that there will be some sort of
relationship that will be satisfactory to them and to us,
arrived at for the benefit of patients.
The Vice Speaker: Mr. Ketchum has some further
information relative to a question that he answered in
part previously.
Mr. Ketchum: Someone put in a supplemental ques-
tion:
“Is Mr. Ketchum referring to gross income of M.D.’s
or net income ? I do not feel the question was adequate-
ly answered
Fortunately, we have a library of intelligence up on
the next floor, which takes up, I would say, a quarter
of the space contained in this audience, but it is never
possible to bring the particular piece of information with
you because you don't know what it is going to be that
you may need to answer a specific question; but in this
case we were able quickly to find the source material to
which I was referring.
These figures are a national average and are not for
the specific trades and professions which I was referring
to, but they will support my statement adequately for
the time being.
The average family income, effective buying income
after taxes, in 1938 was $2,116. In 1954, it was $5,274.
In Michigan, in 1954, that figure was $5,806 compared
to a national average of $5,274. These figures are from
Sills Management Survey of Buying Power, the annual
edition, and it is available to anyone.
The source material for physicians’ income, non-
salaried classification, in 1938 was $4,093; in 1951,
$13,4-32. These figures have not been compiled since
1951 by this source. This is the Statistical Abstract of
the United States for 1955.
I did refer to Michigan physicians’ incomes as being
the highest in the United States — $14,831 for Michigan,
if I remember correctly, which was the highest average
of any state in the United States. I would like to simply
say that when we quote figures, percentages, up here, we
sometimes make mistakes. These are mistakes of the
brain and not of the heart, and if you will just give us
time and opportunity we will dig out the source of in-
formation from which these statements are made.
Thank you. That is after taxes and overhead.
The Vice Speaker: If there are any members of the
press here, I hope they will take this next question easy
and consider it off the record and off the cuff, and all
that sort of thing. The question is this:
“How can I make more money and do no work?”
[Laughter]
I don t know who sent this in. We shall appoint a
subcommittee; that will take care of it.
The next question:
“Is it necessary or desirable to extend fully prepaid
medical service to all segments of the population rather
than to just low income groups ?”
Mr. Ketchum: I touched on this point in the paper
I gave you before lunch. I don’t think there is any
doubt that the idea of restricting voluntary prepayment
to low income classes has been completely rejected by
most of the public. The value of prepayment or insur-
ance for the costs of health care has been proven, has
been accepted, by all classes of people.
772
We talked to the officials of General Motors, Ford,
Chrysler and such organizations as that. They are as
much concerned with their own security in this matter
of health care as is the rank and file on the machines, i
As a matter of fact, and this I can tell you from my f
own personal situation, for the salaried executive today
security is just as much a will o’ the wisp as it is for ,
the man on the machine.
The average salaried executive faced with a long,
prolonged and expensive illness is going to be in just as
much hot water, and maybe more, because of the weak-
ness of the executive today in business of living up to
his income. Almost everything he buys, including his
home, his car, his yacht, his club memberships, is
bought on a time payment basis. Perhaps you men are ]
exceptions, but I doubt it. It is true of everyone in
every walk of life in almost every economic classification,
and this is only a method of creating and extending
credit in the health payment field.
It is accepted generally. It would have been accepted
by the government in connection with the MEDICARE
dependents, except that there is an overriding principle
involved in that particular insurance. The dependents
of the armed services are w^.rds of the government by
virtue of the obligation assumed by government, and are
not people to be insured. The sovereign power does not
need to buy insurance; it has all the wealth of all of its
citizens, and it can tax it to get that wealth. Therefore,
it was not necessary to buy insurance.
It was a fine point which was discussed over a period
of three years in the Hoover Commission, to which I
was an adviser, as to whether or not the government
should buy insurance on a prepaid basis just as the em-
ployees of General Motors, Ford, Chrysler and the rest
of them do, or whether they should simply buy and pay
whatever it costs plus the overhead of administration. It
was decided that only because it was a sovereign power
taking care of its own people, and having a total obliga-
tion to see that these people got care and not just help
in getting care, that they went the way they did in
MEDICARE rather than buying voluntary insurance.
I don’t think there is any question that you must
amend the idea that voluntary prepayment is only for
the lower income classes.
The Vice Speaker: There are several other ques-
tions here which I am sure Jay is the one to answer, if
he will.
“Can the $2,500 medical service program be
eliminated ?”
Mr. Ketchum: It could be, and I doubt whether
we would have too much trouble eliminating it, with a
few exceptions. You all must realize that, for example,
the employers of S. S. Kresge, Woolworth, J. L. Hudson,
Michigan Bell Telephone Company and several groups
of that nature, employ people for small jobs, many on a
part-time basis, whose earnings are definitely below the
$2,500 and $2,000 levels. To force these people to buy
the higher contract — the $5,000, for example, in Michi-
gan— would only increase the cost of medical care to
these people, beyond the point which they are actually
paying even though they are not insured.
Therefore, at the time the $5,000 contract was in-
stituted it was felt absolutely necessary to retain the
$2,500 contract for those classifications. Because of the
nature of Michigan Medical Service being a foresighted
public institution or, as Dr. Brandenburg called it, a
public trust, we are forced to make available to any
qualified applicant any of the contracts that we offer
the public.
Therefore, in the approach to General Motors, Chrys-
ler, Ford and the other large groups, there is selection
within the group, if the group wishes it, as between the
$2,500 and the $5,000 contract. We find some people
with incomes well above $5,000 buying a $2,500 con-
tract, hoping to utilize it as an indemnity contract.
JMSMS
SPECIAL SESSION— MSMS HOUSE OF DELEGATES
I cannot answer as to whether or not the $2,500 con-
,ct will be eliminated in the near future. There is
isideration being given to it.
“Why does the non-group contract offer only hos-
al-surgical coverage and not medical care coverage ?”
Mr. Ketchum: We are seriously considering making
ailable a surgical-medical contract to the non-group
rollees (what we have called our community cam-
ign enrollees) this coming year. There has been one
al reason why it has not been done in the past, and
at is strictly in the area of cost or price. Most of the
ople who buy this contract are the unemployed, the
If-employed, the older people who do not qualify under
oup, and therefore in an attempt to keep the price
iwn and give us a fair break in selection, it has not
en offered to this time. I am not promising, but I
ally believe it will be offered this coming fall, probably
September.
“What proportion of the subscriber’s premium goes to
ue Cross and what proportion to Blue Shield?”
Mr. Ketchum: This is a difficult question to answer
cept as to the total dollars involved, because of the
riation in contracts held by the various subscribers,
ue Cross has four basic contracts. They have three or
ar supplemental contracts. Blue Shield has four basic
ntracts and several small supplemental contracts, to
2 situation would vary in almost every instance.
However, over-all, Michigan Blue Cross’s income last
ar from its subscribers was about $104,000,000. Blue
ield’s was about $44,000,000. So, that proportion just
out represents the split for the average subscriber.
The Vice Speaker: I find that the remainder of the
estions have already been answered by previous speak-
:, and I want to thank you all very much for your
:ention during the time that these questions were pre-
lted. I shall now turn the meeting back to the
eaker.
The Speaker: Thank you. Dr. Lightbody. If you
lows by now are not authorities in insurance, you
ist have been asleep. You certainly have had an in-
lsive course in prepayment insurance.
The time has come for discussion by members of the
>use of Delegates, or the introduction of resolutions or
>tions if you have them. I certainly think it is very
vious to all of us that this problem is something that
nnot be settled today. It will require a great deal of
ry sincere and concentrated evaluation by you men
io have the responsibility of deciding the principles by
Lich Michigan State Medical Society shall operate.
I would like to read to you paragraph M, Section 10,
lapter VIII of the Bylaws:
“Each resolution introduced into the House of Dele-
tes shall be in writing and presented in triplicate to
: Secretary immediately after the delegate has read
: same, and shall be referred to the proper reference
nmittee by the Speaker before action thereon is
;en.”
As I said in my opening remarks, motions that may
presented, which are germane to accomplishing a pur-
se, I believe can be acted upon today. However, any
olutions that are submitted and which have in any
y an effect of binding the House of Delegates or bind-
r, the members of the Michigan State Medical Society
any course of action, I believe properly should be re-
red to the proper reference committee.
The Chair will now entertain motions, resolutions,
cussion by members of the House of Delegates. There
a microphone on each side of the room for your con-
aience; or if you wish to come up here, you are free
do so.
VII. PRESENTATION OF RESOLUTIONS
AND MOTIONS
I. Resolution No. I: Pathology Under
Medicare
W. L. Brosius, M.D. (Wayne) : I have been asked
to present a resolution at this meeting by the Michi-
gan state Pathological Society. The President’s letter,
requesting me to present it, is here. These two resolu-
tions were circularized to the State Society of Pathol-
ogists, of which there are seventy-seven active mem-
bers at the present time, with an expression requested
from them as to whether they wish these resolutions
to be presented or not. Fifty-four answered; fifty-two
for, two against. These were written rather hurriedly,
and probably the reference committee can dress them
in phraseology in one or two places.
“Whereas, the American Medical Association and the
Michigan State Medical Society have declared that the
practice of pathology is the practice of medicine, and
“Whereas, pathology services may be rendered in or
outside of a hospital, and
“Whereas, such pathology services can be performed
only by or under the supervision of qualified physicians,
and
“Whereas, Michigan Medical Service has contracted
for the Michigan State Medical Society and for the
physicians of Michigan and with the Department of
Defense to supply medical services to dependents of
the uniformed forces under Public Law No. 569 of
the 84th Congress, otherwise known as the Dependent’s
Medical Care Act, or Medicare, and
“Whereas, certification of medical services rendered
can be made only by physicians; therefore be it
“Resolved: That the Michigan State Medical So-
ciety hereby declares and affirms that pathology is a
medical service under the terms of the contract which
has been negotiated between the Michigan Medical
Service and the Department of Defense, and as set forth
in contract No. DA-49007 MD823, dated 16 November,
1956, issued by the Department of Defense in com-
pliance with the Dependent’s Medical Care Act, and
fees for such services wherever rendered must be paid
to the physicians rendering the service.”
VII. 2. Resolution No. 2: Pathology in Blue
Cross-Blue Shield
“Whereas, the Michigan Medical Service and Michi-
gan State Medical Society have declared that the prac-
tice of pathologic anatomy and clinical pathology is
the practice of medicine, and
“Whereas, the pathologic services whether rendered
to inpatients or outpatients are medical services, and
“Whereas, such pathologic services can be performed
only by or under the supervision of qualified physicians,
and
“Whereas, Michigan Medical Service has contracted
for the Michigan State Medical Society and for the
physicians of Michigan to supply medical services to
subscribers, and
“Whereas, certification of medical services rendered
can be made only by physicians; therefore, be it
“Resolved: That the Michigan State Medical So-
ciety hereby declares that pathology is a medical serv-
ice, and premiums for such services should be included
in the Michigan Medical Service contracts rather than
in the Michigan Hospital Service contracts; and be it
further
“Resolved: That fees for such services be paid to
the physicians rendering the service.”
ne, 1957
773
SPECIAL SESSION— MSMS HOUSE OF DELEGATES
The Speaker: These two resolutions will be referred
to the proper reference committee when it has been
appointed.
VII. 3. Resolution No. 3: Increased Benefits
in Michigan Medical Service Contracts
E. H. Fenton, M.D. (Wayne) : I have been asked
to present this by the Committee on Prepaid Medical
Care Plans of the Wayne County Medical Society:
‘‘Whereas, the Committee on Prepaid Medical Care
Plans of the Wayne County Medical Society has stud-
ied extensively the various methods of prepaid medical
care available in the United States, and
“Whereas, it is the opinion of the Committee that a
medical society may logically sponsor only a service
type plan, and
“Whereas, the Committee has concluded that the
general public desires wider benefits in a prepaid plan
than are now available in Michigan Medical Service,
and
“Whereas, an essential feature in such a plan should
be a mutual sense of responsibility on the part of the
physician and on the part of the patient, and
“Whereas, the traditional right of the patient to
choose his own physician must be preserved; therefore,
be it
“Resolved: That Michigan Medical Service be re-
spectfully requested after a thorough study of actuarial
factors to devise a contract providing increased benefits
patterned on the General Electric Plan; and be it further
“Resolved: That this contract embody extensive
diagnostic and therapeutic benefits to the subscriber in
the hospital, office and home; provide for both an
initial deductible feature and a co-insurance plan for
more extended and expensive illness; and pay the phy-
sician without a fixed schedule his usual fee for a given
service; and be it further
“Resolved: That this House of Delegates favors con-
tinuation of policies now being offered by Michigan
Medical Service.”
The Speaker: This resolution will be referred to
the proper reference committee when that committee
is appointed.
VII. 4. Resolution No. 4: Limit Blue Shield
Contracts to Those in Specified Income Limits
E. H. Fenton, M.D.: This resolution does not come
from the Committee:
“Whereas, considerable confusion exists in the minds
of the public in regard to income limits of their policies,
and
“Whereas, fee schedules as set up in specific contracts
tend to be accepted by the patient as usual fees for
the various procedures, and
“Whereas, poor public relations may result when fees
in excess of their Blue Shield contracts are charged;
therefore, be it
“Resolved: That the Board of Directors of Michi-
gan Medical Service be encouraged to initiate a plan
as rapidly as possible by which Blue Shield contracts
are limited to those individuals whose family income
falls within the income limits of their policies; and be
it further
“Resolved: That the corporate body of Michigan
Medical Service go on record as favoring the discon-
tinuance of the present $2,500 policy, and a new con-
tract for all incomes above $5,000 be formulated.”
The Speaker: This resolution is referred to a ref-
erence committee when it has been appointed.
VII. 5. Motion No. 1: Authorizing Survey
Determine Consumers’ Attitudes on Services
and Payments
J. R. Rodger, M.D. (Northern Michigan) : I wou
like to present this motion:
In view of the fact that time is of the essence
determining actions to be taken regarding prepaid i
surance consistent with existing evolutionary tren<
and in view of the fact that a committee of this Hou
of Delegates is currently considering certain sped;
phases of this problem, I move:
That to complement better the work of present cor
mittees, the Michigan State Medical Society Coun<
or its Executive Committee be instructed to immediate
conduct a survey to determine the attitude of the co
sumer public generally regarding services which shou
be offered, as well as the economic potential to pay fi
such services, and that it utilize any survey material ar
information already available together with such otb
facts as can be secured to effect that end, this survi
information to be made available to this House <1
Delegates at the September, 1957, meeting through tl
Annual Report of The Council of the Michigan Sta
Medical Society.
M. L. Lichter, M.D.: I second the motion.
The Speaker: I believe this motion is proper f<
action by the House of Delegates at this special sessio;
There has been a second by Dr. Lichter, Dr. Stand<
and Dr. Heidenreich. What is your pleasure? Is the)
discussion of this motion? The Speaker’s interpretatio
of this motion is that in addition to the study con
mittee that is already studying some of the phases <
this matter, this motion directs The Council and/or i
Executive Committee to further complement the effor
of this committee to get adequate information from th
public as to what it wants and its ability to pay for i
for future decision by this House in September.
Is there discussion?
R. A. Rasmussen, M.D. (Kent) : I would like t
amend the motion, that it include a survey of th
doctors’ wishes.
The Speaker: I am not sure the motion stated sue
a fact. I suppose it was implied, but do you wish t
make it in the form of an amendment, that it includ
a survey of the doctors’ wishes? Do you care to eluc
date on that? What do you mean by “the doctor
wishes” — as to whether they want a service plan c
indemnity plan, or what?
R. A. Rasmussen, M.D.: I think, as it is state
now, it would include a survey of the wishes or d<
sires of the consumer. I think, too, that the doctor :
involved in this whole problem, and to stimulate h:
interest it would be well to survey his thoughts on th
matter.
The Speaker: If I understand, Doctor, do you wis
to specify it any more particularly, or do you ju:
want to leave it a blank wish, and that’s all? It is a
right the way you have it.
R. A. Rasmussen, M.D.: If you want to add to i
it might be well to get his impression of the needs.
Otto Vander Velde, M.D. (Ottawa) : I second th
amendment.
The Speaker: We shall dispose of the amendmen
Is there further discussion of the amendment? A
those in favor of the amendment that the physician b
polled as to his wishes in this matter, say “aye”; op
posed, “no.” The amendment is lost.
Now, may we have discussion on the original motion
R. L. Novy, M.D.: I ask a question: Where is th
money coming from? It is not provided for in th
motion itself. I do know that we did conduct a po
way back in 1943 or 1944, and at that time it co:
$15,000. I don’t know what it would cost now, an
774
TMSM
SPECIAL SESSION— MSMS HOUSE OF DELEGATES
it was supposed to be a cut rate that we were given
that time.
The Speaker: Is Dr. Shook in the room? The state-
■nt has been made but not verified that it is going
cost considerable money to conduct a survey as was
ggested by the motion. Do we have the money?
Ralph W. Shook, M.D. (Kalamazoo) : I think it
>uld be up to the House of Delegates to decide where
u were going to get the money — whether you want to
ise it. It is not in the budget. If you conduct a
rvey, my impression is that it is going to take longer
an three or four months.
Dr. Schiller, M.D. (Wayne) : I would like to point
it that in the last four or five years there have been
rveys made in practically every state. It is hard for
e to believe that Michigan is so different that we
.n’t use the judgment that has been obtained through
ese various surveys and apply it to the business of the
ate of Michigan.
G. W. Slagle, M.D.: The consensus was that there
a lot of survey material available. There are research
fits in the various colleges and universities, and The
auncil or its representatives have not had a chance to
scuss in great detail how much it might cost. It was
It that The Council, within the next two or three
;eks, would be able to compile what would be avail-
ile, and would have some idea of what it might cost.
The figures as represented by the group were no-
lere near $10,000 or $15,000. It was a matter of
ily a few thousand dollars that it might cost. In our
lblic Relations reserve fund there is an adequate
nount to take care of something like this, if it is
iproved by the House of Delegates.
J. D. Fryfogle. M.D. (Wayne) : May I suggest a
ty to take a poll without spending very much money
cept for the tabulation? We might use our good
ends in the newspaper business or other publications,
rerybody loves to answer quiz questions, and such a
eet publicized in the local papers in the various corn-
unities throughout the State, and returned to a box
imber, might be tabulated.
I would not vote for the accuracy of such a poll,
it it certainly would be a good cross-section sampling
our State, and it might be good publicity in the sense
at if the doctors were requesting it, it would impress
ion the people the fact that we are concerned with
eir wishes and that we want a good cross-sectional
swer from them. It might be very informative, al-
ough I don’t know if it has ever been done that way.
A. C. Stander, M.D. (Saginaw) : I would like to
k whether we are meeting solely now as members of
e House of Delegates, or whether we are meeting as
smbers of the corporate body of Michigan Medical
rvice.
The Speaker: This is a meeting of the House of
fiegates.
A. C. Stander, M.D.: I understand we also are
imbers of the corporate body of the Michigan Medical
rvice.
My opinion is this: Before we venture on any changes
contract of the Michigan Medical Service, any changes
at should be made should be made with adequate
liberation and with adequate information.
At the MSMS County Secretaries-Public Relations
inference last January, I was very definitely impressed
Mr. John Reid of Lansing who said, “Labor always
<s for more than they expect to get, and they have
ry well-trained bargainers.”
I think we should get as much information as pos-
>le before we consider contract changes, and we cer-
nly should find out what the people want who are
ing to get the benefit and pay for these contracts.
I just wonder whether there is any obligation on
; part of Michigan Medical Service to acquire that
ormation and to spend some of the money in obtain-
j this information.
The Speaker: The question has been called for.
Is there further discussion?
S. L. Loupee, M.D.: I would like to ask someone
in authority whether this resolution as it appears would
permit the accumulation of facts with reference to the
acceptance of Blue Shield by the people of the State
of Michigan, from the data which are already at hand.
There are many sources of data, as has been mentioned
here. There are other ways of getting an appreciation
of the way the people feel about it, other than to go
from house to house or town to town and find out.
We could make it simple and inexpensive. It might not
be considered quite as accurate, but it would give us a
very good idea.
If that would be permitted, then I am for this thing.
If not, I am not sure how we could get through with
it between now and September, so I would be against it.
The Speaker: If I recall the motion correctly, it
specifically stated that all sources of information that
are now available from surveys will be utilized. It is
only a motion to complement the work of the committee
of your House which is already working on the matter.
S. L. Loupee, M.D.: That being the case, I shall
vote for it.
The Speaker: Is there further discussion? The
question has been called for, and I believe it is in
order to now put it to a vote. All those in favor of this
motion, please say “aye”; opposed, “no.” The motion
is carried.
Are there further resolutions or motions?
VII. 6. Resolution No. 5: Recognition of
Internists
N. J. Hershey, M.D. (Berrien) : I present this reso-
lution at the request of the Michigan Society of Internal
Medicine:
“Whereas, this House of Delegates, as representatives
of the medical profession in Michigan, is dedicated to
promote higher standards of medical service, and
“Whereas, the maintenance of high standards of med-
ical care often includes the services of the internist,
and
“Whereas, this House of Delegates is anxious to
maintain unity of the medical profession in Michigan
in order to further favorable solution of the economic
problems of medical care; therefore, be it
“Resolved: That the House of Delegates recognizes
the internist as a medical specialist whose special train-
ing, skills and detailed investigation and service rendered
the patient entitles him to compensation commensurate
with such service both as an attending physician or
consultant.”
The Speaker: This resolution will be referred to
a reference committee when it is appointed.
O. J. Johnson, M.D. (Bay) : I would like to read
the notice of this meeting: “The purpose of this meet-
ing is to acquaint you with the various crises and prob-
lems facing the profession with regard to future prepaid
health insurance in this State.”
I think you have done so very adequately. I think
the resolutions here presented, deciding whether intern-
ists are specialists or pathologists are doctors, are not
germane to the calling of this meeting. I do not see
how we can conduct any business.
The Speaker: It is your privilege to rise to a point
of order The Chair would simply like to explain that
this matter revolved around in his mind from supper to
breakfast for several nights in a row, and he finally
decided that, rather than create any ill-will, it would
be better to accept these resolutions and have them
referred, as is the proper sequence, to the reference
committees when appointed.
I appreciate that your statement, Dr. Johnson, is ab-
solutely true. I think it would be perfectly within
the prerogative of the Chair to rule otherwise, but this
ne, 1957
775
SPECIAL SESSION— MS MS HOUSE OF DELEGATES
is the ruling of the Chair. If you wish to appeal it, I
think these resolutions can properly be disregarded. This
is the way it is being handled at the present moment;
as long as we already have some resolutions committed,
we will proceed unless we get too far distant.
J. R. Rodger, M.D. : Do you mean these resolutions
will be referred to reference committees that will report
back on them next September and be made clear?
The Speaker: That is the point. They will be clear,
if you didn’t understand them.
VII. 7. Resolution No. 6: Change Michigan
Hospital Service-Michigan Medical Service
into Indemnity Plans
Dr. Kelleher, M.D. [Calhoun] : After reviewing the
problems that have been presented to it by representa-
tives of the Michigan State Medical Society, and follow-
ing a ballot vote of the Calhoun County Medical So-
ciety, its delegates have been instructed to present the
following resolution to the special meeting of the House
of Delegates of the Michigan State Medical Society:
“Resolved: That the Calhoun County Medical So-
ciety hereby requests the Michigan State Medical Society
to give consideration to the employment of its influence
and good offices to effect some or all of the following
changes in Michigan Hospital Service-Michigan Medical
Service:
“1. Discontinuance of the ‘service’ concept.
“2. Adoption of a deductible hospitalization plan.
“3. Adoption of an indemnity fee schedule for phy-
sicians’ services.
“4. Adoption of an indemnity fee schedule for out-
patient or office diagnostic x-ray examinations.
“5. Payment of surgical indemnity fees regardless of
where the surgery is performed.”
The Speaker: This resolution will be referred to a
reference committee when it is appointed.
VII. 8. Motion No. 2: Encouraging Extended
Coverage of Service Contracts
H. A. F urlong, M.D.: It is very apparent that a
great deal of study has been made by the Board of Di-
rectors and the officers of the corporation, and that there
is much yet to be done. There are many problems yet
to be met. This effort must be carried on. Therefore,
the Oakland County delegation would like to present this
motion:
That this House of Delegates expresses by this motion
its unqualified confidence in the Board of Directors and
officers of Michigan Medical Service for their manage-
ment of the affairs of the corporation, and encourages
them to continue to evolve plans for extended coverage
of service contracts in conformity with present demands
and in anticipation of future needs within the limits of
sound actuarial experience and reasonable cost.
Further, that the Michigan State Medical Society in-
tensify its efforts to demonstrate the advantages to be
achieved by the close partnership of the public and the
profession in this effort.
W. L. Brosius, M.D. : I second the motion.
The Speaker: Is there discussion of the motion?
The question is called for. All those in favor, say “aye” ;
opposed, “no”. The motion is carried.
Is there any further business at the present moment?
If not, I would like to call on three men for announce-
ments, Dr. Foster, Dr. Wickliffe and Dr. Wiley. Will
those three men come up quickly and make their an-
nouncements,. after which we will have a brief summa-
tion by President-elect Slagle and immediate adjourn-
ment after Dr. Slagle has finished his remarks.
Secretary Foster: I have two announcements that
are of a rather pleasant nature. They have to do with
legislation.
Your attention is invited to the fact that House Bil
515, a legislative proposal introduced in the present ses
sion by the Ways and Means Committee of the House
which would have you re-register at $10 a year, has beei
referred back to the committee and is going to lie ther
for another year. You will recall that The Council ap
proved a re-registration act last year, and then th
House of Delegates disapproved.
The Ways and Means Committee not only raised th
original $5, not only considered it, but raised it to $10
The bill has been returned to committee, and it is hope<
you will thank your legislators when you get home fo
what they did.
The second announcement is that the proposal fo
polio vaccine, some $400, 000-odd in the budget, whicl
was to be used only in public health clinics, taking i
away from the doctors' offices, where 75 per cent of thi
work had been done, was passed with the amendmen
off. That is going to preserve for you in the comini
year this segment of private practice, so thanks again an
due our State Senators and Representatives.
J. T. P. Wickliffe, M.D. [ Hough ton-Baraga-Kewee
naw] : I want to take this opportunity to extend a cor
dial invitation to all Michigan State Medical Society
members to attend the 69th annual meeting of the Uppe
Peninsula Medical Society of Michigan. We shall hav<
a good scientific program. The meeting will be a
Houghton, on June 21-22. We would like to have yot
all come up.
The Speaker: Thank you. Dr. Wickliffe. We shal
all be there.
D. Bruce Wiley, M.D.: I would like to invite tc
your attention the fact that last year, during the summer
Councilor Conferences were held throughout the State
Last September, this House of Delegates authorized The
Council to arrange these Councilor Conferences agair
this year, in each of the districts.
After this meeting, you will probably want to hole
your Conferences earlier than you did last year so that
after you have had your county medical society meeting:
these matters may be discussed, and this particular ques-
tion, along with the other matters pertaining to the prob-
lems of the State Medical Society that will be coming up
in the September annual session of the House of Dele-
gates, will be brought to the Conference in each dis-
trict. By scheduling these conferences earlier, it will give
the State Society officers a better opportunity of fitting
such meetings into their busy schedules.
The Speaker: May I take this opportunity to thanl
each member of the House for his attendance, and each
alternate, the officers of the county societies and the par-
ticipants on this program. As soon as Dr. Slagle finishes
his summary, we shall adjourn.
VIII. SUMMATION
By G. W. Slagle, M.D.
I want to compliment each member of the House oi
Delegates and guests for their attendance during this
whole day. A lot has been tossed your way, and there
has been much to digest. We know that in the next few
months there is a big job to be done.
My charge is simply to go back home, disseminate this
to each individual member, discuss it in the hospital
lounges and at staff meetings, and do not hesitate at
any time to call on the representatives of MSMS and
Blue Shield to meet with you and go over anything that
may be troubling you.
Think it over thoroughly, make good decisions, and
go to Grand Rapids in September ready to get together
as a united profession. We will whip this thing and will
come out on top as we did in 1940.
IX. ADJOURNMENT
The Speaker: The meeting is adjourned.
[The meeting adjourned sine die at 4 p.m .]
776
JMSMS
FOR POSITIVE DIURESIS
ROLICTON'
Brand of Amisometradine
• oral b. i. d. dosage
• continuous control of edema
The new, highly effective oral diuretic,
Rolicton, greatly simplifies the task of main-
taining an edema-free state in the patient
with congestive heart failure. Rolicton meets
the criteria for a dependable diuretic: con-
tinuous effectiveness, oral administration
and clinical safety.
In extensive clinical studies the diuretic
response clearly indicates that a majority
of patients can be kept edema -free with
Rolicton. In these investigations it was noted
that side reactions were uncommon. When
they did occur they were usually mild.
In most edematous patients Rolicton may
be employed as the sole diuretic agent. When
used adjunctively in severe cases, Rolicton
is also valuable in eliminating the “peaks and
valleys” associated with the parenteral ad-
ministration of mercurial diuretics.
One tablet of Rolicton b.i.d., after meals,
is usually adequate for maintenance therapy
after the first day’s dosage of four tablets.
Some patients respond well to one tablet
daily. G. D. Searle & Co., Chicago 80, Illi-
nois. Research in the Service of Medicine.
ine, 1957
Say you saw it in the Journal of the Michigan State Medical Society
Michigan’s Department of Health
Albert E. Heustis, M.D., Commissioner
SUMMER IMMUNIZATION
The Michigan Department of Health recommends:
1. That the routine immunization of infants against
diphtheria, pertussis, tetanus and smallpox be continued
throughout the so-called poliomyelitis season.
2. That because of our high percentage of protec-
tion against diphtheria, tetanus and whooping cough
in older children and with a very low incidence of
these three diseases in Michigan there would be no
objection to delaying booster doses or primary im-
munization of older persons until later on in the year.
3. That poliomyelitis vaccinations be continued
throughout the so-called polio season.
4. That poliomyelitis vaccine not be given to house-
hold contacts of a case of poliomyelitis.
5. That antigens not be given to persons showing
signs of illness.
CHANGE IN LABORATORY
TESTING PROCEDURES
The Department of Health has found on review of
experience with antibiotic sensitivity testing that the
use of more than one of the Tetracycline drugs in test-
ing adds no useful information. There is uniform agree-
ment between the results obtained with all Tetracycline
antibiotics. Bacitracin, Neomycin, Polymyxin B and
Viomycin are of little clinical usefulness. We are there-
fore restricting routine testing to the following anti-
biotics: Chloromycetin, Erythromycin, Penicillin, Strep-
tomycin. and Tetracycline.
Routine gross testing of fecal specimens has been
discontinued. If requested, the Department will per-
form antibiotic sensitivity tests on pure cultures of
known pathogenic bacteria when isolated from fecal
specimens.
STATE SOCIETY MEMBERS ON
RADIO PROGRAM
Beginning in the fall of 1956, the Michigan Depart-
ment of Health's weekly radio program has been aired
over a statewide network of radio stations. Several
members of the State Medical Society have participated
in the broadcasts.
The first series of programs was devoted to maternal
and child health and included most of the material
covered in expectant parent classes as well as a number
of shows on the health of the preschool child. In addi-
tion to health department staff members, featured guests
on this series were Dr. Francis Jones, Lansing, Chair-
man of the Maternal Health Committee, who spoke on
the hygiene of pregnancy, and Dr. Robert Heavenrich,
Saginaw, Chairman of the Child Health Committee,
who spoke on growth and development.
The second series of programs, now in progress, deals
with various aspects of the chronic disease problem.
Featured guests on this series include Dr. Frederick
Swartz, Lansing, member of the Geriatrics Committee,
who discussed aging and long term illness; Dr. Robert
Stow, Lansing, who discussed heart disease; Dr. Frank
van Schoick. Jackson, member of the Rheumatic Fever
Committee who spoke on rheumatic fever; and Dr.
George Thosteson, Detroit, who will discuss diabetes.
The programs are broadcast originally over station
WKAR in East Lansing. Tape recordings of these
broadcasts are then sent to thirteen radio stations
throughout the state for rebroadcast at a later date.
PUBLIC HEALTH NURSES STILL
IN SHORT SUPPLY
The number of public health nurses at work in
Michigan has not kept up with the population in-
crease. according to a recent census conducted by the
Michigan Department of Health.
As of February 1, there were 896 full-time and
seventy-eight part-time nurses employed by all types
of agencies for public health work in the state. The
full-time nurses have increased forty-two in the last
two years, a gain of approximately 5 per cent. Michi-
gan’s population gain in that time was 7 per cent.
Of the 896 full-time public health nurses in the state,
51 per cent have completed a year of public health
training. Of this number, thirty-one are graduates of
basic collegiate nursing programs which are accredited
for public health. Wayne State University has one
of these accredited programs. Twenty per cent of the
nurses have had less than one year of preparation and
29 per cent have had none. A total of forty-seven (5
per cent) have master's degrees. Eleven of these are in
state agencies and thirty-six in local agencies. Bachelor’s
degrees are held by 274 nurses (31 per cent of the
total number) .
NEW OFFICERS OF MICHIGAN PUBLIC
HEALTH ASSOCIATION
C. V. Tossy, D.D.S., of Lansing, was elected presi-
dent of the Michigan Public Health Association at the
organization’s thirty-sixth annual conference in Grand
Rapids in May. Robert G. Willson, D.V.M., of De-
troit, was chosen vice-president and G. Frederick
Moench. M.D., of Midland, was named secretary. Ly-
man Chamberlain, of Charlotte, was continued in the
office of treasurer.
The American Red Cross in 1956 collected 2,130.000
pints of blood — almost a hundred thousand more than
the previous year.
778
JMSMS
CORN OIL LOWERS
serum
cholesterol
Physicians are well aware of recent
reports that blood cholesterol levels
tend to decrease significantly in
humans when a substantial part of
the dietary fat is supplied as polyun-
saturated vegetable oil. Many clinical
and experimental studies have shown
Mazola Corn Oil to be particularly
effective as a cholesterol-reducing
agent.
In the dietary management of blood
cholesterol levels it is practical to de-
crease the total daily intake of fat
and substitute Mazola Corn Oil for a
substantial -amount of the saturated
fat. Corn oil can be included in the
daily diet as salad dressings and in
a variety of other ways* without the
usual inconveniences of dieting.
Mazola Corn Oil is a product every-
one knows, respects, enjoys and keeps
on hand.
Do you have "Vegetable
Oils in Nutrition? '
If not, you may have
this 88-page reference
and monograph
ivithout charge. Write to
Medical Department,
Corn Products Refining
Company, 1 7 Battery
Place, New York 4, N. Y.
MAZOLA® CORN OIL IS
DERIVED 100% FROM CORN
• It is in its natural form —
no f hydrogenated
• It contains no cholesterol
pM I
i •
i •
Over 85% of its component fatty
acids are unsaturated
It is rich in the metabolically
specially important linoleic acid
It is an excellent carrier for
fat soluble vitamins
It is well tolerated, readily
digested and easily absorbed
It is suitable for inclusion in the
daily diet in a wide variety of ways*
*A collection of recipes
using Mazola Corn Oil
is available on request.
e, 1957
CORN PRODUCTS REFINING COMPANY
Say you saw it in the Journal of the Michigan State Medical Society
779
♦ ♦ ♦ ♦ ♦
. NEWS MEDICAL
MICHIGAN AUTHORS
J. Reimer Wolter, M.D., Ann Arbor, is the author
of an article entiled “Retinitis Pigmentosa” published in
AMA Archives of O phthalmology, April, 1957.
Elisha S. Gurdjian, M.D., John E. Webster, M.D.,
Francis A. Martin, M.D., and Warren G. Hardy, M.D.,
Detroit, are the authors of an article entitled “Carotid
Compression in the Neck — Results and Significance in
Carotid Ligation,” read before the Section on Nervous
and Mental Diseases at the 105th Annual Meeting of
the American Medical Association, Chicago, June, 1956,
and published in the Journal of the American Medical
Association, March 23, 1957.
Charles Dorando, B.A., and Max Karl Newman,
M.D., Detroit, are the authors of an article entitled
“Bracing for Severe Scoliosis of Muscular Dystrophy
Patients,” published in the Physical Therapy Review,
April, 1957.
Jack Lapides, M.D., was the moderator, and James
Pierce, M.D., Sheldon Fellman, M.D., Jack Bobbitt,
M.D., James Coppridge, M.D., Ralph Straffon, M.D.,
and James Morrow, M.D., all of the Department of
Surgery, University of Michigan Medical School in
Ann Arbor, were the participants in a symposium pre-
sented for the Section of Urology Seminar on December
11, 1956, entitled “Renal Tubular Acidosis: A Review,”
published in the University of Michigan Medical Bulle-
tin, March, 1957.
Lloyd J. Lemmon, M.D., Pittsburgh, Arthur L.
Drew, M.D., Indianapolis, and Janice G. Glimn, M.D.,
and James E. Higgins, M.D., Ann Arbor, are the au-
thors of an article entitled “Study of Cerebrospinal
Fluid Proteins with Paper Electrophoresis. III. The
Guillain-Barre Syndrome (Preliminary Report),” pub-
lished in the University of Michigan Medical Bulletin,
March, 1957.
Theodore G. Osius, M.D., Ann Arbor, is the author
of an article entitled “The Historic Art of Poisoning,”
published in the University of Michigan Medical Bulle-
tin, March, 1957.
Leo S. Figiel, M.D., and Steven J. Figiel, M.D., De-
troit, are the authors of an article entitled “Gallstone
Obturation of the Duodenal Bulb,” published in the
American Journal of Roentgenology, Radium Therapy
and Nuclear Medicine, July, 1956.
D. K. Rush, M.D., L. S. Figiel, M.D., and S. J.
Figiel, M.D., Detroit, are the authors of an article en-
titled “Rokitansky-Aschoff Sinuses, Historical Review
and Presentation of Three Cases,” published in The
Grace Hospital Bulletin, January, 1957.
S. J. Figiel, M.D., L. S. Figiel, M.D., and H. A,
Shulntan, M.D., Detroit, are the authors of an article
entitled “Gas Within the Fetal Circulation Indicating
Fetal Death,” published in The Grace Hospital Bulle-
tin, January, 1957.
J. S. DeTar, M.D., Milan, is the author of an article
entitled “The Generalist, the Hospital and the AMA,”
which was part of a symposium on “Methods of Evalu-
ating Medical Care in Hospital.,” presented before the
86th annual session of the Colorado State Medical
Society, September, 1956. The article was published
in the Rocky Mountain Medical Journal, December,
1956.
* * *
S. J. Figiel, M.D., L. S. Figiel, M.D., and D. K.
Rush, M.D., of the Department of Radiology, Grace
Hospital, Detroit, Michigan, presented a paper and
exhibit on “High KV Spot Compression Roentgenology
for Detection of Colonic Polyps” at the annual meeting
of the American Proctologic Society held at New Or-
leans, April 22-27, 1957.
* * *
M. K. Newman, M.D., Detroit, presented a paper
before the Wayne County Chiropodist’s Society at the
Veteran’s Memorial Building on April 2, 1957. The
title of the talk was “A Comparison of Objective Ex-
amination in Peripheral Arterial Circulation: Calorim-
etry, Thermometry, Digital Plethysmography and Radio
Isotope Tracer Techniques.”
* * *
Paul R. Dumke, M.D., was chairman of the Pro-
gram Committee for the Second All-Day Meeting of
the Michigan State Society of Anesthesiologists, held
on May 25, 1957 at the Hotel Statler in Detroit. Ap-
pearing on the program were: Ivan B. Taylor, M.D..
N. M. Bittrich, M.D., Arch V’R. Kane, M.D., Robert
E. Mosher, Ph.D., Mary McLaren, M.D., Edward T.
Glowacki, M.D., Shirley Austin, M.D., and William
Myers, M.D., all of Detroit: Thomas B. Bolton, M.D.
London, England: Daniel W. Johnston, M.D., William
B. Jensen, M.D., Mary Lou Byrd, M.D., Richard C,
Houghton, M.D., of Grand Rapids; E. M. Papper,
M.D., New York, N. Y.; John B. Stetson, M.D., Anr
Arbor; Edwin J. de Beer, Ph.D., Tuckahoe, N. Y.
Edward Connor, M.D., and I. D. Nickerson, M.D..
Royal Oak, Michigan.
* * *
A paper entitled “Muscular Dystrophy in Terms oi
Its Evaluation, Prognosis, Diagnosis and Its Manage
ment by Physical Medicine and Rehabilitation” was
( Continued on Page 782)
780
JMSMS
a penetrant emulsion
for chronic
constipation
[PLAIN)
COLLOIDAL EMULSION OF MINERAL OIL AND IRISH MOSS
permeates the hard, stubborn stool of chronic
constipation with millions of microscopic
oil droplets, each encased in a film of Irish moss . .
makes it more movable
makes it more movable
KONDREMUL (Plain)— Pleasant- tasting and
non-habit-forming. Contains 55% mineral oil.
Supplied in bottles of 1 pt.
KONDREMUL (With Cascara)— 0.66 Gm. nonbitter
Ext. Cascara per tablespoon. Bottles of 14 fl.oz.
KONDREMUL (With Phenolphthalein) — 0.13 Gm.
phenolphthalein (2.2 gr.) per tablespoon. Bottles of 1 pt.
When taken as directed before retiring, KONDREMUL
does not interfere with absorption of essential nutrients.
THE E. L. PATCH CO. — STONEHAM, MASSACHUSETTS
ne, 1957
Say you saw it in the Journal of the Michigan State Medical Society
781
KONDREMUL / PATCH
NEWS MEDICAL
(Continued from Page 780)
presented before the American College of Pnysiciar
on April 11, 1957 by M. K. Newman, M.D., Detroi
BURDICK UT-4
ULTRASONIC UNIT
The acceptance of ultrasonic therapy as a standard
office procedure points up the need for an efficient
compact unit.
Combining light weight, effective radiating inten-
sity and automatic control features, the UT-4 sets
a new standard of economy and convenience in
ultrasonic treatment for every physician’s office.
Among the many features of the Burdick UT-4 are:
•Weight — 25 pounds
• Size — 16 x 12 x 9 inches
• Radiating area — 6 cm2
• Effective intensity — 2!/2 watts/cm2
• Automatic timer
• Meter — registers intensity and output
• Price — under $400
For a full appreciation of the many features of
the UT-4 see your Burdick dealer — or write us
for information.
THE BURDICK CORPORATION, MILTON, WISCONSIN
THE G. A. INGRAM COMPANY
4444 Woodward Avenue, Detroit 1, Michigan
* * *
The Student American Medical Association Founda
tion, established to give financial aid to growing nutr
bers of medical students in their last three years of trair
ing, has announced that twenty-four persons prominer,
in the fields of medicine, education, and industry has-
been named honorary trustees of the Foundation.
The honorary trustees, including two men fror
Michigan, who will serve in an advisory capacity ar
as follows:
Donald J. Cowling, Ph.D., past president, Carleto
College, Minneapolis; Gerald D. Dorman, M.D.. medi
cal director, New York Life Insurance Company, Ne\
York; Gilson Colby Engel, M.D., surgeon, Philadelphia
Gunnar Gundersen, M.D., chairman, board of trustee;
A.M.A.; William A. Hyland, M.D., surgeon, Gram
Rapids, Michigan; Ernest E. Irons, M.D., past president
A.M.A., Chicago; L. D. Johnson, Jr., vice president
Mead Johnson & Company, Evansville; Theodore G
Klumpp, M.D., president, Winthrop Laboratories, Nev
York; Harry J. Loynd, president, Parke Davis & Com
pany, Detroit; Edward J. McCormick, M.D., past presi
dent, A.M.A., Toledo; Walter Martin, M.D., pas
president, A.M.A., Norfolk, Va.; J. Roscoe Millei
M. D., president, Northwestern University, Evanston
Franklin Murphy, M.D., chancellor, University o
Kansas, Lawrence, Kansas; W. A. Patterson, president
United Air Lines, Chicago; William Alan Richardson
editor, Medical Economics, Oradell, New Jersey; Edwan
C. Rosenow, Jr., M.D., physician, Pasadena, California
John G. Searle, president, G. D. Searle & Company
Chicago; Austin Smith, M.D., editor, Journal of th
American Medical Association, Chicago; George F
Smith, president, Johnson & Johnson. New Brunswicl
N. J.; Faustin J. Solon, vice president, Owens-Illinob
Toledo; Henry Tenney, senior partner, Tenney, Sher
man, Bartlett & Guthrie, Chicago; Ernest Volwilei
Ph.D., president. Abbott Laboratories, North Chicago
Thomas J. Winn, vice president, Chas. Pfizer, Brooklyn
and James C. Worthy, vice president. Sears, Roebucl
& Company, Chicago.
•*■■*•*
The American Medical Association, through its Coun
cil on National Defense, sponsored its Fifth Annua
National Medical Civil Defense Conference on Satur
day, June 1, at the Waldorf-Astoria, New York City
Four Michigan men were participants in the program
Jack C. Greene, Director, Radiological Defense Divi
sion; Francis B. Stewart, Col. U.S.A.R. Consultant
Chemical and Biological Warfare Defense; Benjamin C
Taylor, Director, Engineering Office; and M. M. Vai
Sandt, M.D., Director. Medical Care Division, all o
Federal Civil Defense Administration, Battle Creek
Michigan.
* * *
The American Board of Obstetrics and Gynecology
announces that applications for certification, new ant
(Continued on Page 784)
782
Say you saw it in the Journal of the Michigan State Medical Society
JMSM:
n Hay Fever or Asthma . . .
Family Physicians use
lesensifization
for perennial
results
easily, pleasantly and economically
IFIC DESENSITIZATION
PERENNIAL RESULTS
ly accomplished quickly and accurately
r physician. First, skin test each patient
simple scratch test method and determine
it allergens the patient reacts. Barry has
1 Pollen Pak for Hay Fever and seasonal
i cases. Cost $1.50 for 21 tests of tree,
and weed pollens, fungi, house dust —
lual selection to meet your botanical re-
lents. Simple, safe, time proven technique
plete directions for your nurse. Ready to
>ort forms included. Send for yours today.
REE SCRATCH TEST SET
th each Rx Specific Desensitization Set
prepared according to your
patient’s own skin test reactions.
are obtained by desensitization against those specific
irritants to which your patients reacted by the scratch
test. Record your reactions on the convenient report
card enclosed in each test set. Each desensitization
formula is individually prepared for each patient ac-
cording to his own needs and thereby renders the best
specific results of any medication possible. Each treat-
ment 3-vial set (20 doses) is ready mixed and diluted
with individually planned treatment schedule. If you
already have skin tested your patient, send your reac-
tions to the Allergy Division, Barry Laboratories, Inc.
Complete service $12.50. Prompt 7-10 day service for Rx’s.
BARRY LABORATORIES, INC
Allergy Division
DETROIT 14, MICHIGAN
since I 1928
NEWS MEDICAL
BAND-AID
TRADE MARK
Plastic Strips
• ELASTIC PLASTIC
• FLESH COLORED
• STAYS CLEAN
• THIN, SMOOTH PLASTIC
• GREASE RESISTANT
• WON'T WASH OFF
1 00’s 1 "x 3"
100’s 3/4"x3"
CoHienienthf facetted
in (fraud Rapid*
• Hospital Equipment
• Pharmaceuticals
• Office Equipment
• Physicians’ Supplies
• Trusses
• Surgical Garments
• Physiotherapy Equipment
Medical Arts Supply Company
233 Washington S. E. Phone GL 9-8274
Grand Rapids 2, Mich.
Medical Arts Pharmacy
20-24 Sheldon S.E. Phone GL 9-8274
Grand Rapids 2. Mich.
(Continued from Page 782)
reopened, for the 1958 Part I Examinations are now
being accepted. All candidates are urged to make sue!
application at the earliest possible date. Deadline datf
for receipt of applications is September 1, 1957. N<
applications can be accepted after that date.
Candidates for admission to the examinations are re
quired to submit with their applications, a typewrittei
list of all patients admitted to the hospitals where the;
practice, for the year preceding their application, oi
the year prior to their request for reopening of theii
application. This information is to be attested to by th<
Record Librarian of the hospital or hospitals where, thi
patients are admitted and submitted on paper 8 l/i x 11.’
Necessary detail to be contained in the list of admission:
is outlined in the Bulletin and must be followed closely
Current bulletins outlining present requirements ma;
be obtained by writing to the Secretary’s office: Rober
L. Faulkner, M.D., American Board of Obstetrics anc
Gynecology, 2105 Adelbert Road, Cleveland 6, Ohio
* * *
Disclosure that Dr. Frederick D. Mott is leaving Johi
L. Lewis for Walter Reuther is new evidence that th<
latter’s new Community Health Association in Detroi
is an ambitious venture. Ever since his New Deal day:
in Farm Security Administration two decades ago, Dr
Mott has been a trail blazer in prepaid, group care
His decision to give up directorship of Miners Memoria
Hospital Association of United Mine Workers and shif
to the Michigan organization, founded and headed b'
Reuther, is assurance that CHA will be a dynamii
undertaking. Dr. Mott will be executive director, effec
tive September 1. He steps out of his present post oi
June 30, to be succeeded by his deputy, Dr. Johi
Newdorp.— W.R.M.S., May 16, 1957.
* * *
British physicians are caught between spiraling cost
and the Ministry of Health which in 1951 arbitrarily
decided that all family doctors should earn the equiva
lent of $6,200 a year. Costs of labor have risen 35 pe
cent, and the physicians asked an increase of 24 pe
cent, but were offered 5 per cent. They are threatenini
to resign in a body. They have been quoted as threat
ening to strike, but will instead carry on a fee fo
service basis, and send their bills to their . patients — no
the government. British medicine failed to form stroni
medical associations, and were given promises whicl
were not kept. They are now convinced.
* * *
The American Psychiatric Association has set up :
project to study ways by which a greater understandini
of psychiatry can be conveyed to physicians in genera
practice. The project has been made possible by a gran
from the National Committee Against Mental Illness
The project will be administered at the Central Offic
of the American Psychiatric Association under the Medi
cal Director, Daniel Blain, M.D., Washington, D. C
A Liaison Committee with the American Academy o
(Continued on Page 786)
784
Say you saw it in the Journal of the Michigan State Medical Society
JMSM
chances are
3 to 1 it'll be a Chest Film*...
;~l. mmzmm — mm&. ^ — %m>&
You might suppose a good chest film would be easy to take.
Yet this “simple” examination is often very troublesome.
The trick is to get consistent uniformity so films
of a given patient taken at long intervals will always be
dependably comparable in density and contrast.
If you’re an expert technician, you juggle kilovoltage,
time, milliamperage and focal spot to suit each patient.
If you’re not, you guess . . . wrong, too often.
There’s no guessing, though, when you work with a
Picker “Anatomatic” x-ray control. It automatically
integrates and sets up the whole complex of correct
exposure factors for individual parts of individual patients.
You need no charts, make no calcidations.
* National hospital surveys indicate that
33% of all roentgen examinations are
chest films. Next in number are all ex-
tremities, averaging 10%.
here's all you do...
CHEST
HEART
PA/Obl
dial the bodypart
this chest station is one of
22 bodypart stations
set its thickness
to the measured thickness
of the part
<?: take it!
^ that's all
Companion to the Picker Anatomatic control
is this efficient “Century” x-ray table
... a table with the rich look you’d expect to find
only in upper-bracket x-ray equipment.
The single tube converts from fluoroscopy
to radiography and vice versa in a jiffy.
100 ma and 200 rna models.
Let your local Picker man tell you more
about this remarkable x-ray machine
... or write Picker X-Ray Corporation,
25 South Broadway, White Plains, New York.
new way in x-ray
PICKER "ANATOMATIC"
DETROIT 21, MICH., 8514 W. McNichols Road
Battle Creek, Mich., 231 Eldred Street
Grand Rapids 8, Mich., 48 Honeoye S.W.
Pontiac, Mich., 1415 Oakwood Drive
Flint, Mich., 4734 Canterbury Lane
me, 1957
Say you saw it in the Journal of the Michigan State Medical Society
785
NEWS MEDICAL
for modern
control of
salt retention
edema
CUMERTILIN'
(Brand of Mercumatilin, Endo)
Tablets
• effective oral diuretic with no sig-
nificant gastrointestinal irritation1
• Suitable for long-term mainte-
nance therapy.
• eliminates need for injections ir
certain cases, lengthens interval
between injections in others
• basically different in chemical
structure, extending the therapeu-
tic choice in organic mercurials
DOSAGE: 1 to 3 tablets daily as required.
SUPPLIED: As orange tablets, in bottles
of 100 and 1000. Also available —
CUMERTILIN Sodium Injection, 1- and 2-cc.
ampuls, in boxes of 12, 25, and 100; and
10-cc. vials, individually and in boxes
of 10 and 100.
1. Pollock, B. E., and Pruitt, F. W.: Am. J. M.
Sc., 226:172, 1953.
THE G. A. INGRAM COMPANY
4444 Woodward Avenue, Detroit 1, Mich.
(Continued from Page 784 )
General Practice will serve the project in an advisor’
capacity.
The Liaison Committee has proposed that the genera
urgent need for expanding psychiatric services in com
munities throughout the nation can most readily an:
practicably be met by general practitioners if they cat
be armed with appropriate basic knowledge of psychiatrii
skills and practices. Ways must be explored to accorn
plish this — by setting up model post-graduate courses
developing standards for training, training films, coursi
materials, and above all a broad promotional effor
which will stimulate the general practitioner’s interes
in psychiatry and community action in this area.
Plans for the Midwest Cardiac Conference, to be helc
October 3, 4 and 5, 1957, at the Iowa State University
Hospitals in Iowa City, have been announced by the
Iowa Heart Association, co-sponsors of the scientific
session. No registration fee will be charged.
* * *
The Detroit Dermatological Society, at its annual
meeting, April 24, 1957, elected to office for the year
1957-1958, the following:
President Coleman Mopper, M.D.
President-elect George B. Sexton, M.D.
Secretary-Treasurer Alice E. Palmer, M.D.
Recorder Robert E. Burns, M.D.
Dr. Sexton is a resident of London, Ontario, Canada.
The other officers are from Detroit.
* * *
For every 10,000 people x-rayed
through community-wide surveys using
small film mobile x-ray units, eight
active cases of tuberculosis are found
in Michigan.
In 1955, the most recent year for
which complete figures are available,
mobile units x-rayed 12 per cent of
Michigan's population fifteen years of
age and older. In only three counties
50 per cent or more of the adult popu-
lation was screened. Mobile units oper-
ated in fifty-nine counties, mostly on a community-wide
basis. On the average, 14 per cent of the adults of these
fifty-nine counties were x-rayed in 1955.
Unknown, untreated cases of tuberculosis are the
sources of new infections and new cases. If the new
cases are not discovered, tuberculosis will continue to
spread to countless other persons. — Michigan Tuber-
culosis Association.
* * *
The American College of Gastroenterology announces
that its annual course in Postgraduate Gastroenterology
will be given at The Somerset in Boston, Massachusetts,
on October 24, 25, and 26, 1957.
The course will again be under the direction and co-
chairmanship of Owen H. Wangensteen, M.D., Professor
of Surgery of the University of Minnesota Medical
School, who will serve as surgical co-ordinator and I.
(Continued on Page 788)
786
Say you saw it in the Journal of the Michigan State Medical Society
JMSMS
water.
Baker s Modified Milk is a complete
infant food, easy to prescribe and pre-
pare in hospital and home.
Available in liquid and powder forms,
both are made exclusively from Grade A
Milk (U.S.P.H.S. Milk Code). Both con-
tain all requirements for complete
infant nutrition.
Baker's Liquid — generally preferred for
its greater ease of preparation.
Baker's Powder — particularly
adaptable for feeding prematures
\ and for use as complemental
and supplemental feedings.
% \ Both forms are extremely
'V,v low in price, costing less
Ik \ than a penny per
w \. ounce of formula.
Furnished to hos-
pitals without
charge, of course.
Liquid
BAKER'S MODIFIED MILK
THE BAKER LABORATORIES, INC.
/idi/A Tfadaotd 'Aw MedimL ffiofe&Aioiv
Powder *'°,B Office? Cleveland 3, Ohio e Plant: East Troy, Wisconsin
)E, 1957
Say you saw it 'in the Journal of the Michigan State Medical Society
787
NEWS MEDICAL
GRADATIONS OF ANALGESIA
‘TABLOID’ WIRIN' COMPOUND®
Acetophenetidin gr. 2Vz, Acetylsalicylic
Acid gr. 3V2, Caffeine gr. Vz
i , ‘TABLOID’ EMPIRIN' COMPOUND
with CODEINE PHOSPHATE gr. >/., No. 1 (n)
‘TABLOID’ ‘EMPIRIN’ COMPOUND
with CODEINE PHOSPHATE gr. 'A, No. 2 (n>
‘TABLOID’ ‘EMPIRIN’ COMPOUND
with CODEINE PHOSPHATE gr. Vz, No. 3 <ni
^‘TABLOID’ ‘EMPIRIN’ COMPOUND
^with CODEINE PHOSPHATE gr. 1, No. 4 m
(N) subject to Federal Narcotic Law
BURROUGHS WELLCOME & CO. (U.S.A.) INC.
Tuckahoe, N. Y.
(Continued from Page 786)
Snapper, M.D., Director of Medical Education, Beth
Hospital, Brooklyn, N. Y., who will serve as medi j
co-ordinator. Drs. Wangensteen and Snapper will
assisted by a distinguished faculty selected from
medical schools in the Boston area.
The subject matter to be covered in the course, fr
a medical as well as surgical viewpoint, will cov
essentially, the advances in diagnosis and treatment
gastrointestinal diseases and a comprehensive discuss:
of diseases of the mouth, esophagus, stomach, pancre
spleen, liver and gall bladder, colon and rectum, w |
special studies of radiology and gastroscopy.
For further information and enrollment, write
the American College of Gastroenterology', 33 West 6(
Street, New York 23, N. Y.
* * *
Thomas Francis, Jr., M.D., Chairman of the Depa
ment of Epidemiology in the University of Michig
School of Public Health, has evaluated the 1954 fie
trials of the Salk vaccine. He advises the booster as
safety measure “until we have a much firmer picture
the lasting potency of the vaccine.” He suggests ch
dren and teen-agers should get the booster to he
“make sure the vaccine has an opportunity to exert
full effect.”
He does not recommend that the Salk booster she
become an annual affair, however. Citing the fact th
this is only the third year the vaccine has been us
on a national basis. Dr. Francis says boosters will pro
ably be needed less frequently as improvements in t
potency and consistency of the vaccine are made.
Should a shortage of vaccine occur. Dr. Franc
believes the under-twenty age group should receive fii
priority in getting their initial series of three sho
Children who had the series a year or more ago shou
receive second priority for vaccine.
* * *
The current fad for non-fat diets runs the risk
doing irreparable harm to liver and kidneys, a Dearbo
heart specialist recently stated.
Lesem J. Baer, M.D., in a talk before the Michig;
Diatetic Association, said: “There is still much to
learned about the harmfulness of fat in the diet.” I
advised the public to “pay no attention to the c
about unsaturated fatty acids, unless under the dire
advice of a physician.” A diet composed of no mo
than 25 per cent fat is restricted to a level that is sa:
he added.
Dr. Baer noted atherosclerosis has been with m
since the days of early Egypt. Evidence of it has be
found in mummies 3,000 years old. “In those da;
people did not have alcoholic beverages as we ha
today, nor did they have too much food,” he sa:
“But they did have taxes and they certainly experienc
psychological stress.”
* * *
The International Society of Internal Medicine I
announced that its Fifth International Congress of 1
ternal Medicine will be held at the new Sheraton Hot
Philadelphia, Pennsylvania, April 24-26, 1958. T1
788
Say you saw it in the Journal of the Michigan State Medical Society
JMSi
NEWS MEDICAL
be the first meeting of the Society outside of Europe,
making the announcement, the International So-
y’s President, Sir Russell Brain, who is also President
the Royal College of Physicians of London, said,
le Executive Committee of the Society has chosen
United States for its Fifth Congress in response to
invitation extended by the American College of Phy-
ins and with the objective of securing greater
erican participation in its deliberations and of
wing foreign members, at first hand, to learn more
it American developments in the medical sciences.”
he previous Congresses, at two year intervals, were
l in Paris, London, Stockholm and Madrid. At those
tings, however, the United States, as well as many
■r nations throughout the world, was represented,
present membership of the Society, including forty-
t nations, is about 3,000.
he objectives of the Society, as stated in its Statutes,
“to promote scientific knowledge in internal medi-
, to further the education of the younger generation
to encourage friendship among physicians of all
itries.” The members are “specialists in internal
ases, acknowledged as such and accepted by the
ropriate national societies of internal medicine.”
t the Philadelphia Congress it is planned, through
ares and panels, to analyze medical achievements of
ld-wide significance, to evaluate certain apparent
ilems and to chart courses of action designed to
ance technical knowledge and to aid in the continu-
war against disease. At the same time, the plan
udes such social and cultural activities as will tend
)romote co-operation, friendship and mutual under-
ding among physicians and peace among their coun-
he 1958 Annual Session of the American College of
sicians will occur in Atlantic City, April 28 to May
nmediately following the Philadelphia Congress. The
ibers of the Congress are invited to attend all the
atific programs and extensive exhibits (the foreign
ibers on a purely courtesy basis). Also, those mem-
of the Society who make an early reservation and
ince payment, may join certain Fellows of the
ege on its customary post-convention cruise to a
•-by foreign country. Tours throughout the United
es may be arranged through an approved travel
icy.
* * *
he Association of Military Surgeons of the United
es will hold its annual convention at the Hotel
ler, Washington, D. C., October 28-30, 1957. The
/ention will have as its theme, “Professional Excel-
e — The Criterion of Military Medicine.”
'riginally, the association was organized to work for
“advancement of military and accidental surgery and
things pertaining to the health and welfare of the
ian soldier,” and was restricted to membership by
ical officers of the National Guard. Although the
ctives of the organization remain the same, member-
is now open to all present and former officers of the
lical, Dental, Veterinary, Medical Service, Nurse,
Medical Specialist Corps of the Army, Navy and
GRADATIONS OF ANALGESIA
with light sedation
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(N) subject to Federal Narcotic Law
BURROUGHS WELLCOME & CO. (U.S.A.) INC.
Tuckahoe, N. Y.
e, 1957
Say you saw it in the Journal of the Michigan State Medical Society
NEWS MEDICAL
Air Force, as well as personnel from the Public Health
Service and Veterans Administration.
Each year the convention draws approximately 2,000
members from all parts of the nation as well as leading
medical members of military organizations from other
countries. * * *
The President's Committee for Traffic Safety believes
that you can help reduce accidents by obtaining (1)
uniform laws and ordinances, (2) education in all
schools, (3) enforcement officers who are specially
trained, (4) an active accident records bureau, (5) an
effective motor vehicle administration including im-
proved driver examinations and re-examinations of re-
peated violators, (6) traffic engineering principles, and
(7) adequate public information and support. — Genesee
County Medical Bulletin.
* * *
Harold F. Falls, M.D., associate professor of ophthal-
mology at the University Medical School, advises that
“children surviving enucleation (removal of the eyeball)
for retinoblastoma should make a decision about steri-
lization.”
Each year this cancer of the eye causes an increasing
number of parents to face the decision of whether to
allow doctors to remove one or both of their children’s
eyes so the youngsters may live.
Retinoblastoma, which appears in children between
the ages of two months and four years, presents not
onlv immediate danger to the youngsters, but perhaps
long-run impairment to the genetic make-up of future
generations.
New unit has big 9x1 6-inch chamber,
bulk supply rack, two oversize trays;
one 8'/2 » 15". In addition, unit
has built-in water level gauge, re-
versible door swing smooth, easy-to-
clean surface.
NOBLE-BLACKMER, Inc.
It is definitely known that if either parent has h
the disease and has survived, the parent may transr
the gene to half his children. Chances are “extreme
remote” that offspring will turn up with the disease
no others in the family have it.
•* * *
Scientists need both freedom and funds to be higf
productive, a University of Michigan study conduct
by the Survey Research Center (SRC) of the U-
Institute for Social Research, shows.
The study deals primarily with the output of resear
publications as a measure of productivity. It does n
cover originality, creativity or other specific facte
related to this phenomenon. In checking the validity
its data, however, the Center found approximately t
same results would have been obtained had professior
citations been used as a measure of productivity.
It was found that a low number of publications d
not detract from performance ratings, but most of the
with high publication output were also regarded as hi
performers by their colleagues.
* * *
A $50,000 gift to the surgery department of Way
State University’s College of Medicine has been a
nounced as a major bequest from the estate of a pron
nent Detroit physician and former instructor at t
University of Michigan medical school.
According to the will of Dr. William A. Spitzley, t
money is in honor of Dr. Grover C. Penberthy, clinic
professor of medicine at Wayne’s College of Medici
( Continued on Page 792)
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CALL US FOR A DEMONSTRATION
267 W. Michigan Ave., Jackson, Mich.
790
Say you saw it in the Journal of the Michigan State Medical Society
TMSI
>T. JOSEPH’S RETREAT
Member: American Hospital Association
Catholic Hospital Association
National Association of Private
Mental Hospitals
The Central Neuro-Psychiatric
Hospital Association
Under the direction of the
Daughters of Charity of St. Vincent de Paul
Serving Metropolitan Detroit
and Michigan almost a century
Martin H. Hoffmann, M.D.
Medical Director
23200 West Michigan Avenue
Dearborn
Logan 1-1400
PREVENTIVE GERIATRICS
a FIRST from TUTAG !
Now — 20 to 1 Androgen-Estrogen
(activity) ratio* !
Each Magenta Soft Gelatin Capsule contains:
Methyltestosterone 2 mg.
Ethinyl Estradiol 0.01 mg.
Ferrous Sulfate 50 mg.
Rutin 10 mg.
Ascorbic Acid 30 mg.
B 12 1 meg.
Molybdenum 0.5 mg.
Cobalt 0. 1 mg.
Copper... 0.2 mg.
Vitamin A.. 5,000 I.U.
Vitamin D 400 I.U.
Vitamin E 1 I.U.
Cal. Pantothenate 3 mg.
Thiamine Hcl. 2 mg
Riboflavin 2 mg
Pyridoxine Hcl. 0.3 mg
Niacinamide 20 mg
Manganese .. I mg
Magnesium 5 mg
Iodine 0.15 mg
Potassium 2 mg
Zinc 1 mg
Choline Bitartrate 40 mg
Methionine . 20 mg
Inositol 20 mg
5. J. TUTAG
W rile for Latest Technical Bulletins.
REFERENCE: J.A.M.A. 163: 359, 1957 (February 2)
MICHIGAN
«e, 1957
Say you saw it in the Journal of the Michigan State Medical Society
791
NEWS MEDICAL
(Continued from Page 790)
since 1913. The bequest was that the money be used
for research as determined by chairman of the surgery
department, Dr. Charles Johnston.
Dr. Spitzley, who died in March, 1956, was a Detroit
pioneer in lung surgery. He co-authored one of the
first modern textbooks on surgery.
In his will, Dr. Spitzley requested that a fund should
be established and named after Dr. Penberthy. Dr.
Spitzley said he wanted to honor Dr. Penberthy and to
pay tribute to him and his work “in expression of my
lifelong admiration for his professional integrity.’’
* * ■*
Wayne State University’s Board of Governors re-
cently reviewed gifts and grants totalling $151,800 at
their monthly meeting. Medical and educational re-
search areas received a major portion of $148,212;
student aid gifts, $4,325 and equipment gifts were
estimated at $1,000. Largest single medical grant of
$25,000 came from the U. S. Public Health Service for
training in neurology under direction of Dean Gordon
H. Scott. * * *
Relief for sufferers of hemophilia and potential bleed-
ers may be in sight as the result of work by Walter H.
Seegers, M.D., of Wayne State University’s College of
Medicine. Dr. Seegers has announced the isolation of
an anti-hemophilic factor (AHF) in blood which he
calls platelet cofactor I.
Speaking before the American Chemical Society, Dr.
Seegers recently said that AHF may be absent from the
blood of persons ill with hemophilia or an inhibitor n
be present which overcomes the effect of AHF, preve
ing the blood from clotting. Existence of AHF
theorized by blood researchers almost thirty years a
Dr. Seegers adds this scientific achievement to
other he made early in his career — the isolation
thrombin.
* * *
John M. Sheldon, M.D., Ann Arbor, was gc
speaker at the 89th Annual Session of the Nebra
State Medical Association in Omaha, May 13.
subject was “Office Management of Allergic Probleir
* * *
John R. Rodger, M.D., Bellaire, was winner of <
of the 1956 Ross Awards to general practice authors
GP , the magazine) for his article “Sleepy Driver a:
Preventive Medicine Problem.”
The award consisted of a scroll and a $1,000 h>
orarium.
Congratulations, Dr. Rodger!
* * *
William A. Hyland, M.D., Grand Rapids (MSI
Treasurer and Past President), is one of the Honor
Trustees of the Student AMA Foundation, establisl
in 1955 to give financial aid to growing numbers
medical students in their last three years of training
Congratulations, Dr. Hyland!
•* * *
The American Association of Rehabilitation The
pists, the Association for Physical and Mental Rehab
BRIGHTON HOSPITAL
A non-profit Foundation
FOR ALCOHOLISM
A facility designed to rehabilitate or to aid
the addict in arresting his addiction.
Walter E. Green, M.D., Superintendent and Medical Director.
Brighton Hospital meets the stand-
ards established by the Michigan
State Board of Alcoholism and is
recommended by that Board.
12851 East Grand River
(U.S. 1G)
Brighton, Michigan
Academy 7-1211
792
Say you saw it in the Journal of the Michigan State Medical Society
JMSI
NEWS MEDICAL
ion, and the Association of Medical Directors and
-ordinators will hold a joint convention at the Con-
I Hilton Hotel in Chicago, July 7 to 12, 1957. For
>gram, write Charles Armon, President, AMD&C,
15 W. Highland Avenue, Chicago 31, Illinois.
* * *
[ohn R. Rodger, M.D., Bellaire, advocated before a
irch Meeting of the House Traffic Safety Subcom-
:tee in Washington that a federal agency to set
omobile safety standards be formed. Dr. Rodger,
resenting the Michigan State Medical Society, said
t Michigan’s experience with such a program indi-
es that a national program would save 4,000 lives
'ear within ten years.
Dr. Rodger is chairman of the MSMS Study Corn-
tee on Prevention of Highway Accidents.
Michigan names in the news during the March
mtific session of the American Academy of General
ctice in St. Louis included John E. Webster, M.D.,
roit neurosurgeon, guest essayist, and Richard A.
rington, M.D., from a small community near Milan,
ffiigan, winner of a Mead Johnson $1,000 award to
.956 medical school graduate who plans a career
i family doctor.
irooker L. Masters, M.D., was honored with a testi-
rial dinner given by the Gerber Memorial Hospital
Fremont in March, following Dr. Masters’ appoint-
lt as Medical Director of Michigan Hospital Service.
)r. and Mrs. Masters were presented by the Hospital
rd with a framed resolution expressing regret at
r departure and wishing him well in his new
eavor.
he Masters had resided in and served the Fre-
it community for the past ten years.
* * *
William Bromme, M.D., Detroit, discussed the “Fu-
of VA Hometown Medical Care Program” at the
il 6 Conference on Veterans' Affairs in New York,
he meeting was called by the AMA Committee on
eral Medical Services and Council on Medical Serv-
for the state medical society representatives of seven-
Eastern Region states.
imilar regional conferences were held in the Central
Western areas of the nation.
* * *
fflliam J. Burns, MSMS Executive Director, was
ar guest and speaker at Past Presidents’ Night of
Detroit Commercial Secretaries Association, Staffer
el, Detroit, April 17. Mr. Burns, who was a mem-
of the DCSA during the years 1930 to 1935, was
ared as Immediate Past President of the Michigan
iciation Executives Forum, composed of some 100
utives of business, professional and technical as-
itions in Michigan. Mr. Burns’ address on April
vas entitled “Changing Association Horizons.”
* * *
he Michigan Academy of Physical Medicine and
abilitation has been organized and incorporated
;r the laws of the State of Michigan. The object
EVERY WOMAN
WHO SUFFERS
IN THE
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DESERVES
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AYERST LABORATORIES
New York, N. Y. • Montreal, Canada
5646
e, 1957
Say you saw it in the Journal of the Michigan State Medical Society
NEWS MEDICAL
Dr. Masters, who graduated from the Indiana Un
versity School of Medicine in 1942, completed his ii
ternship at Sparrow Hospital, Lansing, in 1943.
He entered the U. S. Air Force under the residenc
training program that same year and was discharge
in 1946 as a Flight Surgeon with the rank of Majoi
Dr. Masters, who is thirty-nine, is married and th
father of four children^Diane, eleven; Jeffrey, eigh'
Craig, five, and Lorelie, two.
* * *
The least tangible but probably the most poter
factor in the existing favorable trend in mortality froi
tuberculosis is the general improvement in the standar
of living. Greater earning power has made possibl
more adequate nutrition and better housing. Reductio
in the average size of families has reduced overcrowd
ing, which in turn has lessened opportunities for th
spread of infection. Where economic levels have cor
tinued high, tuberculosis rates have fallen: when wa
or famine has intervened they promptly rise. It is mor
than coincidence that the levels of tuberculosis through
out the world are closely related to the economic levt
of the populations concerned. — Alton S. Pope, M.D
and John E. Gordon, M.D., Am. J. M. Sci., Sept., 1955
* * *
Congratulations, Genesee County Medical Society, o
the Trauma Edition of The Bulletin of May 2, 195
(Volume 29, No. 16). Contributors included George J
Curry, M.D.. on “Medical Aspects of Traffic Safety’’
R. E. Johnson, M.D., on “Effects of Chronic Disease
Conference held in January of this year. (Continued on Page 796)
of the Academy is “to promote the science and art of
medicine and the betterment of public health, through
an understanding and utilization of the functions and
procedures of physical medicine and rehabilitation."
Max K. Newman, M.D., Detroit, is President of the
Academy; James W. Rae, M.D., of Ann Arbor, is
Vice President; Frederic B. House, M.D., Ann Arbor,
is Secretary-Treasurer. Trustees include George K.
Koepke, M.D., Ann Arbor; Robert C. Dean, M.D.,
Detroit; and William C. Schaeffer, M.D., Detroit.
* * *
Brooker L. Masters, M.D., Fre-
mont, was named Medical Direc-
tor of Michigan Blue Cross and
took over the post on March 18.
Wm. S. McNary, executive vice
president of MHS, announced the
appointment. Dr. Masters replaced
Harry Becker, M.D., Battle Creek,
who resigned some months ago for
reasons of health.
Dr. Masters, a general prac-
titioner in Fremont since 1946,
has been active in administrative posts in medicine for
several years.
He is vice president and a member of the board of
trustees of the Michigan Health Council and has been
chairman of the Michigan State Medical Society Com-
mittee on Rural Health Service since 1953. He also
served as chairman of the Tenth Annual Rural Health
794
Say you saw it in the Journal of the Michigan State Medical Society
JMSM
H. G. Fischer & Co. ULTRASONIC Generator
Manufactured Solely in Franklin Park, III.
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3. Light Weight
4. One Control Operation
5. Easy-to-Read Meter Accurately Show*
Amount of Ultrasound the Patient is Re-
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6. Extra Large Active Crystal Surface of 10
Square Centimeters
7. Output of 3 Watts per Square Centimeter —
30 Watts Total
8. Accurate Treatment Timer
9. Highly Efficient Oscillating Circuit
10. Accurate Calibration
11. Beautiful Chrome-Plated Cabinet
12. Operates from the Usual Office Wall Outlet
of 110 Volts, 50-60 Cycles
13. Very Reasonably Priced
the creamy antacid
WORKS IN SECONDS
PROTECTS FOR HOURS
Superior Buffering Capacity
Gastralme stands out in comparison with other
products. In a recent test Gastralme neutralized the
acid within 5 minutes and a pH of 6.4-7. 1 was main-
tained for 120 minutes. After 150 minutes, the
Gastralme mixture continued to show a pH of 5.2, and
it was 180 minutes before the pH dropped to 2.9.
For treatment of
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Literature and
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MEYER & COMPANY
1 6361 Mack Avenue • Detroit 24, Michigan
1957
Say you saw it in the Journal of the Michigan State Medical Society
795
NEWS MEDICAL
Protection against loss of income from
accident and sickness as well as hospital
expense benefits for you and all your
eligible dependents.
PHYSICIANS CASUALTY & HEALTH
ASSOCIATIONS
OMAHA 2, NEBRASKA
Since 1902
SAMMOND PLEASANT LODGE
Oilers to the elderly and chronically ill
Peace and quiet. Freedom of a large and richly
furnished home and acres of lawns and wooded
rolling grounds, scientifically prepared tasty
meals, congenial companionship. A real
"Home away from Home"
Approved by the American Medical Association
and Michigan State Department of Social Wel-
tare — Highly recommended by members of the
Medical Profession who have had patients at
the Lodge.
For further information write to:
SAMMOND PLEASANT LODGE
124 West Gates Street
Romeo. Michigan
(Continued from Page 794)
and Certain Drugs”; Walter Z. Rundles, M.D.,
“Ophthalmology and Traffic Accidents”; Hyra
Branch, M.D., on “Driver Screening of Crippled a:
Afflicted Adults” : C. J. Scavarda, M.D., on “Otolo
and Traffic Accidents”; R. Gordon Brain, M.D.,
“Psychiatric Aspects of Driver Screening”; Franklin
Wade, M.D., on “Emergency Department Musts” a
“Hospital Stay of the Traffic Casualty”; Sydney
Lyttle, M.D., on “Clinical Evaluation of the Auto Cra
Victim”; Otto J. Preston, M.D., on “Medical-Le;
Aspects”; Harold W. Woughter, M.D., on “Summary
Three Controllable Factors in Traffic Safety.”
* * *
M.D. Placement
Through May I, 1957
Assisted by Michigan Health Council
Name Opened Practice
Bernard Veenstra. M.D., Grand Haven, Michigan
Charles R. Bacon, M.D., Coldwater. Michigan
William H. Isham, M.D., Detroit, Michigan (Ford H
pital)
* * *
MSMS President’s Itinerary
1956
Sept. 24-25 — Annual Meeting of House of Delegal
Detroit
Sept. 26 — Board of Directors of MMS
Sept. 26 — Radio interview at WKMH
Sept. 27 — Address at Wayne University Alumni Banqi
Sept. 28 — Council Meeting
Oct. 10 — Board of Directors MMS
Oct. 17 — Conference at Lansing
Oct. 19 — Indiana State Medical Annual Session, '
dianapolis
Oct. 24 — Conference in Lansing
Nov. 6 — Michigan Academy of GP’s Banquet
Nov. 8 — Presiding at morning session of MAGP’s
Nov. 28-30 — AMA Interim at Seattle, Wash.
Dec. 10 — Address before Southfield Kiwanis Club
1957
Jan. 4 — Council Meeting
Jan. 11-12 — CHA Conference at Whittier Hotel
Jan. 17 — Rural Health Conference, Kellogg Cem
East Lansing
Jan. 23-25 — Annual Meeting of the Council, Detroit
Jan. 25-26 — County Secretaries Meeting, Detroit
Jan. 26 — AMA Meeting on Polio, Chicago
Feb. 5 — Industrial Health Assoc. Conference
Feb. 6 — Board of Directors of MMS
Feb. 10 — Appearance on WJBK Television
Feb. 10 — Conference in Detroit
Feb. 21 — Conference in Lansing — two meetings
Feb. 23 — Wayne County Medical Society Preside'
Banquet
Feb. 26 — Conference with MHS
Feb. 27 — Address before Men’s Club Lutheran Chu
Mar. 3 — Committee on MMS at Lansing
Mar. 4 — Address before Economic Club at V
Memorial
Mar. 6 — Presiding at Conference on Trauma at Ls
ing ( AAGP)
Mar. 9 — Appearance on WWJ Television on Polio
Mar. 9 — Meeting at Lansing
Mar. 9 — Press Conference for MCI
Mar. 12^Executive Committee of The Council Meeti
Detroit
Mar. 13 — Board of Directors of MMS
Mar. 13-15 — Michigan Clinical Institute
Mar. 29 — Address of welcome before Michigan Inc
trial Conference
April 3 — Address at banquet of Restauranteurs ;
(Continued on Page 798)
796
Say you saw it in the Journal of the Michigan State Medical Society
IMS
Thirst, too.
Flint Medical Laboratory
633 Mott Foundation Building
Flint
Phone CE. 4-9312
E. G. Murphy, M.D.
W. T. Hill, M.D.
W. L. Eaton, M.D.
C. J. Flanagan, M.D.
J. D. Wheeler, M.D.
W. Caraway, Ph.D., Biochemist
M. Dumoff, Ph.D., Microbiologist
COMPLETE SERVICES IN LABORATORY
MEDICINE
rissue diagnosis
jerology
Chemistry
Bacteriology
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Exfoliative cytology
Basal Metabolism
Electrocardiograms
Pregnancy tests
Hematology
Urinalysis
Autopsies
Pfizer'
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BRAND OF MECLIZINE HYDROCHLORIDE
•Trademark
IE, 1957
Say you saw it in the Journal of the Michigan State Medic-al Society
797
NEWS MEDICAL
for a modern-day
HOLIDAY
that brings to life
the historic past ,
come to
In no other area can you
see such sharp contrasts
between past and present
America. Just a few min-
utes from Dearborn Inn
are Henry Ford Museum
and Greenfield Village,
where thrilling American
tradition becomes alive.
Then, nearby is famous
Ford Rotunda with its ex-
hibits of modern produc-
tion techniques. It’s also
the gateway to the vast
Ford Rouge Plant.
Enjoy traditional hospitality of
THE DEARBORN INN
Here in a colonial setting,
a half hour from downtown
Detroit, there’s every mod-
ern comfort. Fine food in two
restaurants, cocktail lounge,
135 guest rooms with TV
and air conditioning from
$8 single, $13 double.
For reservations, please write or call The Dearborn Inn,
Dearborn, Michigan. LOgan 5-3000. R. D. McLain, Mgr.
All important laboratory exam-
inations; including —
Tissue Diagnosis
The Wassermann and Kahn Tests
Blood Chemistry
Bacteriology and Clinical Pathology
Basal Metabolism
Aschheim-Zondek Pregnancy Test
Intravenous Therapy with rest rooms for
Patients
Electrocardiograms
Central Laboratory
Oliver W. Lohr, M.D., Director
537 Millard St.
Saginaw
Phone. Dial 2-4100 — 2-4109
The pathologist in direction is recognized
by the Council on Medical Education
and Hospitals of the A.M.A.
(Continued from Page 796)
Stewards
April 8 — Address of Welcome to Michigan Dental
sociation
April 10 — Committee Meeting at Sheraton Cadillac
April 16 — Conference with Legislators on Polio
April 16 — Meeting with Ingham County Medical Soi
April 17 — Executive Committee of the Council, Deti
April 22 — Meeting with Anesthetists of Wayne Coun
April 22 — Wayne County Banquet
April 24 — Telecast A. A. Medical Education
April 26 — MMS Board meeting
April 27 — House of Delegates Emergency Meeting
April 28-30 — Meeting with Congressmen. Washing
D. C.
May 7 — Wisconsin State Medical Meeting, Madisoi
May 8-9 — President's Committee on Higher Educat
May 14 — Ohio State Medical Meeting, Columbus
May 15 — Executive Committee of The Council, Deti
May 16 — 1958 MCI Committee on Arrangements,
troit
* * *
MEDICAL TELEVISION SHOWS PRODUCED
BY MICHIGAN HEALTH COUNCIL
WJBK-TV, Detroit
April 7 — Subject: Child Dental Care — Guests: Al
E. Sevier, D.D.S., Detroit; Zallman Konil
D.D.S., Royal Oak; Miss Annamae No
Detroit; and Mike Kantner, East Lan
April 14 — Subject: Old Age — (Film — “Proud Yea
April 21 — No show scheduled due to Easter
April 28 — Subject: Cancer — (Films — “From One C
and “Man Alive”)
WKAR-TV, East Lansing
April 11 — Subject: Red Cross Donor Program — Gu
John Scully, Joseph Venier, M.D., Will
Wilkinson, Mrs. Margaret Sneed, R.N.,
H. D. Anderson, M.D., all of Lansing.
April 25 — Subject: Preface to a Life (Film)
,TM<
798
Say you saw it in the Journal of the Michigan State Medical Society
THE DOCTOR’S LIBRARY
THE DOCTOR’S LIBRARY
nowledgments of all books received will be made in this column,
this will be deemed by us as full campensation to those
ling them. A selection will be made for review, as expedient.
NAGEMENT OF EMOTIONAL PROBLEMS IN
1EDICAL PRACTICE. Edited by Samuel Liebman.
LD., Medical Director, North Shore Health Resort,
Vinnetka, 111. * Clinical Assistant Professor of
sychiatry, University of Illinois College of Medicine,
'hiladelphia, Montreal: J. B. Lippincott Company,
956. Price $5.00.
’he lectures are entitled: “Psychiatric Emergencies,”
te Use and Abuse of Sedatives and Stimulants,”
te Management of the Anxious Patient,” “The De-
>sed Patient,” “The Management of Emotional Re-
ons in the Male Involutional Period,” “The Man-
ment of the Multiple Complainer,” “The Manage-
lt of Overeating, Overdrinking and Oversmoking,”
1 Avoiding the Production of Iatrogenic Disease,”
te Utilization of Community Resources in Medical
ctice.”
’he material in these lectures is presented in a con-
practical arrangement which lends itself to easy
ling and provides a source for quick reference for
busy practitioner. Thus the intent of this volume
provide some help to the physician in the manage-
tt of everyday emotional problems, is clearly
:essful.
W.D.M.
TTLE FOR THE MIND. By William Sargeant.
larden City, N. Y. : Doubleday & Company, Inc.,
957. Price $4.50.
’his work offers one main thesis: exploit the sub-
’s most fearful point, inflame his emotions to the
at of collapse, and strong positive suggesting will re-
anize his thought patterns.
’he production of “abreaction” through drugs is well
anicled. The similarity of method using psycho-
lysis to “abreact” is brought out.
’his is, indeed, an interesting volume showing how
[ous types of beliefs can be implanted in people after
in function has been sufficiently disturbed by ac-
intally or deliberately induced fear, anger or excite-
lt.
J.c.
THE ROAD TO INNER FREEDOM. The Ethics. By
Baruch Spinoza. Edited and with an Introduction by
Dagobert D. Runes. New York: Philosophical Library,
1957. Price $3.00
The aims of Spinoza are most ideal: how to live
with emotions, passions, and God. It may well be with
a seemingly newly aroused interest in psychology, re-
ligion and mental diseases, that this decade may re-
discover Spinoza. The pensive mind will find this an
unusual volume for stimulating reflection.
J. C.
ALBERT SCHWEITZER. The Story of His Life. By
Jean Pierhal. New York: Philosophical Library,
1957. Price $3.00.
Men of music and medicine will find this a relaxing
review of a dedicated life. It is refreshing evidence that
a man trained in traditional backgrounds can retain per-
spective and achieve success.
J. C.
EXPERIMENTAL PSYCHOLOGY AND OTHER ES-
SAYS. By I. P. Pavlov. New York: Philosophical
Library, 1957. Price $7.50.
The reading of some of the basic writings of this
Nobel prize winner in physiology may well elevate his
stature in the mind of the mature physician. His great
regard for experimental method, and, particularly in
working with a whole normal animal, is as refreshing
in our modern era as it was in his. To the vast army
of investigative imitators, there are here interned les-
sons of clarity they have never closely copied.
J. C.
RHEUMATIC DISEASES, Rheumatism and Arthritis.
By Heinrich G. Brugsch, M.D., F.A.C.P., Assistant
Professor of Medicine, School of Medicine, Tufts Uni-
versity; Physician-in-Charge, Arthritis Clinic of The
Boston Dispensary, a Unit of the New England Med-
ical Center; Diplomate, The American Board of In-
ternal Medicine. Montreal and Philadelphia: J. B.
Lippincott Company, 1957.
As many as ten million persons suffer from “presump-
tive” rheumatism and arthritis, and 100 million days
are lost from work annually because of it. The field of
rheumatology has been the stepchild of medicine be-
cause of the complexity of disease processes involving
such an array of structures and functions which often
make the therapeutic approach disappointing. Brugsch
provides a concise introduction to the field from the
MARY POGUE SCHOOL, Inc.
Complete facilities for training Retarded and Epi-
leptic children educationally and socially. Pupils
per teacher strictly limited. Excellent educational,
physical and occupational therapy programs.
Recreational facilities include riding, group games,
selected movies under competent supervision of
skilled personnel.
Catalogue on request.
G. H. Marquardt, M.D. Barclay J. MacGregor
Medical Director Registrar
26 GENEVA ROAD, WHEATON. ILL.
(Near Chicago)
IE, 1957
Say you saw it in the Journal of the Michigan State Medical Society
799
THE DOCTOR S LIBRARY
point of view of the internist. Controversial and the-
oretical aspects of Rheumatic Fever. Rheumatoid Arth-
ritis. Ankylosing Spondylitis, Diffuse Collagen Disease,
Degenerative Arthritis, Gout. Infectious Arthritis, and
other subjects are covered in a bibliogrphy of over 250
papers from the American literature, and the “essentials”
are discussed in a very readable fashion with emphasis
placed on conservatism and the long-continued use of
simple methods of treatment rather than on the expecta-
tion of reversing the disease processes by “miracles.”
The section on physical medicine could be amplified
and that on rehabilitation is cursory. Prophylaxis of
rheumatic fever is adequately discussed but not included
in the Table of Contents.
Some of the illustrations (p. 191) are excellent while
others (p.309) leave something to be desired. While
the Index refers to pages by generic name of drugs in
some instances (Butazolidin- See Phenylbutazone )-
(Phenylbutazone- P. 235), the reverse is true in others
(Probenecid- See Benemid)- (Benimid- P. 82, 238).
The book contains no startling innovations, but the
essentials contained therein could well be applied by any
physician treating adults to the majority of his patients.
R.E.F.
agement of pregnancy. "Much of it is based on routi
teaching given to medical students and pupil midwh
in lectures, antenatal clinics and antenatal ward round
However, the author lives in England, and many of t
ideas are compatible with the situation as it exists
that country' and not particularly applicable to t
United States.
The entire field of normal pregnancy, abnormal pr<
nancy and diseases complicating pregnancy is covered
one small volume, so, of necessity, the book must
considered only as a guide. It is well written, print
on good quality glossy paper, and the illustrations ;
adequate. There is a minimum of references to curn
literature: therefore, it is not a source of referer
material.
The book is a guide to the broad field of obstetr
as applied to technicians, midwives, and to some ext(
nurses. The medical missionary and obstetrical sup
visor in outlying districts might find it helpful in
teaching. But its value to the average practici
physician is limited, as it contains only basic informatii
S.T
THE CARE OF THE EXPECTANT MOTHER. Jose-
phine Barnes. New York: Philosophical Library,
1956. 266 pages.
As the author states in the preface, this book is writ-
ten as a practical guide for all who undertake the man-
brand of meclizine hydrochloride
prevents nausea,
vomiting and vertigo
associated with
vestibular disturbances
WOLVERINE
the GOODWILL
Uoteib i„ DsTfJOiT
Home of The Tropics
500 ROOMS famous Detroit
each with NITESPOT
Shower Bath Overlooks
Grand Circus
Singles $4.50-$7 Park
Doubles $6.00-$ 1 2 Immediate facilities for
Suites $IO-$20 shopping, theatres.
. transportation.
Elizabeth Street
1 BLOCK EAST OF WOODWARD
800
Say you saw it in the Journal of the Michigan State Medical Society
JMS
CORRESPONDENCE
Correspondence
• Dr. Haughey:
Dngratulations on your publication of Dr. Fox’s
le, “Narcotic Addiction Among Physicians” in the
uary issue of The Journal. It helps focus much
led attention upon an extremely serious problem,
rug addiction of any type is a problem that con-
tly confronts the physician, law enforcement authori-
the addicted person, his family and the community
irge. Its cost to society in terms of self-degradation,
ly disintegration and social disorganization is well
vn.
he Detroit Department of Health is attempting to
: the various aspects of this problem through the
ation of its Narcotics Clinic. The psychiatric and
il consultative services are available to physicians,
r professional people, the addicted person and his
ly, and the community at large. The Clinic func-
i as a clinical and administrative arm of the Health
artment, totally unrelated to any police function.
:t adherence is effected to all concepts of medical
:s.
he question that Dr. Fox raises regarding education
tedical students in the relationship of the physician
ddicting drugs and addicted persons is a valid one.
at Wayne State University College of Medicine
: instituted a minimum of four hours lecture, case
mtation and discussion with the junior medical stu-
s as part of the curriculum in psychiatry. We agree
this comprises an essential facet of education among
icians.
he Clinic would welcome any requests for consulta-
from anyone beset with a problem concerning the
or abuse of narcotic drugs. Our office is located at
» St. Antoine Street (second floor) and the tele-
te number is Wo. 1-7302, extension 217.
Respectfully,
Herbert A. Raskin, M.D.
Medical Director
State Board of Alcoholism
oit, Michigan
i 24, 1957'
: Doctor Haughey:
wish to take this opportunity to thank you in behalf
he Genesee County Medical Society for the very
llent presentation of our annual Cancer Day Pro-
i that appeared in several places in the February
• of The Journal of the Michigan State Medical
Society. This particular issue of The Journal has
enabled us to have this program well publicized over
the state, and I have heard many favorable comments
on this presentation every time I have made a trip
out of this city since the issue appeared.
If our program this Wednesday is not an outstanding
success, it will certainly not be due to any deficit that
could reflect on The Journal of the MSMS.
Flint, Michigan
April 15, 1957
Postscript April 20, 1957
The record of attendance for all programs is as
follows:
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957
Sincerely yours,
H. B. Elliott, M.D.
Chairman, Cancer Day Committee
Genesee County Medical Society
215
175
225
238
221
248
.264
.266
253
.292
.247
.356
Carlson School for Cerebral Palsy announces
two informal summer sessions for ambulatory
Cerebral Palsy patients.
First session: June I5-August 1
August 1 -September 15.
; second session:
Located on ocean; swimming
therapy.
pool; supervised
For informaiton write to Carlson
Beach. Florida.
School/ Pompano
ii ACIHI HOSP’iTAL
125 N. BIRCH RD., FORT LAUDERDALE, FLORIDA
GERIATRICS (care of the aging)
REHABILITATION . . . CONVALESCENT CARE
A private hospital especially planned for the medical care and rehabilitation of the
CHRONICALLY ILL, the AGED, and the HANDICAPPED.
Departments of Medicine, Radiology, Laboratory, Dietary, Dentistry, Rehabilitation,
Occupational and Physiotherapy.
Patients accepted for long or short term care under direction of private physician.
MEDICAL RESIDENT STAFF
FOR information write to
Louis L. Amato, M.D., Medical Director Kenneth A. Dahl, Administrator
e, 1957
Say you saw it in the Journal of the Michigan State Medical Society
801
Plainuell
Sanitarium
PLAINWELL, MICHIGAN
Member American Hospital Association
EDWIN M. WILLIAMSON, M.D.
Psychiatrist-in-Chief
Professional care for the nervous
and mentally ill.
Telephone MUrray 5-8441
Restful Six-acre Estate Overlooking the Kalamazoo River
Classified Advertising
$2.50 per insertion of fifty words or less, with an
additional five cents per word in excess of fifty.
WANTED: Young Protestant, Christian, ambitious gen-
eral practitioner, for a private partnership practice
with middle aged established general practitioner in
center of progressive farming communities. Excellent
opportunities and hospital facilities. Reply Box No. 1,
606 Townsend Street, Lansing, Michigan.
INTERNIST-GASTROENTEROLOGIST: Certified in
both. Six years’ training, including Mayo Clinic and
faculty University gastroenterology section. Qualified
bone marrow interpretation, gastroscopy, other tech-
niques. Societies, publications. Desires group or indi-
vidual association. Reply No. 2, 606 Townsend
Street, Lansing, Michigan.
FOR SALE: Medical Practice of Dr. A. R. Hayton
(deceased) of Shelby, Michigan. Established 50 years.
Includes a fully furnished office and home on two
lots. May be purchased by low monthly payments.
Can be seen during the month of June. For further
details, address Stanley West, 1315 S. Main Street,
Corona, California.
PHYSICIANS AND PSYCHIATRISTS
FOR CALIFORNIA
State hospitals, correctional facilities and veterans home.
No written exam required.
Three salary groups:
$10,860 to $ 1 2 000;
$1 1,400 to $12,600;
$12,600 to $13,800;
Increases being considered effective July.
U. S. citizenship and possession of, or eligibility for
California license required
Write:
Medical Recruitment Unit, Box A,
State Personnel Board, 801 Capitol Ave.
Sacramento, California
FOR SALE: On main street, office building with liviil
quarters on second floor, fully equipped — populatii i
8,000 — New Hospital — Opportunity for General
Board eligible surgeon. Priced to sell. Retiring. Co
tact: Marco M. Hansen, M.D., Greenville, Michiga
OFFICE SPACE: Rent or lease. Newly remodelc
excellent location with established dentist near ne
state office building. Available at once. Contacl
O. S. McElmurry, D.D.S., 607 W. Ottawa Stree
Lansing, Michigan. Telephone IVanhoe 4-0829.
EYE, EAR, NOSE AND THROAT PRACTICE: goo
location, furniture, equipment and records. Very res
sonable. Contact: Marvin L. Stocker, M.D., 116 A
Adams Street, Ypsilanti, Michigan. Phone Hunte
2-9856.
A REAL OPPORTUNITY to open practice in one o
West Michigan’s fastest erowing communities. Oi
White Lake and Lake Michigan. Excellent schools
fishing, boating, hunting. Suite of offices available ii
modern Professional Build’ng. Write, call nr bette
yet come and see Clarence E. Pitkin, Whitehall, Michi
gan.
LOCUM TENENS WANTED: Three to four weeks
Former Michigan practitioner, now in Surgical Resi
dency. 1952 graduate. Reply: B. F. Shockley, M.D.
6601 W. Clarke Street, Wauwatosa 13, Wisconsin
Phone Spring 4-5368.
ALLERGY PRACTICE FOR SALE: Splendid oppor-
tunity for some physician who desires to take up
allergy as a specialty. Allergist retiring because of
illness. Practice for sale in a Michigan city of 175,000.
Gross cash income $50,000 annually. Would remain
with purchaser sufficiently long for him to become
familiar with the work. Reply Box 3, 606 Townsend
Street, Lansing 15, Michigan.
FOR SALE: Cambridge Simpli-Trol Portable Electro-
cardiograph. Guaranteed to be in excellent condition.
Clyde H. Chase, M.D., 8868 Hendrick Drive, Brigh-
ton, Michigan. Telephone Academy 7-1082.
802
Say you saw it in the Journal of the Michigan State Medical Society
JMSMS
Contributors to This Issue
William B. Taylor,
M.D.
The Problem of Progressive Exophthalmos in
Thyroid Disease
John W. Henderson, M.D 849
The Thyroid Gland in Obstetrics and Gynecology
Edwin J. DeCosta, M.D 854
Evaluation of Chlorpromazine and Reserpine in
Intensive Treatment of Chronic Psychotic Patients
/. A. Belisle, M.D., S. B. Jenkins, M.D., J. E.
Carson, M.D., and C. Jones, R.N 859
The General Practitioner in Chronic Disease and
Disability in Industry
Seward E. Miller, M.D 863
ACTH and Cortisone in Trichinosis
Geoffrey L. Brinkman, M.D., and Laslo Koos,
M.D 867
Ecthyma Contagiosum (Orf) in Sheep and Man
William B. Taylor, M.D., and Walker A. Lea, Jr.,
Indications for the Treatment of Hemorrhoids
Norman D. Nigro, M.D., and George L. Walker,
M.D 875
The Economic Royalist in Medicine
Jackson Livesay, M.D 878
Lente Insulin: A Clinical Evaluation
Louis Jaffe, M.D., Robert B. Leach, M.D., and
Edward S. Salem, M.D 882
President’s Message:
Our Number One Problem 885
Editorial:
Thirty-three Million, Five Hundred and Sixty-
nine Thousand 884
Michigan Medical Service 884
Investigations and Reports 887
What Is a Hospital? 888
Michigan State Medical Society — Ninety-second
Annual Session:
1957 Guest Speakers 890
Men With New Messages — For You 891
MSMS Past Presidents, 1866-1955 892
Annual Session Information 893
Program of Assemblies and Sections 896
Annual Reports 906
Michigan’s Department of Health 914
In Memoriam 916
Blue Cross-Blue Shield Rate Announcement faces 916
Correspondence 919
News Medical 920
The Doctor’s Library 931
You and Your Business 818
American Medical Association — Special Report 820
AMA Washington Letter 830
Editorial Opinion 832
Heart Beats 834
PR Report 836
© 1957 by Michigan State Medical Society
THE JOURNAL
of the Michigan State Medical Society
VOLUME 56 JULY, 1957 NUMBER 7
Table of Contents
July, 1957
807
THE JOURNAL
of the Michigan State Medical Society
VOLUME 56 JULY, 1957 NUMBER 7
PUBLICATION COMMITTEE
G. B. SALTONSTALL, M.D., Chairman Charlevoix
WILLIAM BROMME, M.D Detroit
B. M. HARRIS, M.D Ypsilanti
O. B. McGILLICUDDY, M.D Lansing
W. S. STINSON, M.D Bay City
T. P. WICKLIFFE, M.D Calumet
Office of Publication
2642 University Avenue
Saint Paul 14, Minnesota
Editor
WILFRID HAUGHEY, M.D.
610 Post Bldg., Battle Creek, Michigan
Assistant Editor
L. J. BAILEY. M.D.
620 Vinewood Avenue, Birmingham, Michigan
Secretary and Business Manager of THE JOURNAL
L. FERNALD FOSTER, M.D.
441 E. Jefferson, Detroit, Michigan
Executive Director
WM. J. BURNS, LL.B.
606 Townsend Street, Lansing 15, Michigan
All communications relative to exchanges, books for review, manu-
icripts, should be addressed to Wilfrid Haughey, M.D., 610 Post
Bldg,, Battle Creek, Michigan.
All communications regarding advertising and subscription should
be addressed to Wm. J. Burns, 2642 University Avenue, Saint
Paul 14, Minnesota, or 606 Townsend Street, Lansing 15, Michigan.
Telephone Ivanhoe 57125.
© 1957, by Michigan State Medical Society.
Published monthly by the Michigan State Medical Society as its
official journal at 2642 University Avenue, Saint Paul 14, Minnesota.
Entered at the post office at Saint Paul, Minnesota, as second
class matter. May 7, 1930, under the Act of March 3, 1879.
Acceptance for mailing at special rate of postage provided for
in Section 1103 Act of October 3, 1917, authorized August 7, 1918.
Yearly subscription rate, $6.00; single copies, 60 cents. Additional
postage; Canada, $1.00 per year; Pan-American Union, $2.50 per
year; Foreign, $2.50 per year.
PRINTED IN U.S.A.
OFFICERS OF THE SOCIETY
1956-1957
President ARCH WALLS, M.D Detroit
President-Elect G. W. SLAGLE M.D Battle Creek
Secretary L. FERNALD FOSTER, M.D Detroit
Treasurer W. A. HYLAND, M.D Grand Rapids
Speaker K. H. JOHNSON, M.D Lansing
Vice Speaker J. J. LIGHTBODY, M.D Detroit
Editor WILFRID HAUGHEY, M.D Battle Creek
THE COUNCIL
D. BRUCE WILEY, M.D., Chairman, Utica
W. B. HARM, M.D., Vice Chairman, Detroit
L. FERNALD FOSTER, M.D., Secretary, Bay City
Term
District Expires
A. E. SCHILLER, M.D 1st Detroit 1961
O. B. McGILLICUDDY, M.D 2nd Lansing 1960
H. J. MEIER, M.D 3rd Coldwater 1960
RALPH W. SHOOK, M.D 4th Kalamazoo 1961
C. ALLEN PAYNE, M.D 5th Grand Rapids 1961
H. H. HISCOCK, M.D 6th Flint 1961
H. B. ZEMMER, M.D 7th Lapeer 1957
L. C. HARVIE, M.D 8th Saginaw 1957
G. B. SALTONSTALL, M.D 9th Charlevoix 1957
W. S. STINSON, M.D 10th Bay City 1957
W. M. LeFEVRE. M.D 11th Muskegon 1958
B. T. MONTGOMERY, M.D 12th Sault Ste. Marie . 1958
T. P. WICKLIFFE, M.D 13th Calumet 1959
B. M. HARRIS, M.D 14th Ypsilanti 1959
D. BRUCE WILEY, M.D 15th Utica 1960
G. THOMAS McKEAN. M.D 16th Detroit 1960
W. B. HARM, M.D 17th Detroit 1958
WILLIAM BROMME, M.D 18th Detroit 1959
ARCH WALLS, M.D President Detroit
G. W. SLAGLE, M.D President-Elect Battle Creek
K. H. JOHNSON, M.D Speaker Lansing
J. J. LIGHTBODY, M.D Vice Speaker Detroit
L. FERNALD FOSTER, M.D Secretary Detroit
W. A. HYLAND, M.D Treasurer Grand Rapids
W. S. JONES, M.D Past President Menominee
EXECUTIVE COMMITTEE OF THE COUNCIL
D. BRUCE WILEY, M.D Chairman
W. B. HARM, M.D Vice Chairman
W. M. LeFF.VRE, M.D Chairman, County Societies Committee
G. B. SALTONSTALL, M.D Chairman, Publication Committee
RALPH W. SHOOK, M.D Chairman, Finance Committee
K. H. JOHNSON, M.D Speaker, House of Delegates
J. J. LIGHTBODY, M.D Vice Speaker, House of Delegates
<\RCH WALLS, M.D President
G. W. SLAGLE, M.D President-Elect
L. FERNALD FOSTER, M.D Secretary
W. A. HYLAND, M.D Treasurer
Dermatology and Syphilology
Wm. T. Kruse, M.D Grand Rapids
Chairman
Coleman Mopper, M.D Detroit
Secretary
Gastroenterology and Proctology
N. D. Nigro, M.D Detroit 1
Chairman
E. J. Tallant, M.D Detroit
Secretary
General Practice
F. P. Rhoades, M.D Detroit 2
Chairman
F. C. Brace, M.D Grand Rapids
Secretary
Gynecology and Obstetrics
J. H. Beaton, M.D Grand Rapids
Chairman
R. W. McClure, M.D Detroit 26
Secretary
Medicine
J. M. Kaufman, M.D Detroit 26
Chairman
J. W. Hall, M.D Traverse City
Secretary
SECTION OFFICERS
Nervous and Mental Diseases
W. R. Slenger, M.D ...Ann Arbor
Chairman
S. C. Mason, M.D Ann Arbor
Secretary
Occupational Health
O. J. Johnson, M.D Bay City
Chairman
P. B. Rastello, M.D Detroit 9
Secretary
Ophthalmology and Otolaryngology
B. C. Wildgen. M.D Muskegon
Chairman (Ophth.)
W. K. Locklin, M.D Kalamazoo
Co-Chairman (Oto.)
II. A. Dunlap, M.D Detroit 1-4
Secretary (Ophth.)
H. L. LeVett, M.D Lansing
Co-Secretary ( Oto.)
Pediatrics
C. E. Booher, M.D Grand Rapids
Chairman
A. M. Hill, M.D Grand Rapids
Secretary
Public Health and Preventive
Medicine
J. D. Monroe, M.D Pontiac
Chairman
J. K. Altland, M.D Lansing 4
Secretary
Radiology, Pathology, Anesthesiology
R. B. Sweet. M.D Ann Arbor
Chairman (Anes.)
E. R. Jennings, M.D Detroit
Vice-Chairman (Path.)
E. O. Pearson, M.D Kalamazoo
Secretary (Rad.)
Surgery
E. T. Thieme, M.D Ann Arbor
Chairman
H. M. Bishop, M.D Saginaw
Secretary
Urology
R. P. Lytle, M.D Detroit 1
Chairman
J. F. Harrold, M.D Lansing
Secretary
Delegates DELEGATES
W. A. Hyland, M.D.. Grand Rapids, Chairman 1957
J. S. DeTar, M.D., Milan 1957
C. I. Owen, M.D.. Detroit 1957
W. D. Barrett, M.D., Detroit 1958
W. H. Huron, M.D.. Iron Mountain 1958
R. L. Novy, M.D., Detroit 1958
Section
G. C. Penberthy, M.D. (Surgical
TO A. M. A. Alternates
W. WT. Babcock. M.D.. Detroit
E. F. Sladck, M.D., Traverse City
O. J. Johnson, M.D.. Bay City
William Bromme. M.D.. Detroit
J. R. Rodger, M.D., Bellaire
G. W. Slagle, M.D., Battle Creek
Delegate
Section) Detroit
1957
1957
1957
1958
1958
1958
808
JMSMS
Successful appetite control
begins in the supermarket
If your overweight patient can resist
the temptation to buy high calorie
snacks, he's well on the road to suc-
cessful weight reduction. You will
find that one Dexedrine* Spansule
sustained release capsule taken in
the morning controls appetite all day
long— both at mealtimes and in the
supermarket.
*T.M. Reg. U.S. Pal. Off. for dextro-amphetamine sulfate,
S.K.F. tT.M. Reg. U.S. Pat. Off.
fuLY, 1957
Say you saw it in the Journal of the Michigan State Medical Society
817
You and Your Business
HIGHLIGHTS OF EXECUTIVE
COMMITTEE OF THE COUNCIL
Meeting of May 15, 1957
• Referred by the House of Delegates, Special
Session April 27, 1957. — Motion calling for a
market opinion survey — plan of this study re-
garding the people’s wants in medical prepay-
ment was presented, discussed and adopted for
immediate activation, in order to report to the
House of Delegates in Grand Rapids next Sep-
tember.
• Survey of Michigan’s Two Service Corpora-
tions.— This plan, proposed by Michigan Hos-
pital Service, was approved in principle with
final approval to be contingent upon submission
of the completed outline to be prepared by Dr.
McNierney of the University of Michigan
School of Business Administration.
• VA Home Town Medical Care Program. — The
Committee (Wm. Bromme, M.D., Detroit; W.
S. Jones, M.D., Menominee, and G. W. Slagle,
M.D, Battle Creek) reported on its May 6-7
meetings with VA officials in Washington and
presented a resolution for introduction into the
AMA House of Delegates June 3, NYC.
• Michigan-Comell University Medical School
Auto Crash Study. — A letter to be signed by
President Arch Walls, M.D., for mailing to some
900 M.D.’s located in fifteen counties of Michi-
gan in which the Cornell Crash project will be
conducted, was approved.
• President Walls announced he had selected
Walter P. Reuther of Detroit as Biddle Lecturer
for 1957.
• Mayor Paul G. Goebel and Congressman Gerald
R. Ford, both of Grand Rapids, are to be in-
vited to present welcome addresses at the open-
ing meeting of the 1957 MSMS House of Dele-
gates Session in Grand Rapids.
Scientific exhibitors for the 1957 Annual Ses-
sion were selected.
• Annual Registration of Doctors of Medicine. —
Report on possible future activity concerning
annual registration, as drafted by L. A. Drolett,
M.D., Lansing, was referred to the Legislative
Committee with request that it draft a resolu-
tion for presentation to The Council, and after
approval by The Council, for subsequent sub-
mission to the MSMS House of Delegates in
September.
• Appointments. — Max L. Lichter, M.D., De-
troit, to represent MSMS at AMA Civil Defense
meeting June 1, 1957. E. F. Crippen, M.D.,
Mancelona, R. W. Pomeroy, M.D., Lansing,
and A. Hazen Price, MD., Detroit, as official
MSMS representatives to attend Seminar on
“The Chronically 111,” May 26-28. A. Hazen
Price, M.D., Detroit, to represent MSMS at
HEW Regional Seminar on “Health of the
Aged,” Chicago June 11-12.
• Monthly Financial Report and bills payable
were presented and approved.
• 1958 Michigan Clinical Institute. — The closed
color television facilities of Smith, Kline and
French Laboratories, Philadelphia, again were
offered for use at the March, 1958, MCI — and
were accepted with thanks. Ford Hospital, De-
troit, was selected as the hospital of origin for
the color television program; Brock E. Brush,
M.D., Detroit, was appointed Chairman of the
Special Committee on Color Television Pro-
gram.
“Yesterday’s Hopeless” was decided as the
theme for the 1958 MCI.
• The Public Relations Counsel’s report included
information on medical bills before the 1957
Michigan Legislature; progress of the PR Li-
brary; exhibit at the State and two county fairs;
report on Congressional Breakfast in Washing-
ton, D. C.; and report on meeting of Michigan
Health Officers Association, Grand Rapids,
May 2.
• Councilor Conferences. — Council Chairman D.
Bruce Wiley, M.D., urged all councilors to
arrange date, place and hour of their councilor
conferences as soon as possible, to eliminate con-
flicts and to permit MSMS Officers on these
programs a less crowded schedule than last year.
• Committee Reports. — Meeting with Board of
Pharmacy, April 4. Beaumont Memorial meet-
ing in Governor’s and Attorney General’s offices
May 2 and May 8; Michigan Cancer Co-ordi-
nating Committee, May 9; Arbitration Com-
mittee, May 10.
HOUSE BILL 586
House Bill 586, dealing with hospital care pay-
ments for persons receiving old age assistance and
for other categories of dependent persons, passed
the Michigan legislature this year.
The bill was written by the Michigan Social
Welfare Department to modify existing law so
that Michigan could better qualify for funds avail-
able from the federal government on a matching
basis.
Briefly, the law sets up an irrevocable medical
assistance fund which cannot be used for any other
purpose. Into this account each month will be
paid $6.00 for each person receiving assistance.
This sum will come half from federal funds and
half from State funds up to the limit of avail-
(Continued on Page 889)
818
TMSMS
Current Practices in Dietary Management of
Infant Allergies
Infants are not born hypersensitive but may develop
hypersensitivity to foodstuffs shortly after birth.
The earliest sensitizations are likely to be to milk,
wheat, eggs and orange juice, with which contact is
established early in life. Heredity is usually a domi-
nant factor in the tendency of infants to develop
allergy. Infants with a family history of both pater-
nal and maternal allergy tend to develop clinical
symptoms earlier than those with unilateral inherit-
ance. Both the allergen and the symptom in the
for allergic infants
2^-hour formulas made with
hypoallergenic milk and KARO Syrup
WHOLE GOAT’S MILK FORMULAS
No. of
Age
Months
Fluid Milk Water
Fluid Oz. 0*-
KARO
Tbsp.
Birth
1
2
3
4
5
6
7
8
10
10
12
15
17
20
23
26
28
30
32
10
13
13
9
11
11
10
11
11
9
2
21/2
3
3
3V2
4
4
3
2V2
2
Each ,A.,i
Feeding Feedings Total
Oz. in 24 Hrs. Calories)
320
3
4
41/2
5
6
6V2
7
71/2
8
8
390
480
520
610
700
760
740
750
760
formulas
Each No. of
KARO Feeding Feedings
Evap.
Total
Age Weight Goars Milk Water ™ ’ ~n~z.’° in 24 Hrs. Calories |
Months Lbs.
Oz.
Birth
1
2
3
4
5
6
7
8
10
7
8
10
12
14
16
17
18
19
21
6
8
9
10
12
12
13
14
15
16
12
16
14
15
18
21
22
21
20
16
1
2
3
31/2
4
4
4
3
2
1
3
4
41/2
5
6
6V2
7
7
7
8
6
6
5
5
5
5
5
5
5
4
290
395
520
590
695
695
730
710
690
730
1 IOUID SOV MILK FORMULAS
. No. of
Evap" » KARO F ng Feedings Total
Milk Water KARO B jn 24 Hrs. Calories
Fluid Oz. Oz.
Age
Months
Birth
1
2
3
4
5
6
7
8
10
6
8
9
10
12
12
13
14
15
16
DRIED SOY MILK FORMULA
Age
Months
Dry
Milk
Water
Oz.
KARO
Tbsp.
Each
Feeding
Oz.
infant may be different from those of the father or
mother.
Allergic disorders of infants include gastrointestinal
disturbances, infantile eczema, urticaria and asthma.
Gastrointestinal allergy may be manifested by
vomiting, colicky abdominal pain and diarrhea.
Allergic dermatitis may be evidenced by wheal-like
cutaneous reactions which may develop into exuda-
tive lesions over the scalp, face and body. A systemic
food hypersensitivity may produce an asthmatic
response manifested by dyspnea and wheezing,
although infection is usually associated with this
type of response.
Common treatments include avoidance of the
allergen, desensitization, antihistaminics and, in the
presence of infection, antibiotics. Infants sensitive
to the proteins of cow’s milk whey may be fed
human, goat or mare’s milk reinforced with KARO®
Syrup. Casein-sensitive infants may be offered soy-
bean milk or amino acid mixtures reinforced with
KARO Syrup.
The same problems of infant feeding recur from
generation to generation, but solutions may differ
with each era. The carbohydrate requirement for
all infants is as completely fulfilled by KARO Syrup
today as a generation ago. Whatever the type of
milk adapted to the individual infant, KARO Syrup
may be added confidently because it is a balanced
mixture of low molecular weight sugars, readily
miscible, well tolerated, palliative, hypo-allergenic,
resistant to fermentation in the intestine, easily
digestible, readily absorbed and non-laxative.
KARO is readily available in all food stores.
MEDICAL DIVISION
CORN PRODUCTS REFINING CO.
17 Battery Place, New York 4, N. Y.
Birth
1
2
3
4
5
6
7
8
10
6
8
9
10
12
13
14
14
15
15
20
22
24
29
33
33
33
33
33
33
2
2
2V2
3
31/2
31/2
31/2
21/2
2
2
3
4
4
6
7
7
7
7
7
8
No. of
Feedings Total
in 24 Hrs. Calories
Produced by
Corn Products Refining Co.
July, 1957
Say you saw it in the Journal of the Michigan State Medical Society
819
American Medical Association
Special Report
The 106th annual meeting of the American
Medical Association was held in New York City,
June 3-7, 1957. For many years, this has been the
occasion of many other meetings of national im-
port, some of which have a very distinct bearing
on the well-being of the whole medical profession.
There were many groups of medical specialists,
medical research workers and kindred groups,
such as medical fraternities, alumni of many
schools, and former students of renowned teachers.
National Medical Civil Defense
The fifth annual conference on Civil Defense
was held Saturday, June 1, 1957, in the Serf room
of the Waldorf-Astoria, New York. A very careful
program had been prepared with the theme, “The
ultimate responsibility for the health and medical
care of the nation’s population, in peace or war,
rests on the medical and allied professional groups
and they can discharge their responsibilities wisely
only if they are adequately informed and equipped.”
David B. Allman, M.D., president-elect of the
AMA, welcomed the conference. Meetings were
scheduled from 9:00 a.m. The importance and
grave import of the program was stressed; also,
the apparent lack of enthusiasm by the general
public and by some professional people. The
Council on National Defense sponsored the pro-
gram, the value of which can best be illustrated
by listing the participants:
David B. Allman, M.D., President-Elect, American
Medical Association, Atlantic City, New Jersey
Cyril Comar, Ph.D., Chief, Biomedical Research, Oak
Ridge Institute for Nuclear Studies, Oak Ridge,
Tennessee
James P. Cooney, Major General, MC, USA, Deputy
Surgeon General, Department of the Army, Wash-
ington, D. C.
Robert L. Corsbie, Division of Biology and Medicine,
Atomic Energy Commission, Washington, D. C.
Eugene P. Cronkite, M.D., Head, Division of Experi-
mental Pathology, Medical Department, Brookhaven
National Laboratory, Upton, Long Island, New York
Cortez F. Enloe, Jr., M.D., Member, Committee on
Civil Defense, Council on National Defense, American
Medical Association, New York, New York
Jack C. Greene, Director, Radiological Defense Divi-
sion, Health Office, Federal Civil Defense Administra-
tion, Battle Creek, Michigan
Honorable Chet Holifield, U. S. Congressman, 19th
District of California, Chairman, Subcommittee on
Military Operations, Committee on Government Op-
erations, Washington, D. C.
Joseph W. Howland, M.D., Chief, Medical Division,
Atomic Energy Commission Project, University of
Rochester, Rochester, New York
Carroll P. Hungate, M.D., Member, Committee on
Civil Defense and Council on National Defense,
American Medical Association, Kansas City, Missouri
820
Fred Oleson, Radiological Defense Officer, Region 1,
Federal Civil Defense Administration, Harvard, Mas-
sachusetts
Francis B. Stewart, Colonel USAR, Consultant, Chem-
ical and Biological Warfare Defense, Health Office,
Federal Civil Defense Administration, Battle Creek,
Michigan
Benjamin C. Taylor, Director, Engineering Office,
Federal Civil Defense Administration, Battle Creek,
Michigan
M. M. Van Sandt, M.D., Director, Medical Care Divi-
sion, Health Office, Federal Civil Defense Administra-
tion, Battle Creek, Michigan
Council on Medical Service
The Council on Medical Service of the AMA
and the Blue Shield Commission spent several
days in conference of many of the important prob-
lems of the voluntary prepaid medical program of
the nation. Many and new questions must be
solved. New economic conditions are developing
which have direct bearing on the problem of care
for the veteran, not only for service-connected
disabilities, but for any number of other condi-
tions. Reports were made that the Veterans Ad-
ministration is now making an effort to review the
oath of “need” signed by entrants into their hos-
pitals by many who actually have industrial and
occupational conditions for which they have
entered the VA hospitals. If found out in time,
these persons are given a citation and are sent to
civilian hospitals, especially when they are eligi-
ble for workman’s compensation care. The officials
reported the Administration is currently collecting
about 20 per cent of this insurance. Blue Shield
is not now involved in this problem, for there is a
provision exempting responsibility for care in gov-
ernment hospitals.
The problems of Medicare are still in a state of
flux. The program has not yet been completely
worked out. Conditions are different in different
states, probably no two state contracts with the
Military being the same. So far, there is still
dispute as to payments for different services. The
Government is still planning on resurveying the
contracts, and the renewal dates are being dis-
tributed over several months.
In the meantime, most of these dependents are
being cared for willingly by most of the doctors.
Two state medical societies have refused to sign
the covering contracts on certain technicalities, the
most important being their unwillingness to set
any fee guarantees. Commercial companies are
supervising the work, and the patients are being
attended.
(Continued on Page 822)
JMSMS
V •
m
Ml
■
the original
gj£H
m
prednisolone and hydroxyzine
ferred corticoid, Sterane® (prednisolone) • control of emotional factors
by tranquilization enhances response to the corticoid for greater clinical
improvement • often permits substantial reductions in corticoid dosage,
accompanied by reduction of hormonal side effects • confirmed by marked
success in-*'"" ***'"“* — 1
I S
ATARAXOID now written
mm
oxyzine hydro-
chloride, in green, scored tablets. Bottles of 30
and 100.
and now available as IM I
r ~ .
2.5 mg. prednisolone, 10 mg. hydi
hydrochloride, in blue, scored tablets
of 30 and 100.
rox
Bo
SBS
Rtaraxoid /.
mi
1.0 mg. prednisolone, 10 mg. hydroxyzine
hydrochloride, in orchid, scored tablets. Bottles
of 100.
advantages: (1) greater flexibility o
(2) effective tranquilization permii
corticoid dosage
1. Personal communication*
*
m
., Inc. Bro
er
AMA SPECIAL REPORT
(Continued from Page 820)
Conference of Presidents
The Conference of Presidents and Other Offi-
cers of State Medical Associations was held on
Sunday, June 2, 1957, at the Waldorf-Astoria, New
York, with an attendance of several hundred. This
was the thirteenth annual meeting. Many of our
members in Michigan will remember the begin-
ning of this group. Andrew S. Brunk, M.D., of
Detroit, then president of the Michigan State
Medical Society, invited a group of presidents and
other administrative officers of the state medical
societies in the eastern part of the United States
to a conference in Detroit to discuss some very
important problems facing the profession: the
socializing influence from Washington and efforts
to solve prepayment, and demonstrate the possi-
bilities of the independent medical profession.
Many very important meetings have been held,
and now the group has increased in stature and
influence. The program of June 2 consisted of
the speech of the newly installed president, reports,
election of officers, and three important talks.
Congressman Oren Harris, Arkansas, chairman
of the House Foreign and Interstate Commerce
Committee, talked about “The Third Party in
Medicine.” He told how it happens that most
medical legislation goes to his committee, and
described the efforts of pressure groups, including
the government, to encroach on the field of medi-
cine. The very number of bills introduced each
year, in which the medical profession by choice or
force is involved, points to the gradual loss of
much of our work — it being taken over by the
Government, or some of its branches. He listed a
number of encroachments and gave us the same
advice we have had so many times before — quit
being always put in the position of being opposed
to legislation. He cautioned the profession to
consult with its leaders and advisors, and advised
us to write some legislation ourselves, propose it,
and demand its passage. The profession can take
the lead and be its own third party.
Charles B. Shuman, Chicago, president of the
American Farm Bureau Federation, talked on
“Agriculture Looks to the Future.” He cautioned
about the danger of creeping socialism. “This is a
condition where the government does things for
people. It has more or less always existed and
has gone under many names such as Fascism,
Socialism, and Communism. Once it starts, it
must be controlled or it will continue to grow
until in the end it encompasses all services. The
farmers are in the trap. Certain basic crops upon
which they must rely to make a living are in the
control of government. A farmer cannot plant
more acreage*; in these crops than he has done
before. He has to get permission to change to
another crop pattern?' Of necessity, he has had to
improve his methods and produce more on the
822
same acres. This has been done, but it has resulted
in enormous surpluses. Some of our excess crops
are being sold in foreign exchange, and many of
them subsidized so that our neighbor’s crops can-
not be sold in the same market. That is not called
socialism, but it actually is socialism following
true to form. It is constantly increasing. This
must be a warning to the medical profession.
We have some of it, too.
Oswald D. Heck, Schnectady, New York, speak-
er of the New York Assembly, talked on “The
Doctor and the Legislator.” He repeated much
that Congressman Harris had said, but in a dif-
ferent application. He stated that we have the
opportunity to propose beneficial legislation and
to insist on its being the basis of new laws. Mem-
bers of the profession know better than anyone
the needs in many fields. If we do not propose
the new laws in the things about which we are
most concerned, someone who has an ulterior
motive will write the new laws for us. Once the
bill has been written and introduced and we do
not like it. we must assume the attitude of opposi-
tion, a very unnecessary and unfortunate situation.
We should propose instead of oppose.
Actions of the House of Delegates
Revision of the Principles of Medical Ethics,
relations with the United Mine Workers of Ameri-
ca Welfare and Retirement Fund, the federal gov-
ernment’s Medicare program, new standards for
medical schools, a new statement on occupational
health programs and the issue of Social Security
benefits for physicians were among the wide variety
of subjects acted upon by the House of Delegates.
Dr. Gunnar Gundersen of La Crosse, Wiscon-
sin, member of the AMA Board of Trustees since
1948 and chairman for the past two years, was
unanimously chosen president-elect for the year
ahead. Dr. Gundersen, who also was first chair-
man of the Joint Commission on Accreditation of
Hospitals from 1951 to 1953, will become presi-
dent of the American Medical Association at the
June, 1958. meeting in San Francisco. There he
will succeed Dr. David B. Allman of Atlantic
City, N. J., who became the 111th president at
the Tuesday night inaugural ceremony in the
Grand Ballroom of the Waldorf-Astoria Hotel.
The House of Delegates voted the 1957 Distin-
guished Service Award of the American Medical
Association to Dr. Tom Douglas Spies, head of
the department of nutrition and metabolism at
Northwestern University Medical School, Chi-
cago, and director of the nutrition clinic at Hill-
man Hospital, Birmingham, Ala., for his outstand-
ing contributions to the science of human nutri-
tion. For only the third time in AMA history, the
House also voted a special citation to a layman for
outstanding service in advancing the ideals of
(Continued on Page 824)
1MSMS
/
/
Youngsters really go for the taste-true orange flavor of
Achromycin V Syrup. But this new syrup offers more than
“lip-service” to your junior patients. It provides the new
benefits of rapid-acting, phosphate-buffered Achromycin V —
a faster-
acting
oral
form
§, accelerated absorption in the gastrointestinal tract
* earlier, higher peaks of concentration in body tissue and fluid
* quicker control of a wide variety of infections
0 unsurpassed true broad-spectrum action
^minimal side effects
* well-tolerated by patients of all ages
ACHROMYCIN V SYRUP: aqueous, ready-to-use, freely
miscible. 125 mg. tetracycline per 5 cc. teaspoonful
phosphate-buffered.
DOSAGE: 6-7 mg. per lb. of body weight per day.
*Reg. U. S. Pat. Off.
LEDERLE LABORATORIES DIVISION. AMERICAN CYANAMID COMPANY.
PEARL RIVER. NEW YORK
July, 1957
Say you saw it in the Journal of the Michigan State Medical Society
823
AMA SPECIAL REPORT
(Continued from Page 822)
medicine and contributing to the public welfare.
Recipient of this award was Henry Viscardi, Jr.,
of West Hempstead, New York, founder and presi-
dent of Abilities, Inc., which employs only severely
disabled persons.
Physician registration at the New York meeting
had already reached an all-time high at 5 p.m.,
Thursday, with 18,982 counted and scores of regis-
tration cards still unprocessed. The previous high
was chalked up at the 1953 New York meeting
when the five-day total was 17,958 physicians.
New Principles of Medical Ethics. — The House
approved the long-discussed revision of the Prin-
ciples of Medical Ethics, originally submitted at
the 1956 annual meeting in Chicago. The final
version, presented by the Council on Constitution
and Bylaws and then amended by reference com-
mittee and House discussions in New York, now
reads as follows:
PREAMBLE
These principles are intended to aid physicians indi-
vidually and collectively in maintaining a high level of
ethical conduct. They are not laws but standards by
which a physician may determine the propriety of his
conduct in his relationship with patients, with colleagues,
with members of allied professions, and with the public.
Section 1. — The principal objective of the medical
profession is to render service to humanity with full
respect for the dignity of man. Physicians should merit
the confidence of patients entrusted to their care, rend-
ering to each a full measure of service and devotion.
Section 2. — Physicians should strive continually to im-
prove medical knowledge and skill, and should make
available to their patients and colleagues the benefits of
their professional attainments.
Section 3. — A physician should practice a method of
healing founded on a scientific basis; and he should
not voluntarily associate professionally with anyone who
violates this principle.
Section 4. — The medical profession should safeguard
the public and itself against physicians deficient in moral
character or professional competence. Physicians should
observe all laws, uphold the dignity and honor of the
profession and accept its self-imposed disciplines. They
should expose, without hesitation, illegal or unethical
conduct of fellow members of the profession.
Section 5. — A physician may choose whom he will
serve. In an emergency, however, he should render
service to the best of his ability. Having undertaken
the care of a patient, he may not neglect him; and
unless he has been discharged he may discontinue his
services only after giving adequate notice. He should
not solicit patients.
Section 6. — A physician should not dispose of his
services under terms or conditions which tend to inter-
fere with or impair the free and complete exercise of
his medical judgment and skill or tend to cause a deteri-
oration of the quality of medical care.
Section 7. — In the practice of medicine a physician
should limit the source of his professional income to
medical services actually rendered by him, or under his
supervision, to his patients. His fees should be com-
mensurate with the services rendered and the patient’s
ability to pay. He should neither pay nor receive a
commission for referral of patients. Drugs, remedies or
824
appliances may be dispensed or supplied by the physiciar
provided it is in the best interests of the patient.
Section 8. — A physician should seek consultation upor
request; in doubtful or difficult cases; or whenever i
appears that the quality of medical service may be
enhanced thereby.
Section 9. — A physician may not reveal the confidence:
entrusted to him in the course of medical attendance
or the deficiencies he may observe in the character oi
patients, unless he is required to do so by law or unless
it becomes necessary in order to protect the welfare ol
the individual or of the community.
Section 10. — The honored ideals of the medical pro-
fession imply that the responsibilities of the physiciar
extend not only to the individual, but also to society
where these responsibilities deserve his interest and par-
ticipation in activities which have the purpose of im-
proving both the health and the well-being of the indi-
vidual and the community.
In approving the new Principles of Medical
Ethics, the House of Delegates also reaffirmed the
“Guides for Conduct for Physicians in Relation-
ships with Institutions,” adopted in 1951, and re-
quested the Board of Trustees to devise and initiate
a campaign to educate both physicians and the
general public to the dangers inherent in the illegal
corporate practice of medicine in its various forms.
Guides for Relations with UMW A Fund. — In a
key action on the basic issue of third-party inter-
vention, as it affects the patient’s free choice of
physician and the physician’s method of remunera-
tion, the House adopted the “Suggested Guides to
Relationships Between State and County Medical
Societies and the United Mine Workers of Ameri-
ca Welfare and Retirement Fund,” which were
submitted by the AMA Committee on Medical
Care for Industrial Workers. In approving the
guides, the House also recommended that the
Board of Trustees study the feasibility and possi-
bility of setting up similar guides for relations with
other third-party groups such as management and
labor union plans.
The statement, which outlines both medical so-
ciety and UMWA responsibilities, contains these
“General Guides”:
1 . All persons, including the beneficiaries of a third-
party medical program such as the UMWA Fund, should
have available to them good medical care and should be
free to select their own physicians from among those
willing and able to render such service.
2. Free choice of physician and hospital by the
patient should be preserved:
(a) Every physician duly licensed by the state to
practice medicine and surgery should be assumed
at the outset to be competent in the field in which
he claims to be, unless considered otherwise by
his peers.
(b) A physician should accept only such terms or
conditions for dispensing his services as will
insure his free and complete exercise of inde-
pendent medical judgment and skill, insure the
quality of medical care, and avoid the exploita-
tion of his services for financial profit.
(c) The medical profession does not concede to a
third party such as the UMWA Welfare and Re-
( Continued on Page 826)
JMSMS
C*jL#.AJLil
in Hay Fever or Asthma * . .
Family Physicians use
desensifizcation
for perennial
results
easily, pleasantly and economically
ECIFIC DESENSITIZATION
PERENNIAL RESULTS
easily accomplished quickly and accurately
any physician. First, skin test each patient
the simple scratch test method and determine
what allergens the patient reacts. Barry has
mall Pollen Pak for Hay Fever and seasonal
hma cases. Cost $1.50 for 21 tests of tree,
ss and weed pollens, fungi, house dust —
ividual selection to meet your botanical re-
rements. Simple, safe, time proven technique
:omplete directions for your nurse. Ready to
report forms included. Send for yours today.
FREE SCRATCH TEST SET
with each Rx Specific Desensitization Set
prepared according to your
patient’s own skin test reactions.
are obtained by desensitization against those specific
irritants to which your patients reacted by the scratch
test. Record your reactions on the convenient report
card enclosed in each test set. Each desensitization
formula is individually prepared for each patient ac-
cording to his own needs and thereby renders the best
specific results of any medication possible. Each treat?
ment 3-vial set (20 doses) is ready mixed and diluted
with individually planned treatment schedule. If you
already have skin tested your patient, send your reac-
tions to the Allergy Division, Barry Laboratories, Inc.
Complete service $12.50. Prompt 7-10 day service for Rx’s.
AMA SPECIAL REPORT
(Continued from Page 824)
tirement Fund in a medical care program the
prerogative of passing judgment on the treatment
rendered by physicians, including the necessity of
hospitalization, length of stay, and the like.
3. A fee-for-service method of payment for physicians
should be maintained except under unusual circum-
stances. These unusual circumstances shall be determined
to exist only after a conference of the liaison committee
and representatives of the Fund.
4. The qualifications of physicians to be on the hos-
pital staff and membership on the hospital staffs is to
be determined solely by local hospital staffs and by local
governing boards of hospitals.”
The Medicare Program. — The House considered
three resolutions dealing with the federal govern-
ment’s Medicare program for the dependents of
servicemen. The delegates adopted one resolution
condemning any payments under the Medicare
program “to or on behalf of any resident, fellow,
intern or other house officer in similar status who
is participating in a training program.” Govern-
ment sanction of such payments, the House de-
clared, would give impetus to the improper cor-
porate practice of medicine by hospitals or other
nonmedical bodies. Such proposals, the House
added, would violate traditional patterns of Amer-
ican medical practices, seriously aggravate prob-
lems of hospital-physician relationships, encourage
charges by hospitals for residents’ services to pa-
tients not under the Medicare program, and create
a variety of additional problems in such areas as
medical licensure and health insurance.
In another action on Medicare, the House rec-
ommended that the decision on type of contract
and whether or not a fee schedule is included in
future contract negotiations should be left to indi-
vidual state determination. In this connection,
however, the House restated the AMA contention
that: the Dependent Medical Care Act as enacted
by Congress does not require fixed fee schedules;
the establishment of such schedules would be more
expensive than permitting physicians to charge
their normal fees, and fixed fee schedules would
ultimately disrupt the economics of medical prac-
tice.
The House also suggested that the AMA at-
tempt to have existing Medicare regulations
amended to incorporate the Association’s policy
that the practice of anesthesiology, pathology, ra-
diology and physical medicine constitute the prac-
tice of medicine, and that fees for services by phy-
sicians in these specialties should be paid to the
physician rendering the services.
New Statement on Medical Schools. — To re-
place the “Essentials of an Acceptable Medical
School,” initially approved by the House of Dele-
gates in 1910 and most recently revised in 1951,
the House adopted a new statement entitled
“Functions and Structure of a Modern Medical
School.” Presentation of the document followed a
year of careful study by the Council on Medical
Education and Hospitals in collaboration with the
Association of American Medical Colleges.
The statement is intended to provide flexible
guides which will “assist in attaining medical edu-
cation of ever higher standards” and “serve as
general but not specific criteria in the medical
school accreditation program.” The document
encourages soundly conceived experimentation in
medical education, and it discourages excessive
concern with standardization.
“No rigid curriculum can be prescribed for ac-
complishing the objectives of medical education,”
it states. “On the contrary, it is the responsibility
of the faculty of each school continually to re-
evaluate its curriculum and to provide in accord-
ance with its own particular setting and in recog-
nition of advances in science a sound and well-
integrated educational program.”
Occupational Health Programs. — The House
also approved a new statement on the “Scope,
Objectives and Functions of Occupational Health
Programs,” submitted through the Board of Trus-
tees by the Council on Industrial Health. The
Board report to the House said : “The statement
describes and defines orthodox in-plant medical
programs as understood in this country today and
distinguishes clearly between such programs and
the various plans for comprehensive medical care
of the sick. It should help to resolve misunder-
standings concerning the specialty of occupational
medicine.”
In adopting the statement, the House agreed
with a reference committee report which declared
that “the House has before it a statement which
for the first time clearly defines the scope, objec-
tives and functions of occupational health pro-
grams. It marks the needs and boundaries of
occupational medicine. It states in a positive
fashion the proper place of occupational health
programs in the practice of medicine and it clear-
ly charts the pathways of communication between
physicians in occupational health programs and
physicians in the private practice of medicine.”
Social Security for Doctors. — Two resolutions
favoring compulsory inclusion of physicians in the
federal Social Security system and another one
calling for a nationwide referendum of AMA
members on the issue were rejected by the House.
The delegates reaffirmed their opposition to com-
pulsory coverage of physicians under the Old
Age and Survivors Insurance provisions of the
Social Security Act. They also recommended a
strongly stepped-up informational program of
education which will reach every member of the
Association, explaining the reasons underlying the
position of the House of Delegates on this issue.
The Blouse at the same time reaffirmed its support
of the Jenkins-Keogh Bills.
(Continued on Page 828)
826
JMSMS
Rauwiloid *
A Better Antihypertensive
. . . because among all Rauwolfia preparations Rauwiloid
(alseroxylon) is maximally effective and maximally safe
. . . because least dosage adjustment is necessary . . .
because the incidence of depression is less . . . because
up to 80% of patients with mild labile hypertension and
many with more severe forms respond to Rauwiloid alone.
A Better Tranquilizer, too
. . . because Rauwiloid’s nonsoporific sedative action
relieves anxiety in a long list of unrelated diseases
not necessarily associated with hypertension . . . with-
out masking of symptoms . . . without impairing in-
tellectual or psychomotor efficiency.
Dosage: Simply two 2 mg. tablets at bedtime.
After full effect one tablet suffices.
Best first step when more potent drugs are needed
Rauwiloid is recognized as basal
medication in all grades and types
of hypertension. In combination with
more potent agents it proves syner-
gistic or potentiating, making smaller
dosage effective and freer from side
actions.
Rauwiloid+Veriloid®
In moderate to severe hypertension
this single-tablet combination per-
mits long-term therapy with depend-
ably stable response. Each tabletcon-
tainslmg. Rauwiloid and 3 mg.Veri-
loid. Initial dose, 1 tablet t.i.d., p.c.
Rauwiloidd-
Hexamethonium
In severe, otherwise intractable hy-
pertension this single-tablet com-
bination provides smoother, less
erratic response to hexamethonium.
Each tablet contains 1 mg. Rauwi-
loid and 250 mg. hexamethonium
chloride dihydrate. Initial dose, 34
tablet q.i.d.
Riker LOS ANGELES
July, 1957
Say you saw it in the Journal of the Michigan State Medical Society
827
AMA SPECIAL REPORT
(Continued from Page 826)
Miscellaneous Actions. — In considering 66 reso-
lutions and many additional reports from the
Board of Trustees, councils and committees, the
House also:
Congratulated the Board and the Committee on
Poliomyelitis for their prompt action in stimulat-
ing national interest in the polio immunization
program ;
Recommended further study and a progressive
program of action, probably including legislative
changes, to solve the problem of narcotic addic-
tion;
Urged a more careful screening of television
and radio patent medicine advertisements ;
Directed the Board of Trustees to investigate
the indiscriminate use of stimulants such as
amphetamine, particularly in relation to athletic
programs ;
Directed the Speaker to appoint a committee
of five House members to study the Heller Report,
a management survey of the Association’s organi-
zational mechanisms;
Commended the Law Department for its spe-
cial report on professional liability and urged state
and county medical societies to establish claims
prevention programs and to show the new film,
“The Doctor Defendant” ;
Opposed the establishment of any further veter-
ans’ facilities for the care of non-service-connected
illnesses of veterans;
Condemned the compulsory assessment of medi-
cal men and staff members by hospitals in fund-
raising campaigns ;
Commended the television program, “Dr. Hud-
son’s Secret Journal,” its producers and its star,
Mr. John Howard, for an outstanding contribu-
tion to the public interest and welfare, and
Recommended payment of transportation ex-
penses of Section Secretaries for AMA meetings
which they are required to attend.
Opening Session. — At the Monday opening ses-
sion Dr. Dwight Murray, retiring AMA president,
stressed the triple theme of the personal touch in
medicine, the necessity for freedom in medical
practice and the need for professional unity. Dr.
Allman, then president-elect, warned against the
dangers of third-part contractual agreements in-
volving fixed fee schedules. The Goldberger Award
in nutrition research was presented to Dr. Paul
Gyorgy of Philadelphia. An AMA citation was
awarded to the Parke-Davis & Company for its
continuing series of institutional advertisements
telling the story of medicine and medical progress.
Dr. H. G. Weiskotten, who retired after many
years as chairman of the Council on Medical
Education and Hospitals, received two bound
volumes of letters of appreciation and also an
ovation from the House of Delegates.
828
Inaugural Ceremony. — Dr. Allman, in his Tues-
day night inaugural address, declared that the
physician is constantly striving for a balance be-
tween personal, human values, scientific realities
and the inevitabilities of God’s will. The inaugural
ceremony, which was telecast over Station WABD-
TV in New York, included presentation of the
Distinguished Service Award to Dr. Spies and
the special layman’s citation to Mr. Viscardi. Also
taking part in the program was the United States
Army Chorus of Washington, D. C.
Election of Officers. — In addition to Dr. Gun-
dersen, the new president-elect, the following offi-
cers were selected by the House on Thursday:
Dr. Jesse Hamer of Phoenix, Arizona, vice presi-
dent; Dr. George F. Lull of Chicago, secretary;
Dr. J. J. Moore of Chicago, treasurer; Dr. E.
Vincent Askey of Los Angeles, speaker, and Dr.
Louis Orr of Orlando, Florida, vice speaker.
Four new members were elected to the Board
of Trustees: Dr. George Fister of Ogden, Utah,
to succeed Dr. James R. Reuling; Dr. Cleon Nafe
of Indianapolis, Indiana, to succeed Dr. James R.
McVay; Dr. James Z. Appel of Lancaster, Penn-
sylvania, to replace the late Dr. Thomas P. Mur-
dock, and Dr. Raymond McKeown of Coos Bay,
Oregon, to replace Dr. Gundersen. Dr. Edwin S.
Hamilton of Kankakee, Illinois, was elected chair-
man of the Board at its organizational meeting
after the elections in the House.
Dr. Homer L. Pearson, Jr., of Coral Gables,
Fla., was renamed to the Judical Council. Two
new members were elected to the Council on
Medical Education and Hospitals: Dr. Clark Wes-
coe of Lawrence, Kansas, to succeed Dr. Weiskot-
ten, and Dr. Warde B. Allan of Baltimore, Md.,
to succeed Dr. F. D. Murphy of Lawrence, Kansas.
For the Council on Medical Service, Dr. Robert
L. Novy of Detroit, Michigan, was re-elected, and
Dr. Hoyt Woolley of Idaho Falls, Idaho, was
chosen to replace Dr. McKeown. Dr. Warren W.
Furey of Chicago was re-elected to the Council
on Constitution and Bylaws.
At the Wednesday session of the House the
Illinois State Medical Society made a record state
society contribution to the American Medical
Education Foundation by turning over $170,450
to Dr. Louis H. Bauer of New York, foundation
president.
VETERANS ADMINISTRATION
The Veterans Administration anticipates an average
daily case load during 1957 of 142.000 patients. The
administrator, Harvey Higley. reported they are prac-
tically at the peak of expected medical spending. This
year they ask $831,000,000.
JMSMS
advance in potentiated multi-spectrum therapy-
higher, faster levels of antibiotic activity
OLEANDOMYCIN TETRACYCLI N E- PHOSPHATE BUFFERED
Signemycin V—the new name
for multi-spectrum Sigmamycin
—now buffered for higher
antibiotic serum levels.
capsules
New added certainty in antibiotic therapy
—particularly for that 90% of the patient
population treated at home or office where
susceptibility testing may not be practical.
Signemycin V Capsules provide the unsur-
passed antimicrobial spectrum of tetracy-
cline extended and potentiated to include
even those strains of staphylococci and
certain other pathogens resistant to other
antibiotics. The addition of the buffering
agent affords higher, faster antibiotic blood
levels following oral administration.
Supplied: Capsules containing 250 mg. (oleando-
mycin 83 mg., tetracycline 167 mg.), phosphate
buffered. Bottles of 16 and 100. ^Trademark
World leader in antibiotic development and production \PjlZCr) Pfizer Laboratories, Brooklyn 6, N.Y.
^ Division, Chas. Pfizer & Co., Inc.
AMA Washington Letter
THE MONTH IN WASHINGTON
The 85th Congress is in the final few weeks of
its first session with prospects that it will enact few
major medical bills this year, but that next year
will be a different story. On at least half a dozen
important measures action has been postponed,
with the understanding that the issues will be
fought out in 1958.
Circumstances prevented any delay on one bill
that is of considerable importance to the younger
doctors — a new version of the doctor draft act. It
had to be enacted by July 1, the Defense Depart-
ment insisted, or not enough doctors would be
available to maintain the military medical serv-
ices at an acceptable level.
The problem is that the Armed Forces require
a higher ratio of physicians to troops than exists
between physicians and the general population.
Without some special law, the services would either
have to make out with fewer doctors than they
say they need, or draft thousands of non-physi-
cians merely to obtain the doctors who are in the
particular age groups.
This scheme was devised: Amendment of the
regular draft act to allow the call up, to age 35,
of the necessary' numbers of doctors from among
those who had received educational deferments;
they could be called because they are physicians,
not because they are of a certain age. Also, the
national, state and local Medical Advisory Com-
mittees of Selective Service would be continued,
as would a number of provisions in the original
act that protect the rights of drafted doctors.
As Congress moved toward adjournment, pros-
pects also were that it would enact a bill to help
out some states caught in a financial squeeze
because of a new act, passed last year but not
scheduled to go into effect until July 1, 1957, to
increase federal payments for the medical care of
persons on the state-federal public assistance rolls.
Under the old system, states could use the U. S.
dollars to pay directly to the individuals for their
medical care, or directly to the vendors of medical
service — hospitals, physicians, dentists. Many
states, adopting the second plan in all or part of
their counties, used the federal money to help
maintain pooled funds, which support various
medical care programs.
All U. S. money paid out under the new act
must be used in the form of vendor payments —
that is, not turned over directly to the public
assistance cases. At the same time, the law as
originally passed stipulated that any money re-
ceived under the old plan henceforth would have
to be handled as “recipient payments,” that is
830
going directly to the persons on public assistance
rolls.
A number of states thus faced the prospects of
drastically revising their carefully-established med-
ical care programs or sacrificing large amounts
of federal money. Congress came to their rescue
by means of a bill that would allow them to use
the old money as before, yet take full advantage
of the new federal program.
In the closing weeks of the session, however, two
major medical bills were making little, if any
progress — those for federal grants to medical
colleges to build teaching facilities and for initiat-
ing a program of health insurance for federal
civilian employees.
A number of bills had been introduced on aid
to medical education, representing virtually all
the viewpoints in Congress and the administration,
but nothing much was happening. Here one fac-
tor was the economy drive, which was not too
successful in cutting the administration’s health
budget, yet which virtually precluded any new
programs involving large appropriations.
On federal employe health insurance, these long-
standing differences of opinion still blocked any
compromise: Should emphasis be on basic health
insurance, or on major medical (catastrophic)
coverage? Should U. S. payroll deductions be per-
mitted, or would this open the door to demands
for many other payroll deductions, such as for
union dues? What safeguards could be set up
to prevent either the commercial insurance com-
panies or the nonprofit organizations (union plans
and Blue Cross-Blue Shield) from gaining a domi-
nant position?
On these two major bills — as well as on many
others, sponsors were not too discouraged. Al-
ready they were making plans to press them still
more vigorously next year when Congress, looking
toward the fall elections, may be more responsive.
Notes
Doctors are asked by PHS to be on the alert for
a new type A influenza strain expected to work
its way into this country from the Far East. De-
tails from state health departments.
vf * *
National Library of Medicine officials were
still hopeful, as the end of the session neared, that
Congress would vote enough money to start con-
structing the library’s new building next year.
* * *
For the first time the U. S. contribution to
(Continued on Page 835)
TMSMS
optimal dosages for atarax,
based on thousands of case histories:
mg. ( t.i.d.J
7' rjr-j,;-, :j7/J,T,Crr.fj.G7?^:
TENSION SENILE ANXIETY MENOPAUSAL SYNDROME ANXIETY PREMENSTRUAL TENSION
PHOBIA HYPOCHONDRIASIS TICS FUNCTIONAL G. I. DISORDERS PRE-OPERATIVE ANXIETY
HYSTERIA PRENATAL ANXIETY • AND ADJUNCTIVELY IN CEREBRAL ARTERIOSCLEROSIS
PEPTIC ULCER HYPERTENSION COLITIS NEUROSES DYSPNEA INSOMNIA
PRURITIS ASTHMA ALCOHOLISM DERMATITIS PARKINSONISM PSORIASIS
perhaps the safest ataraxic known
P6AC6 OF MIND ATARAX
(BRAND 0? MY0R0XY2INE) hi 11.
lablets-byrup
Consider these 3 atarax advantages:
• 9 of every 10 patients get release from tension,
without mental fogging
• extremely safe— no major toxicity is reported
• flexible medication, with tablet and syrup form
Supplied:
In tiny 10 mg. (orange) and 25 mg. (green)
tablets, bottles of 100.
atarax Syrup, 10 mg. per tsp., in pint bottles.
Prescription only.
July, 1957
Say you saw it in the Journal of the Michigan State Medical Society
831
Editorial Opinion
WALTER REUTHER S PLANS
FOR MEDICINE
United Auto Workers, a powerful and influen-
tial union, finds present conduct of the practice
of medicine not to its liking. This is not a new
dissatisfaction. Criticism of medical practice was
used as the basis for UAW support of govern-
mental control when Mr. Harry Becker was wel-
fare director of the union and its very effective
mouthpiece. The same attitude has prevailed
ever since as the union has continued to seek legis-
lation for a program of national compulsory health
insurance. Now, since the Congress has not
enacted the legislation it wanted, the union has
intensified its criticisms, using alleged failure of
the medical profession as justification for develop-
ment of plans of its own.
Plans of the union to enter the field of medical
practice would find little support unless all exist-
ing plans were first shown to be inadequate,
incapable or unwilling to give proper medical
care. This appears to have been the effect sought
by Mr. James Brindle, Director, Social Security
Department of United Auto Workers, when he
addressed a section of the American Public Health
Association at Atlantic City, New Jersey, Novem-
ber 13, 1956. He reported plans of the union but
first denounced all present systems of prepayment.
He did not conceal the fact that the union is
transferring its interest from the method of pay-
ment to actual conduct of the practice of medicine.
Mr. Brindle says that UAW members find
existing - plans unsatisfactory because premiums
rise constantly, because they are usually left with
substantial bills for services they thought covered,
because there has been little sound development
in extending areas of coverage and because exist-
ing plans have demonstrated no concern and '
accepted no responsibility for the quality of medi-
cal care.
He objects to indemnity plans because they
do not pay enough of the bill but condemns full
service plans for not providing incentives to effi-
ciency and economy. He rebukes present plans
for failure to exercise controls but disparages coin-
surance and deductible features. He reiterates his
displeasure at continually rising premium costs but
insists that benefits must include prevention, diag-
nosis and rehabilitation. He calls for removal of
the economic barrier to needed medical care but
wants no artificial encouragement of unnecessary
surgery and hospitalization.
Mr. Brindle believes that all of medicine’s pres-
ent faults will be corrected when doctors work in
clinic groups, on salary. He said, “We reject the
832
fee-for-service method because it introduces finan-
cial incentives which often conflict with medical
considerations. * * * There are arrangements for
reimbursement now in use which relieve the doc-
tor from preoccupation with business and fiscal
functions and allow him to devote his entire re-
sources to rendering high grade medical care.”
Aspirations of the union were revealed quite
clearly by Mr. Brindle in a few brief but signifi-
cant , remarks, made at intervals in his address.
He said, “We now realize that in order to obtain
care of high quality at reasonable cost, we must
address ourselves to medical care itself — its organi-
zation and quality — and not just to the methods
of financing such care. * * * Today the UAW is
spearheading a move to make (plans like HIP of
New York and the Kaiser plan) available in
Detroit. The President of our Union recently
called together a group of interested community
leaders to set up a comprehensive prepaid medical
care program based on group practice by salaried
physicians in community hospitals, open to every-
one in the community — not just our members.”
It is suggested that the above paragraph be read
more than once. Considering the thoroughly
demonstrated ambitions of UAW leadership this
can only be taken as the opening gambit by a
player who never moves without planning his
future position and never plays without expecting
to win. Those who think Mr. Reuther intends to
confine his interests in the practice of medicine to
controlling a clinic in Detroit should think again.
— Editorial, Northwest Medicine, May, 1957.
Retinoblastoma is found only in children.
* * *
Malignant melanoma is seen most often between 50
and 70 years of age.
* * *
Neuroblastoma is one of the most common tumors of
childhood, and occurs most frequently during the first
five years of life.
* * *
An unexplained abdominal mass often is the only
indication of neuroblastoma in infants.
* * *
The most common site for neuroblastoma in childhood
is the adrenal medulla. They may also arise from the
celiac plexus, superior cervical ganglion, or other
sympathetic nervous tissue.
* * *
Definite diagnosis of neuroblastoma is established by
biopsy.
JMSMS
kids really like..
SQUIBB IRON. B COMPLEX AND Bu VITAMINS ELIXIR
■ to correct many common anemias
■ to correct mild B complex deficiency states
■ to aid in promotion of growth and stimulation of appetite in poorly nourished children
Sqjjibb
Squibb Quality —
the Priceless Ingredient
»m*luiTOH-© re * eauiDg tuduuki
Each teaspoonful (5 cc.) supplies;
Elemental Iron 38 mg,
(as ferric ammonium citrate and colloidal iron)
(equivalent to 130 mg. ferrous sulfate exsiccated)
Vitamin B12 activity concentrate 4 meg.
Thiamine mononitrate 1.0 mg.
Riboflavin 1.0 mg.
Niacinamide 5 mg.
Pantothenic acid (Panthenol) 1.5 mg.
Pyridoxine hydrochloride 0.5 mg.
Alcohol content : 12 per cent
Dosage: 1 or 2 teaspoonfuls t.i.d.
Supply: Bottles of 8 ounces and 1 pint.
July, 1957
Say you saw it in the Journal of the Michigan State Medical Society
833
Heart Beats
RHEUMATIC FEVER PROPHYLAXIS IN MICHIGAN
The Michigan Heart Association provides the
funds for the operation of twenty-seven Rhuematic
Fever Diagnostic Centers by County Medical So-
ciety components of the Michigan State Medical
Society. The Centers are located throughout
Michigan and receive guidance from the MSMS
Rheumatic Fever Control Committee. The physi-
cal examination and the opinion and advice of
local specialists, especially trained in the detection
of rheumatic fever through fellowship, training made
possible by the Michigan Heart Association at
recognized Rheumatic Fever Control Centers
throughout the country, are provided gratis by
Doctors of Medicine. For patients unable to bear
the cost of the examination, the family physician
may request an order of the Probate Court for
such service as a public charge, and the cost will
be paid by the Michigan Crippled Children Com-
mission, which expends one-tenth of its medical
budget for the hospital care of children with
rheumatic heart disease or rheumatic fever who
have no insurance or other means of payment
therefor. Those hospitalized because of recurrence
of rheumatic fever would not have had recurrences
in most instances if adequate prophylaxis had
been administered, and upon formal request, the
Michigan Crippled Children Commission is willing
to bear the cost of prophylaxis (cost of the drug
excepted) for persons under twenty-one years of
age who have rheumatic heart disease or who
TABLE I. PROCUREMENT OF FORMS AND DRUGS FOR
RHEUMATIC FEVER PROPHYLAXIS BY CITIES
COUNTIES AND AREAS
HEALTH DEPARTMENT
AREA
FORM
A
OBT.
c-62a
b
RET.
PENICILLIN OR
SULFADIAZINE
C D
INITIAL SUBSEQ.
Detroit City
l
10
32
25
Dearborn City
2
7
19
20
Rest of Wayne County
1
6
17
27
Arenac-Clare-Gladwin
(District VII)
2
8
12
27
Barry
5
11
12
24
Bay
3
7
12
27
Berrien
4
11
28
Branch-Hillsdale
5
8
12
27
Chippewa-Luce-Mackinac
1
8
12, 16
28
Crawford-Kalkaska-
Roscommon- Wexford-
Missaukee (District I)
3
8
16
29
Delta-Menominee
30
7,9
13
20
Gratiot
I
6
20
28
Houghton-Keweenaw-
Baraga-Ontonagon
3
8
16
27
Ingham-Lansing
1
8
12
23
Mason
3
8
16
27, 31
Jackson
1.2
6, 8
12, 17
23, 29
Kalamazoo
1, 2
6, 8
12, 17
28
Kent
3
7
13
26
Manistee-Mason
2
8
12
27
Marquette
1
8
12
28
Macomb
1
6
17
26
Monroe
2, 3
7,8
12, 16
21
Montcalm
2
8
12
27
Muskegon
2
7, 8
12
33
Saginaw
1, 2
6
12, 16
22, 23
St. Clair
1
6
17
28
Shiawassee
5
8
12
28
Washtenaw
4
11
15
28
Key to Table
A. Form C-62A obtained from Health Department
1. On mail or telephone request by mail.
2. By hand, at H.D. office.
3. By hand, when penicillin delivered.
4. “Given to physician.”
5. Not stated.
30. Doctor has forms on hand.
B. Form C-62A returned to Health Department
6. By mail, by physician, before drug is issued.
7. By mail, by physician, after drug is issued.
8. By hand, when drug is issued to physician or nurse only.
9. By hand, when drug is issued to physician, nurse, or family.
10. By hand, when drug is issued to physician “or his
messenger.”
11. Not stated.
C. Penicillin or sulfadiazine obtained
12. By hand, by physician, nurse, or family at H.D. office.
13. By hand, by physician, nurse, or family at H.D. office.
14. By hand, by physician, or his messenger at H.D. office.
15. By hand, by physician, nurse, or family at H.D. office
bringing the Physician’s Prescription.
16. H.D. nurse delivers while on circuit.
17. By mail, after receipt of C-62A completed.
18. By mail, pending receipt of C-62A completed.
19. “Like polio vaccine” — physician or nurse signs receipt
in office when drug picked up.
20. Not stated. “Issued upon receipt of completed forms.”
32. By hand, by physician, or his messenger at Herman Kiefer
Hospital — Registrar’s Office, entrance on Taylor Street.
Hours: 8:00 A.M. to 11:30 P.M. daily. Telephone Trinity
2-3334.
D. Subsequently obtained.
21. On special supplementary forms mailed out by H.D. and
in by physician.
22. Bv note or letter from physician to H.D.
23. Physician fills out forms on file at H.D.
24. Physician or nurse fills out forms at H.D.
25. By note or letter by messenger.
26. Physician obtains H.D. copy by mail or messenger, adds to
it and returns it by mail.
27. “Foregoing is repeated.”
28. Not stated.
29. Physician’s copy of C-62A sent to H.D. and foregoing
repeated.
31. H.D. nurse takes office copy to doctor.
32. By hand, by physician, or his messenger at Herman Kiefer
Hospital — Registrar’s Office, entrance on Taylor Street.
Hours: 8:00 A.M. to 11:30 P.M. daily. Telephone Trinity
2-3334.
33. Progress report in triplicate required before penicillin is
disbursed.
834
JMSMS
HEART BEATS
have had rheumatic fever and have never been the
subject of a court order under the Crippled ©r
Afflicted Children’s Acts. There are between 4,000
and 5,000 such children at any one time and there
may be in Michigan as many as 35,000 children
under twenty-one who have had rheumatic fever
or who have rheumatic heart disease but who are
not known to the Commission. Each of these chil-
dren should be on prophylaxis, and those over
twenty-one who are associating with children —
parents, teachers, older siblings — might well be.
In an “all-out” effort to curb recurrent attacks
of rheumatic fever, the MSMS Rheumatic Fever
Control Committee recommended and approved a
plan of the Michigan Health Department, whereby
a Michigan physician may secure at no cost from
his local health department (from which he se-
cures gamma globulin, poliomyelitis vaccine,
triple toxoid, and other special preparations for
use in prevention of reportable communicable dis-
eases) two of the antistreptococcal agents which
have been found to be effective in the long-term
prevention of reactivation of rheumatic fever.
These are benzathine penicillin G and sulfa-
diazine. They are available only for administration
over a period of years to anyone who has had
rheumatic fever or who has rheumatic heart dis-
ease and are not to be used for treatment of an
acute disease. The drug is obtained by the doctor
when he has reported the case, or confirmed its
having been previously reported, and sign a receipt
for the medication. Each county has developed a
method suitable to its circumstances, and the pro-
cedures in each county are shown below. The
family physician is expected to exercise professional
supervision of prophylaxis and is not expected to
render gratuitous service in this connection, unless
he desires to do so in the interests of economy in
government.
Twenty-five counties replied to the request,
'“Briefly outline the method by which benzathine
penicillin G is secured by doctors in your area.”
In all areas, the physician or his nurse or secretary
may go to the distributor, report the case, receive
the drug, and sign a receipt for it at the same
time. For other mechanisms, refer to Table I.
Counties not listed did not reply in time to be
included.
\MA WASHINGTON LETTER
(Continued from Page 830)
WHO this year is expected to drop to a third
?f the total WHO budget. In dollars, however,
die U. S. share continues to go up, as the charges
:o other countries.
* * *
The Export-Import Bank is making long-term,
ow-interest loans to some Central American coun-
;ries to build health facilities, such as hospitals
md sewage plants.
fuLY, 1957
Just Published!
A New Quiclc-Reference Text
Gius*
Fundamentals of
General Surgery
Ideal for all doctors of medicine who
feel the need for re-establishment of
background in surgical fundamentals
Stressing the pathophysiologic mechanisms of surgical
diseases, Dr. Gius describes in brief, easy-reading style
the essential facts and factors— short of actual operative
technic— surrounding the management (both diagnostic
and therapeutic) of the surgical patient.
Nor is this book confined only to the problems of
major surgery. Specific and useful guidance is also in-
cluded for application to conditions which frequently are
treated in the office of both the general practitioner and
the surgeon.
More than 20 years of surgical experience have gone
into the writing of this book ... private and university
hospital practice, extensive teaching at both undergradu-
ate and postgraduate levels, military practice, and clinical
research. Every one of the 31 chapters reflects this broad
background and the resulting capacity to separate the
wheat from the chaff.
Well illustrated, expertly written, thoroughly up-to-
date, this new book will indeed prove a boon to physi-
cians seeking refresher material. Professors of surgery
will quickly discover it to be the ideal text for instruct-
ing students in the basic elements of general surgery.
By JOHN ARMES GIUS, M.D., Professor of Surgery, College
of Medicine, State University of Iowa. 720 pages; 275
illustrations on 151 figures. Approx. $12.50.
THE YEAR BOOK PUBLISHERS, INC.
200 East Illinois St., Chicago 11, Illinois
Ywr Hook
PUBLISHERS
Please send the following for 10 days' examination.
4-7-7
I~1 Gius' Fundamentals of General Surgery, approx.
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Say you saw it in the Journal of the Michigan State Medical Society
835
PR REPORT
TV HEART OPERATION SHOWERED
WITH PRAISE
Following the March 12 color television broad-
cast of a live heart operation from The Grace
Hospital in Detroit, stacks of mail were received
congratulating sponsors for the educational TV
venture.
Out-state viewers also had an opportunity to
see the local history-making event since a kine-
scope of the hour-long show was made for later
re-broadcast. Sponsors of the kinescope were
MSMS, Michigan Heart Association, and Smith.
Kline & French Laboratories of Philadelphia.
Thus far, TV stations in the following Michi-
gan cities have showm the kinescope or carried the
original broadcast:
Bay City WNEM-TV
Cadillac WWTV-TV
Detroit WWI-TV
Grand Rapids WOOD-TV
Kalamazoo WKZO
Lansing WJIM-TV
Traverse City WPBM
Excerpts of viewers’ comments are printed be-
low and represent typical reaction to the program.
“My wife and I wish to thank you for presenting
the heart operation on TV last night. It was terrific —
a convincing demonstration of the skill a surgeon must
have. ... I could not help but wonder at the tremen-
dous amount of study and research that had to be done
before such operations were possible.”
“. . . As a high school student, it was very inter-
esting and educational because we are studying the
heart and heart diseases in Biology. For almost six
years now my ambition in life is to become a doctor and
maybe some day I’ll make it.”
* * *
“. . . Your program left us in a better state of mind
in regards to our son’s future. As long as such great
strides are being taken in heart surgery his chances for
a normal life seem almost certain.”
* * *
“In my opinion it was the best program I have ever
seen on a TV screen in North America. It was nice
for a change — no advertising, no quiz or gunsmoke.”
* * *
“If more programs of this type could be made avail-
able to the general public, I sincerely believe that any
misunderstanding that may exist between the layman
and the medical profession with respect to the high cost
of medical and hospital treatment would be forgotten.
•*•*■*•
“The outstanding service rendered the patient from
the time he enters the hospital, during surgery, and
until he is released from the hospital, to insure a healthy
future, more than outweighs the cost involved.”
“The program was a public relations plus for the
medical profession. Again, congratulations and thanks.”
“This is just a short note to express my appreciation,
as a layman, for your ‘Heart Operation’ program.
“I truly believe such presentations will serve much
in the way of creating an interest, understanding and
appreciation of the medical advances that have been,
and are being made, today. I sincerely hope that we
will once again have an opportunity, in the near future,
of witnessing such a rewarding presentation.”
“As an interested teenager, I gained much from the
program with its panel of distinguished doctors. I
would have enjoyed it more if I was assured the surgeon
could work as well in the noise as in silence.”
* * *
“. . . in ten years of viewing, I have never before
written to . . . express my thanks and gratitude for a
presentation.”
* ■* *
“I wish to congratulate you on your Heart Operation
program. Hope we can see more programs of this
nature. Also, a note of thanks to the doctors who talked
in terms that we could understand.”
* * *
“In our opinion, we feel that the showing of such
an operation will give the patients and viewers a feeling
of complete confidence in the hands of their doctors.”
* * *
“I didn’t relax during the entire hour, but when the
telecast was over, I felt that I had been very privileged
to witness a heart operation and see the skill and
dexterity of dedicated surgeons.”
MSMS PUBLIC OPINION SURVEY
UNDER WAY
The people of Michigan are going to have a
chance to tell doctors exactly what kind of medi-
cal service they want.
In one of the biggest public opinion samplings
of its type ever undertaken in Michigan or the
nation, Michigan’s M.D.’s are going straight to
the people to get the facts with a statewide study.
On May 23, the first public announcement of
the survey was made. The people were told of the
action of the House of Delegates at the Detroit
April meeting, when The Council of MSMS was
instructed to conduct a survey to determine just
what the people prefer in the way of medical-
surgical coverage from prepayment plans and
health insurance.
Speaking to the assembled delegates, L. Fernald
Foster, M.D., Secretary of the Michigan State
Medical Society and President of Michigan Medi-
cal Service, said:
“Evidently, to date, the service afforded the patient
by the doctor has been very acceptable to the patient
or he would not have continued his support of the pro-
gram. We, who have the responsibility for the admin-
istration of the program, have the task of giving all the
patients what they want and are willing to pay for
within the philosophies of the plan.”
(Continued on Page 838)
836
JMSMS
STERANE® wow’ £ straighten his -hook, cure his slice or put him on
the green in three . . . hut Sterane may reduce your rheumatoid
arthritic’s handicap of joint pain, swelling and immobility. The
most potent anti-rheumatic steroid, Sterane (prednisolone) is
supplied as white, scored 5 mg. tablets (bottles of 20 and 100)
and pink, scored 1 mg. tablets (bottles of 100).
{Pfizer) PFIZER LABORATORIES Division, Chas.P fixer & Co., Inc. Brooklyn 6, New York
July, 1957
Say you saw it in the Journal of the Michigan State Medical Society
837
PR REPORT
MSMS PUBLIC OPINION SURVEY
(Continued from Page 836)
George W. Slagle. M.D., of Battle Creek,
President-Elect of the Michigan State Medical
Society, made the proposal for the complete study
when he addressed the House of Delegates at the
same time. He said:
“I propose that we find out what the public really
wants and that we get incontrovertible evidence to that
effect. This will help us greatly when we talk to certain
pressure groups who would have us believe that the real
wants of the people are the same as the demands made
by the leaders of pressure groups. ... In other words,
I propose that we go to the people through a survey or
study that will give us part of the knowledge we need
upon which to predicate any changes in our service as
well as the information necessary to meet any false claims
that may be made. I propose, further, that this study
or survey determine the extent and willingness of people
to pay for certain categories of medical and surgical serv-
ice so that we can better determine upon the most
attractive, as well as the most valuable, package to offer.”
The May 29 press release disclosed that the
services of Professor David Luck, prominent re-
searcher and Director of the Business Research
Institute, Michigan State University, had been
retained as survey consultant. Also, D. Bruce
Wiley, M.D., chairman of the MSMS Survey Com-
mittee, announced that Richard Oudersluys, presi-
dent of the Market-Opinion Research Company of
Detroit, had been engaged to work with Dr. Luck
in carrying through the survey development and
evaluation. A special survey assistant, Miss Kay
Asby, has been retained by MSMS to assist in the
multitudinous details surrounding the survey.
The fact that the Michigan Health Council had
agreed to aid MSMS in conducting the mail por-
tion of the survey was disclosed in early June by
J. K. Altland, M.D., Health Council president.
Survey Methods Detailed
Fifty-one thousand people will be asked to give
their preference as to the medical-surgical services
they would like included in any system or plan
for medical service coverage. This was pointed
out in the June 4 release. The statement also said
that two survey methods will be employed. One,
the mail survey to 50,000 citizens, the other, a
personal interview with at least 1,000 Michigan
families. The latter survey will be carried out by
Mr. Oudersluys’ firm by means of a staff of trained
researchers.
In every public announcement, the point was
restated that the doctors are anxious for this sur-
vey because they recognize that the M.D.’s and
the public are partners under any form of medical
service coverage. Therefore, the wants, needs and
desires of the public are important considerations
in the development of any improved version of
prepayment plan or health insurance policy.
Not Blue Shield Survey
Significantly, there is no mention of either Blue
Shield or Blue Cross except as they come under
the heading of prepayment plans. This is deli-
berate and accurate. This is not a Blue Shield
survey. It is an MSMS survey of what the people
want from any plan or system of medical coverage.
Four-Part Study
Actually, the public-opinion survey is but one
part of a four-part study of the problem. In addi-
tion, every member of MSMS will be surveyed by
means of a mail questionnaire. The doctors will
be asked their views on medical service plans and
coverage. The information will be collated with
results of the other “partner’s” survey.
All existing information on what the public’s
medical needs are will be brought together and
included in the final survey report. In addition,
there will be an evaluation of the public’s willing-
ness to pay for the services they feel most import-
ant. Thus, the report will show in pretty clear
terms just how much the public wants and how
much it expects to pay.
The survey timetable calls for the actual surveys
to be completed in July. This will allow needed
time for the tremendous job of evaluating the
material and preparing the final survey report.
The survey report will be presented to the Sep-
tember meeting of the MSMS House of Dele-
gates in Grand Rapids.
Additional plans for the study call for the
co-operation of county medical society speakers
bureaus. By this means, the doctor can person-
ally acquaint the people with the background and
purpose of the study.
Other methods to acquaint the public with the
facts and obtain information are envisioned utiliz-
ing newspapers and exhibits at county and state
fairs.
1957 MEDICAL FORUMS
As predicted in the MSMS PR manual “Win-
ning Friends for Medicine,” public forums on
medical subjects of general public interest con-
tinue to be top public relations vehicles for county
medical societies.
So far this year, at least seven CMS’s have
joined hands with their local press facilities and
organized top-notch well-attended public forums
on such most-discussed subjects as geriatrics, can-
cer, mental illness, polio and the cost of medical
care.
The willingness of the press to provide the
necessary publicity, the public’s eagerness to par-
ticipate in the programs, and the wholehearted
support of civic and service groups have con-
tributed to the success of these public service
undertakings.
( Continued on Page 842)
838
TMSMS
Meat . . .
and Protection
Against Hypochromic Anemia
Hypochromic anemia, the most common nutritional deficiency in
children in the United States, occurs most frequently in the second
six months after birth. 1 A major cause of anemia in early infancy
may arise from insufficient transfer of iron from the mother to
the fetus,2 since anemia is not uncommon in pregnant women.
A first step, then, toward prevention of hypochromic anemia in
the infant is the provision of a prenatal diet rich in available iron
and in high quality protein. A second and most important step is
the addition of foods high in utilizable iron (egg yolk, sieved meat
and vegetables) to the infant’s daily diet as early as possible
(usually 3 months after birth).1
Meat contributes valuable amounts of anabolically effective pro-
tein, B vitamins, readily available iron, and other minerals to the
nutrition of the pregnant and lactating woman. The feeding of
sieved meat to infants after the third month provides well-utilized
iron and aids in the prevention of hypochromic anemia.
1. Jackson, P. L.: Iron Deficiency Anemia in Infants, Editorial, J.A.M.A. 160: 976
(Mar. 17) 1956.
2. Martin, E. A.: Roberts’ Nutrition Work with Children, Chicago, The Uni-
versity of Chicago Press, 1954, p. 211.
The nutritional statements made in this advertisement
have been reviewed by the Council on Foods and Nu-
trition of the American Medical Association and found
consistent with current authoritative medical opinion.
American Meat Institute
Main Office, Chicago. ..Members Throughout the United States
July, 1957
Say you saw it in the Journal of the Michigan State Medical Society
841
PR REPORT
1957 MEDICAL FORUMS
(Continued from Page 838)
The Menominee County Medical Society, in co-
operation with the Menominee High School Adult
Education Program, on March 18 successfully con-
cluded a six-week series of lectures on community
health problems. Among the topics discussed were
highway safety, polio and the virus diseases, and
other topics of general community interest.
Four of the nation’s top medical problems were
discussed during the 1957 series of free medical
forums sponsored in Grand Rapids by the Kent
County Medical Society in co-operation with the
Grand Rapids Kiwanis Club and The Grand
Rapids Press. Jack Hoogerhyde, M.D., Chairman
of the Forum Committee, announced that the
forums attracted a total of about 1,750 persons.
The topics which were presented during the series
were “What Can Be Done About Mental Illness?”;
“Recent Trends in Cancer Treatment”; “New
Hope for the Heart Patient” and “Cost of Medi-
cal Care.”
The Kalamazoo Academy of Medicine and the
Kalamazoo Gazette joined forces during February
and March to present a series of medical forums
on health topics of public interest. Health prob-
lems discussed were “High Blood Pressure”; “Can-
cer”; “Disorders of Digestion” and “Your Chil-
dren, From Tots to Teens.” Glen C. Callander,
M.D., of Kalamazoo, served as general chairman
of the forum series.
The Calhoun County Medical Society recently
inaugurated a medical forum series in Battle
Creek. The series were sponsored by the medical
society in co-operation with the Battle Creek
Enquirer and News. Two forums were held, the
first on the subject of heart disease and the sec-
ond on cancer. Plans are now being made for
continuing the series in the fall of 1957. General
Chairman of Arrangements for the series is Robert
E. Fisher, M.D., of Battle Creek.
A series of medical forums on geriatrics topics
began April 24 in Lansing. Among co-sponsors
of the forum series is the Ingham County Medical
Society. There will be five forums in the present
series.
A medical forum was held in Bay City on
March 27 on the subject of cancer. Nine Bay City
physicians conducted a panel discussion on the
subject to herald “Cancer Month,” a fund-raising
drive which began April 1.
Ypsilanti was the scene of a free medical forum
on April 8 sponsored by the Ypsilanti Kiwanis
Club in co-operation with the Washtenaw County
Medical Society. The topics discussed were arthri-
tis and backache. Also sponsored by the Wash-
tenaw County Medical Society was an Ann Arbor
forum series. The four medical forums in Ann
Arbor were also sponsored by the Ann Arbor
Kiwanis Club, the Ann Arbor News , and the Uni-
versity of Michigan Medical School.
AMA SURVEYS ROLE OF
MEDICAL ASSISTANTS
The key to improved efficiency in a physician’s
office may be in the hands of his medical office
personnel, a nationwide survey reveals. The survey
supports the long-held view of MSMS on the vital
role that medical assistants must play in the
modern medical office.
Are medical secretaries and assistants properly
trained for their jobs? Does the physician-employer
properly delegate duties to office personnel to
make best use of individual skills and training?
Are there tasks which the physician should assign
to an aide in order to give him more time to see
patients?
These are some of the questions which are
answered in a study conducted last year to deter-
mine the ideal knowledges, skills and personal
qualities of medical secretaries. The study was
conducted by Harold Mickelson in connection
with his work toward a Doctor of Education
degree at Indiana University as a co-operative
venture with the American Medical Association.
Mickelson concludes that “physicians are not
making maximum use of their extensive training
when they unnecessarily perform semitechnical
medical and business activities.” To help physi-
cians determine what responsibilities can be
properly delegated to office personnel, Mickelson
is currently preparing a system for assigning duties
which will be furnished by AMA to medical
societies.
According to a recent Medical Economics sur-
vey, “81 per cent of all self-employed doctors now
have at least one full-time or part-time secretary,
nurse, technician or Girl Friday. Four years ago,
only 75 per cent had such assistants.”
The Mickelson-AMA study was made to pro-
vide a basis for the development and improvement
of educational programs in schools for the train-
ing at a high level of secretaries for physicians’
offices. The ultimate objectives are:
1. To provide physicians with the most competent
business-medical assistance possible and
2. To raise the level and status of physicians’ secre-
taries by improving the quality of their work.
On the basis of the survey, a number of steps
which medical associations and medical secretary-
assistants groups can take to help provide a greater
force of better-trained aides in the future are
suggested :
1 . Encourage schools with the necessary personnel
and facilities to offer high-quality medical secre-
tarial training.
2. Recruit high school graduates for high-quality
medical secretarial training.
(Continued on Page 889)
842
IMS MS
nv JOU R M A L
of the Michigan State Medical Society
Issued Monthly Under the Direction of the Council
VOLUME 56 JULY, 1957 NUMBER 7
The Problem of Progressive Exophthalmos
in Thyroid Disease
John W. Henderson, M.D.
Ann Arbor, Michigan
HP HE PATIENT with progressive exophthalmos
associated with thyroid disease has become in
the past decade a challenge to the surgeon, to the
ophthalmologist and to the internist alike. The
term progressive exophthalmos is preferable to
thyrotropic exophthalmos, exophthalmic ophthal-
moplegia, malignant exophthalmos and hyper-
ophthalmopathic syndrome as being more descrip-
tive and less likely to infer an improved etiology.
The distressing complications of forward proptosis
of the globe such as ulceration and even perfora-
tion of the cornea and at times associated glau-
coma and optic nerve involvement, have been a
perplexing problem to the ophthalmologist.
When the comprehensive article of Mulvaney14
appeared in 1944, a complete and logical basis
for the division of exophthalmos into thyrotoxic
and thyrotropic types appeared to be established.
Mulvaney made a clear-cut distinction between
the thyrotoxic and thyrotropic types as he con-
ceived of them. The thyrotoxic type of exoph-
thalmos was one in which there was a small
measurable exophthalmos due to weakening of the
extraocular muscles and usually not exceeding
one to two millimeters, appearing in association
with thyrotoxicosis, more frequently in younger
females, and usually relieved by the successful
treatment of the thyrotoxicosis. In contradistinc-
Dr. Henderson is Associate Professor of Ophthalmol-
ogy, University of Michigan.
Presented at the 91st Annual Session of the Michigan
State Medical Society, Section on Surgery, Detroit, Sep-
tember 27, 1956.
July, 1957
tion. he described thyrotropic exophthalmos which
was more frequently present in middle-aged males,
not necessarily associated with an elevation of the
basal metabolic rate, and demonstrating typical
signs of congestion within the orbit. He con-
ceived of this as being an orbital reaction result-
ing from lack of the inhibitory effect of the thyroid
gland on the pituitary with side effects in the
orbit as the result of undamped TSH production.
He further distinguished between thyrotoxic and
thyrotropic types on the basis of pathologic
changes in the extraocular muscles. However,
it soon became apparent in following patients
with exophthalmos, that such a clear-cut distinc-
tion was not always possible. While a patient
might demonstrate the pure signs of thyrotoxicosis,
there would also be an associated progression of
thyrotropic findings. Whereas Mulvaney stressed
the relief of myasthenic weakness of the extra-
ocular muscles following treatment of thyrotoxi-
cosis, explaining in this way the relief of the
prominence of the eyes following surgery, other
authors found different evidence on this point.
Dobyns6 for example, studied 233 consecutive
thyroidectomy patients with serial exophthalmom-
eter measurements and found that the eyes of
all but nine of the patients definitely increased in
prominence after surgery and significantly so in
more than 50 per cent. The majority of these
patients showed gross improvement in appearance
of the eyes regardless of the increasing proptosis.
He also found that the greater the fall in basal
849
PROGRESSIVE EXOPHTHALMOS— HENDERSON
metabolic rate, the greater was the increase in
exophthalmometer measurement. Therefore, one
must distinguish between the relief of the lid re-
traction following treatment of thyrotoxicosis
which in itself gives an improved appearance to
the patient, and the actual measurement of the
protrusion of the eye regardless of the patient's
appearance.
Dobyns7 was also able to collect 129 patients
from the literature where loss of vision or of the
eye had occurred during severe thyrotoxicosis, fur-
ther casting doubt upon the sharp demarcation
of the two types discussed.
The thyrotropic group of Mulvaney in which
released thyrotropic activity after thyroidectomy
produced orbital changes, has been widely docu-
mented and studied. However, many reports of
failure of thyroid administration to uniformly
inhibit thyrotropin, (or TSH) production, to-
gether with the failure to demonstrate increased
TSH production in all cases of progressive exoph-
thalmos during an active phase, have raised other
doubts.
Cordes5 separates exophthalmos cases into pro-
gressive and non-progressive, since in his opinion
the ocular changes that occur in thyrotoxicosis
should not be confused with the progressive disease
referred to as “thyrotropic exophthalmos.” He
further feels that blood TSH levels would aid in
the distinction. Unfortunately, a simple and re-
liable method for such a determination is not
readily available.
Falconer and Alexander9 pointed out that al-
though all of their patients who developed malig-
nant exophthalmos after thyroidectomy showed
an excess of blood TSH, so also do most patients
after medical or surgical therapy for toxic goiter.
Purves and Griesbach15 found that nine of thirty-
seven sera tested for TSH in malignant exophthal-
mos did not show elevation, even in the progres-
sive phase. They felt also that in most individuals
the presence of excess TSH in the blood does not
lead to malignant exophthalmos, and suggested
a correlation between the two but no direct causal
relationship. Recent work by Dobyns8 using the
Atlantic minnow, fundulus, suggests a further
potent pituitary hormone EPS, which is not the
same substance as TSH, and which can be dem-
onstrated in the blood serum of patients suffer-
ing with severe or progressive exophthalmos. A
correlation was suggested between the degree of
exophthalmic response in the fish and the stage
and severity of the patient's exophthalmos.
The current view may be stated that severe
progressive exophthalmos appears in three clinica!
states : ( 1 ) as a part of Grave’s disease — in addi-
tion to the thyrotoxic signs; (2) more often aftei
thyroidectomy when the picture of thyrotoxicosis
has been ameliorated; (3) in patients without
goiter or preceding thyrotoxicosis.
Dobyns7 believes that these are all basically
the same phenomenon, and can occur in all de-
grees from slight increase in prominence of the
eyes to severe proptosis. If the course is rapid
orbital congestion does not allow adaptation anc
severe ocular changes may occur. If the course is
slower, there may be gradual compensation with-
out serious ocular damage, but the longer the
process lasts, the more irreversible it becomes. The
process may be self-limiting, and when the driving
force behind the disease abates, exophthalmos maj
regress or remain fixed, with return of as much
extraocular muscle function as reversibility ma)
permit.
Falconer and Alexander9 also felt that theii
findings tended to refute Mulvaney’s idea of twc
distinct types of exophthalmos, favoring the view
that the condition is a single entity. By examining
their pathology specimens of involved muscle anc
reviewing Mulvaney's differential on a pathologi
cal basis, they believed that their findings sug
gested a common histologic process which varie
in intensity and degree between individual pa
tients. They concluded that malignant exophthal
mos is a single pathologic entity which can occui
either in association with or independently of en
largement of the thyroid and thyrotoxicosis.
Hedges and Rose11 state that the hyperophthal
mopathic syndrome may best be regarded as ;
clinical spectrum, ranging from simple proptosi
and lid retraction to the most severely progres
sive form with congestive phenomena and visua
loss. They could not justify the division of th<
syndrome into the so-called thyrotropic and thy
rotoxic forms, in spite of the undoubted occur
rence of wide clinical variation.
In addition to the reports of failure of thyroit
administration to inhibit thyrotropin productiot
uniformly or to produce improvement in case
with the progressive form of exophthalmos, th
results which have been gained with pituitar
irradiation might likewise cast doubt upon the
850
TMSM
PROGRESSIVE EXOPHTHALMOS— HENDERSON
basic hypothesis. Our experience with pituitary
irradiation in treatment of these cases has been
mainly that of Beierwaltes2’3 at the University
Hospital, and we have been able to follow closely
all patients so treated. Twenty-eight patients with
malignant exophthalmos were treated with x-rays
directed to the region of the pituitary gland, and
thirteen of these showed a significant response in
exophthalmometer measurements after treatment.
Eleven of the patients began to respond in less
than seven months, and maximum recession
reached a median of 3 to 4 mm. during the nine-
teen-month average follow-up procedure. Beier-
waltes also suggested that response occurs only
if the exophthalmos has been present less than
one year.
A point made by Beierwaltes, and often over-
looked, is that the size of x-ray ports is sufficient
to overlap some retrobulbar soft tissue. The type
of acute change in the orbit in the congestive
phase of progression might well be expected to
respond to irradiation. Other workers have not
uniformly reported the size of ports, but in some
this has been done, and their size is comparable.
Beierwaltes believes at the present time that the
x-ray acts primarily on the retrobulbar tissue
rather than the pituitary'. He followed the FSH
levels serially in several patients, and no change
was found after irradiation, indicating lack of
pituitary response.
Arnold1 has shown that the hypophysis is re-
sistant to high doses of x-irradiation and demon-
strated in monkeys that the hypothalamus shows
changes in the paraventricular and supraoptic
nuclei when x-ray is directed to the pituitary re-
gion. He also stated that the delayed intervals
before change after irradiation observed by Beier-
waltes in his clinical study conformed rather
strikingly with the time intervals found for hypo-
thalamic nuclear change in his experiments.
More recently, Ganong, Fredrickson, and Hume10
have shown that selective lesions of the anterior
median eminence of the hypothalamus produced
thyroid atrophy in the dog. Therefore, it is not
certain at present whether the results of irradia-
tion observed clinically are due to pituitary
change, hypothalamic alteration or effects on the
retrobulbar soft tissue. Further, the tendency of
progressive exophthalmos to run a self-limiting
course in many cases raises other questions.
A further interesting study has been that de-
scribed by Reynolds, Corrigan and Haydn16 from
the Radiological Research Division at Harper-
Hospital in Detroit, and further reported by Mc-
Kean and Hamburg.13 In the patients who
showed progressive exophthalmos frequently re-
ported as so-called “euthyroid” types, where the
laboratory studies ordinarily used in thyroid func-
tion are usually within essentially normal limits,
but where there are with a careful history mani-
festations of both hypothyroidism and hyperthy-
roidism, a precise surface scanning technique in
the I131 tracer studies shows a peculiar spotty type
of radioactive iodine uptake. This is character-
ized by a low level accumulation of the labeled
iodine over much of the gland but with a rapid
and sustained uptake in one area or several areas
usually in the central thyroid zone. It is the
feeling of these authors that these toxic foci are
directly related to the progression of the exoph-
thalmos in what otherwise might be considered
a “euthyroid” patient. Therapy has been the
use of therapeutic radioactive iodine together with
an appropriate dosage of thyroid extract follow-
ing such treatment.
From his studies at the University of Michigan
at the present time, Beierwaltes1 believes that the
patient with signs of progressive exophthalmos
should be managed as follows: Hyperthyroidism
should be treated first, if present, preferably with
radioactive iodine. If no improvement or increase
of eye signs occurs, dessicated thyroid should be
tried for a few months. If no improvement or
progression occurs, pituitary- and retro-orbital ir-
radiation should be done. If, after six months,
the patient is worse or stationary with a high
measurement endangering the eyes, decompres-
sion is indicated.
From the ocular point of view, four basic
problems in management must be considered: (1)
protrusion of the globe sufficient to endanger the
cornea; (2) the occurrence of muscle palsy suf-
ficient to produce visual disturbance; (3) the
occurrence of glaucoma during the course of the
disease and, (4) direct involvement of the optic
nerve.
When, in addition to the upper lid retraction
and infrequent blinking which are often seen in
thyrotoxicosis, a progressive protrusion of the eye-
ball also ensues, the added factors of evaporation
and lack of closure of the eye during sleep will
often result in superficial drying of the cornea,
July, 1957
851
PROGRESSIVE EXOPHTHALMOS— HENDERSON
and at times an actual ulceration occurs. In
severe cases, this may even lead to secondary
intraocular infection and loss of the globe. Such
a patient must be examined carefully with the
use of fluorescein dye in order to detect early
points of surface drying of the cornea. If these
are present, a prescription is usually given for 1
per cent methylcellulose drops, to be used at in-
tervals frequent enough to maintain corneal mois-
ture. In addition, covering the eyes with well-
vaselined eye pads at night may be necessary. The
judicious use of lateral tarsorrhaphy, bringing the
lids together to allow better protection of the
cornea, is often also an important measure. How-
ever, if corneal drying and staining become
marked even with such management, surgical
decompression of the orbits is almost mandatoiy.
Involvement of the extraocular muscles can
often lead to a distressing diplopia. The charac-
teristic muscle paralysis of progressive exophthal-
mos may often be a weakness of convergence but
more frequently a paralysis of the superior rectus
muscles occurs, limiting upward gaze of the eyes.
In many cases, the progress of the disease may be
more advanced in one eye than the other, lead-
ing to a troublesome vertical diplopia. In other
cases, a more complete lack of motility may re-
sult from the basic pathologic changes in the ex-
traocular muscles. Characteristically, the involved
muscles enlarge and undergo degeneration with
the accumulation of lymphoid tissue and final
fatty breakdown of muscle fibers. In several cases
of our series, orbital exploration has been done
in individuals with unilateral progressive exoph-
thalmos only to reveal the enlargement of a single
extraocular muscle with characteristic pathologic
changes on biopsy. During the acute phase of
the process, aid can often be given the patient
by the incorporation of corrective prisms in his
lenses in order to overcome the double vision.
After the process has reached its peak, and then
quieted, certain cases with residual diplopia may
be aided by surgery of the extraocular muscles.
There is little information in the literature as
to the glaucoma occurring during the course of
progressive exophthalmos. In the routine follow-
up of such patients in our clinic, tonometry is
done on each visit, and it has been surprising to
find that a large number of these patients will
show an elevation of the intraocular pressure at
some time during the course of the disease. One
must be extremely cautious in evaluating this as a
true glaucoma, since the pressure of the lids upon
the globe may, in itself, elevate the ocular pres-
sure during the time of measurement. With full
lids due to herniation forward of orbital fat, any
pressure exerted by the examiner upon the lids
in making the examination can affect the final
answer. This has been referred to by Reudeman
as “thumb glaucoma.” In addition, weakness of
the elevator muscles of the globe due to the basic
pathologic process may in itself create a great
effort on the patient's part in looking upward
during the time the pressure of the eyeball is
measured. One patient in our series was shown
to have a difference of almost 30 mm. of mercury
on the tonometer scale between the high pressure
recorded when he was looking upward against his
weakened superior rectus muscles and the normal
pressure recorded when he was looking downward
away from such involved muscles. In most in-
stances, the routine use of pilocarpine or other
miotic drugs has been sufficient to control the
elevation of tension in those where it has been
found. However, there is a group in which it
is very difficult to determine whether the reduc-
tion in vision together with change in the visual
fields and elevated pressure are the result of true
glaucoma or of pressure effects upon the optic
nerve at the apex of the orbit during an acute
congestive phase. It is likely also that the orbital
congestion at this time delays venous return from
the eyeball sufficiently to interfere with the normal
pressure gradient of fluid exchange through the
eye. In these cases, it is very difficult to decide
when the use of drops has failed to reduce the
tension whether orbital decompression or direct
glaucoma surgery upon the globe should be per-
formed.
During the acute phase of congestion in the
orbit, direct pressure effects upon the optic nerve
may sometimes result in a marked reduction of
vision in one or both eyes. It is unlikely that
traction on the optic nerve due to proptosis is a
factor, since there is approximately 8 mm. of
“slack” present in the normal optic nerve. In
certain cases, the process may be severe enough
to produce papilledema with associated central
visual loss. This, of course, is different from the
papilledema of increased intracranial pressure
where central vision is usually spared unless some
associated localizing visual field defect occurs. Ig-
ersheimer12 recently reported on six such patients
852
TMSMS
PROGRESSIVE EXOPHTHALMOS— HENDERSON
with visual changes and commented on the treat-
ment necessary. He believed that some of the
cases run a self-limiting course with gradual visual
improvement. In one case where systemic corti-
cotropin was used, considerable improvement in
the optic nerve involvement resulted, but little
regression in the exophthalmos was noted. In
two cases, orbital decompression was felt neces-
sary, and good visual recovery resulted. Iger-
sheimer believes that a pallor of the optic nerve
head appearing during the course of visual loss
gives a poorer prognostic outlook for return of
vision. At the present time, if a patient presented
with severe papilledema and visual loss associated
with progressive exophthalmos, we would consider
orbital decompression to be necessary. The more
extensive Naffziger procedure, in which the roofs
of the orbits are removed through a transfrontal
craniotomy, has not been used in recent months
at our hospital since the development of a new
procedure by Dr. Robert C. Bassett of our neuro-
surgical staff. Utilizing a modified extradural ap-
proach similar to that used in trigeminal rhizot-
omy, he has been able to remove the lateral and
superior walls of the orbits without exposure of
frontal lobes and the results to date have been
most encouraging.
In conclusion, I should like to review some
of the basic signs of progressive exophthalmos
which should lead to suspicion on the part of
the surgeon in managing a patient with acute
thyrotoxicosis. These findings are in addition to
the usual signs of retraction of the upper lid and
the other numerous lid signs given to us by our
eponymic medical ancestors. Any evidence of
congestion within the orbit as shown by fullness
of the lids, lack of reducibility of the globes into
the orbits, interference with ocular motility,
chemosis of the conjunctiva together with injec-
tion of the anterior ciliary vessels overlying the
lateral rectus muscles, should lead to caution in
the surgical management of such a case. For-
tunately, the incidence is not high in the usual
run of thyrotoxicosis patients, but the avoidance
of later ocular complications is much to be de-
sired.
References
] . Arnold, A. : Effects of x-irradiation on the hypo-
thalamus. J. Clin. Endocrinol. & Metab., 14:859-
868 (Aug.) 1954.
2. Beierwaltes, W. H. : Irradiation of the pituitary in
the treatment of malignant exophthalmos. J. Clin.
Endocrinol., 11:512-530 (May) 1951.
3. Beierwaltes, W. H.: X-ray treatment of malignant
exophthalmos: A report on twenty-eight patients.
I. Clin. Endocrinol. & Metab., 13:1090-1100
(Sept.) 1953.
4. Beierwaltes, W. H. : Personal communication.
5. Cordes, F. C.: Endocrine exophthalmos: An evalua-
tion of present knowledge. Am. J. Ophth., 38:1-21
(July) 1954.
6. Dobyns, B. M.: The influence of thyroidectomy on
the prominence of the eyes in the guinea pig and
in man. Surg. Gynec. & Obst., 80:526-533 (May)
1945.
7. Dobyns, B. M.: Present concepts of the pathologic
physiology of exophthalmos. J. Clin. Endocrinol.
& Metab., 10:1202-1230 (Oct.) 1950.
8. Dobyns, B. M.: An exophthalmos-producing sub-
stance in the serum of patients suffering from prog-
ressive exophthalmos. J. Clin. Endocrinol. &
Metab., 14:1393-1402 (Nov.) 1954.
9. Falconer, M. A., and Alexander, W. S.: Experiences
with malignant exophthalmos. Brit. J. Ophth.,
35:253-283 (May) 1951.
10. Ganong, W. F. ; Fredrickson, D. S., and Hume,
D. M.: The effect of hypothalamic lesions on
thyroid function in the dog. Endocrinology, 57 :
355-362 (Sept.) 1955.
11. Hedges, T. R., Jr., and Rose, E.: Hyperophthal-
mopathic Grave’s disease. Arch. Ophth., 50:479-
490 (Oct.) 1953.
12. Igersheimer, J.: Visual changes in progressive exo-
phthalmos. Arch. Ophth., 53:94-104 (June) 1955.
13. McKean, R. M., and Hamburg. R. H. : Some medi-
cal aspects of exophthalmos. J. Michigan S. M. S.,
54:1326-1351 (Nov.) 1955.
14. Mulvaney, J. H.: The exophthalmos of hyperthy-
roidism. Parts I, II, III. Am. J. Ophth.. 27:589-
611 (Tune); 693-712 (July); 820-832 (Aug.)
1944.
15. Purves, H. D., and Griesbach, W. E.: Thyrotropic
hormone in thyrotoxicosis, malignant exophthalmos
and myxoedema. Brit. J. Exper. Path., 30:23-30
(Feb.) 1949.
16. Reynolds, L.; Corrigan, K. E., and Hayden. H. S.:
Diagnostic use of radioactive isotopes. Am. J.
Roentgenol., 68:421-434 (Sept.) 1952.
The ever-present possibility of cancer must always be
kept in mind, and the conscientious physician will be
unhappy and worried until the question is settled pro
or con, whether by himself or by someone else.
* * *
The absolutely minimal requirement for cancer de-
tection is a thorough pelvic examination, with careful
palpation and meticulous inspection of the cervix in the
best possible light.
The easier the diagnosis of cancer, the worse the
prognosis.
* * *
The most important single thing that women can do
to protect themselves against cancer is to have a
competent gynecologic examination every six months.
* * *
In the breast, obvious cancer is late cancer.
July, 1957
853
The Thyroid Gland in Obstetrics and Gynecology
A S Will Rogers was wont to say, “All I know is
•*- what I read in the newspapers.” I have often
wondered how much we know because we read
it in a medical advertisement or because the de-
tail man told us so. Specifically, let me quote
from current advertising of a so-called improved
thyroid medication: “The current literature
stresses that a puzzling sterility, annoying obesity
or refractory menstrual disorder is more often
the expression of hypothyroidism than is classic
myxedema.” If we spend a moment in analyzing
this phrase, we can recognize masterful innuendo
because actually the advertiser does not say that
hypothyroidism is the cause of sterility, obesity
or menstrual disturbances — he merely says that
these conditions are more often an expression of
hypothyroidism than is myxedema.
Nor can we blame it all on those who make and
sell the products; the physician, too, contributes
his all to further the acceptance of questionable
tenets. Only a few months ago the following
statement was made by one of our own members
and was widely circulated to the profession:
“The most common obstacles to ovulation are ex-
cessive gain in weight and thyroid hypofunction. Nor-
mal ovulation returns to some patients with no evidence
of hypothyroidism when given thyroid extract — hence
this hormone may be tried to clinical tolerance without
reference to basal metabolic rate, blood cholesterol,
or protein bound iodine determination.”11
The entire question of the use of thyroid ex-
tract in the presumed normal individual is one
of utmost confusion. You will find many enthusi-
astic dissertations lauding thyroid even as the
only potent hormone we possess. You will find a
fair number of iconoclasts, too. But most illumi-
nating of all is the individual who can be enthus-
iastic in 1948 and a doubting Thomas in 1954. I
am not being critical. I only site this example
to show how difficult the problem of therapy can
Dr. De Costa is Associate Professor of Obstetrics and
Gynecology. Northwestern University Medical School.
Presented at the 91st Annual Session of the Michigan
State Medical Society, Detroit, September 26, 1956.
Edwin J. DeCosta, M.D.
Chicago, Illinois
be, because I am referring to the published papers
of one of the best and most careful and most
honest workers in the field. In 1948, in a study
of the use of thyroid extract in gynecologic ab-
normalities, it was concluded that thyroid therapy
is advantageous in many cases of abnormal men-
struation and sterility in the absence of clinical
hypothyroidism.5 In 1954, the same author, in
reviewing a group of euthyroid patients with
menstrual disturbance or sterility, concludes that
it is questionable whether thyroid administration
for the treatment of menstrual abnormalities and
sterility is of any value in these patients.4
Obviously, we can have three states of thyroid
activity: hypothyroidism, normal or euthyrodism
and hyperthyroidism with innumerable grada-
tions between one extreme and the other. We
should consider not only the effects of obvious
deviations from the normal but also the effects
of small variations. In the following paragraphs
this large order will be applied to gynecology and
to obstetrics.
Before we can discuss either hypothyroidism or
hyperthyroidism, we must have a clearly estab-
lished concept of what is normal. Here we en-
counter, I believe, the basic cause for much of
the confusion and controversy to be found in the
literature over the past thirty-five years. We may
have difficulty in determining what is normal.
The diagnosis of abnormal thyroid activity is
based upon a careful history and physical exami-
nation. This is augmented by certain laboratory
procedures, which are far from the specifics we
would like, but which often play a very important
part in the ultimate decision.
The oldest and most frequently employed lab-
oratory procedure is still the determination of
basal metabolic rate. It is subject to many errors
and determines thyroid activity by inference. The
normal range of this rate is considered to be from
—(—10 to — 10 or -(-15 to — 15. Recently, we have
come to recognize hypometabolism and hyper-
metabolism without thyroid aberration. Thus a
person with hypometabolism may have a basal
854
JMSMS
THYROID GLAND— DECOSTA
metabolic rate of — 30 and not be hypothyroid
at all. The basal metabolic rate is least reliable
when needed most; namely, in the recognition
of mild degrees of dysfunction. Technical errors
can play an enormous role. The patient must be
relaxed and must have had a good night’s sleep.
There even exists a difference of opinion as to
the limits of normal of the basal metabolic rate.
TABLE I. CONDITIONS RAISING THE BASAL
METABOLIC RATE
Fever (7 per cent for each degree F.)
Congestive heart failure
Pulmonary insufficiencv
Anxiety states
Leukemia
Lymphomata
Erythremia (polycythemia)
Pheochromocytoma
Diabetes insipidus
Hyperpituitarism
Acremegaly
Cushing’s syndrome
Poisoning with thyroid substance
Technical errors in the test
Improper preparation of patient
Factors other than thyroid function also in-
fluence the basal metabolic rate in either direction.
Table I enumerates those conditions which raise
the basal metabolic rate. Attention is particularly
called to fever, anxiety, and technical errors.
Table II lists those conditions which will lower
the basal metabolic rate, particularly obesity,
anemia, and again technical errors.
Then, we have the determination of blood
cholesterol, once thought to be a specific indi-
cation of thyroid disturbance, now merely another
tool which serves as a signpost. The serum
cholesterol is usually elevated in hypothyroidism,
but the normal variation of 150-300 mg,/ 100 cc.
is such as to render the test more or less useless.
In addition, conditions other than hypothyroidism
can cause hypercholesteremia, especially diet, dia-
betes, and kidney disorders.
Today we are concentrating more directly on
the activity of the thyroid gland. The level of
circulating thyroxine can be determined chemi-
cally by the iodine content of the plasma (PBI or
SPI). The amount of iodine is infinitesimal, vary-
ing normally from 4 to 8 micrograms per 100 cc.
As a result, the test is useless unless great techni-
cal care is exercised and all extraneous sources of
iodine are eliminated. Incidentally, if the patient
has recently received stable iodine, particularly in
oil or colloid, the determination of protein-bound
iodine is of no value.
We may also utilize the radioactive isotope,
I131, in determining thyroid gland activity. This
may be done in several ways which we shall not
consider here, but the determination of the amount
of radioactive iodine taken up by the thyroid is
probably our best index of thyroid activity.25
Having briefly outlined the methods available to
reach a satisfactory diagnosis, we must spend a
TABLE II. CONDITIONS LOWERING THE BASAL
METABOLIC RATE
Starvation (or even temporary reduction
of caloric intake below expenditure)
Obesity
Shock
Severe anemia
Nephrosis
Addison’s disease
Hypopituitarism or Simmonds’ disease
Hypothalamic disorders
Use of old soda lime in apparatus
Inward leak of air in apparatus
moment considering the very important physiologic
relationship of the thyroid and pituitary glands,
and the effect of administrating thyroid extract to
normal and to hypothyroid individuals, where
incidentally the effects are quite different.
The activity of the thyroid is controlled by the
thyrotropic hormone, secreted by the pituitary.
Between these two endocrine glands, there exists
a reciprocal relationship. Thus, thyroxin secreted
by the thyroid inhibits thyrotropin, and a proper
balance between the two leads to normal thyroid
function, clinically to euthyroidism. If thyrotropin
secretion is excessive, hyperthyroidism may ensue;
if deficient, hypothyroidism. This relationship then
parellels that of the pituitary-ovarian and pitui-
tary-adrenal axes.
Now the administration of exogenous thyroid
does two things: It floods the body with thyroxin
and suppresses thyrotropin. In the hypothyroid
patient, the increased thyroxin of exogenous origin
may be desirable, but in the euthyroid person the
suppression of thyrotropic activity leads to a de-
crease in endogenous production and even to tem-
porary hypothyroidism.12 This suppression of thy-
roid activity in the normal person can be readily
demonstrated clinically.
Thus, from both the theoretical and clinical
viewpoint, there is no reason to administer thyroid
extract to euthyroid individuals. Unless the dos-
age is excessive, one merely substitutes exogenous
thyroid extract for endogenous secretion.
We therefore dissent from the counsel of those
July, 1957
855
THYROID GLAND— DECOSTA
who refer to “puzzling sterility, annoying obesity
or refractory menstrual disorders” as evidence of
a hypothyroid state and, of course, an indication
for thyroid medication. We must have actual
evidence of thyroid deficiency. If hypothyroidism
is evident, we shall use thyroid medication whether
the patient is infertile, obese, or not.
What do we know about the relationship of the
thyroid and the gonads? One could postulate that
some relationship must exist, if only that due to a
general tissue response to thyroxin. After all, if
the brain or muscle needs thyroxin, so does the
gonad. Perhaps this is the only relationship. Per-
haps it is more complicated. We must remember
that the adenohypophysis is motor to the gonad
as well as the thyroid. There does appear to be
some association, and perhaps one more closely
related to female metabolism than to that of the
male. Why, for example, should toxic goiter be
many times more common in the female than the
male individual? Why should the thyroid gland
become enlarged at puberty, during pregnancy
and at the menopause? Why should hyperthyroid-
ism often appear during or just after pregnancy?
These questions certainly indicate more than a
casual relationship between the thyroid gland and
femaleness, but the details still await elucidation.
Let us consider the relationship of thyroid iunc-
tioi and fertility. I have chosen fertility since it
is the prime expression of ovarian activity. Actu-
ally, we run into problems almost before we start
because we do not know the extent of thyroid
activity which is to be considered normal even in
different strains of the same species. Perhaps one
animal may get along well with minimal thyroid
function, while another may require a much great-
er activity. For example, it has been shown that
certain mammals may conceive, carry and deliver
live young after destruction of the thyroid gland
by one of several methods.10’15'17 Our experimental
work confirms this with reference to the rabbit,
although thyroidectomized rabbits make very poor
mothers and the young die within a few days from
neglect. Others have reported contradictory obser-
vations using the same animals. Chu and Chu
and You noted that rabbits did not conceive after
thyroidectomy until thyroid extract was admin-
istered.7'8 They believe that the interference with
pregnancy was an expression of interference with
gonadotrophic activity. No one has confirmed this
work.
In the human being, one frequently encounters
reference to pregnancy following thyroid therapy.
No small part of our modern attitude toward
the importance of thyroid in the management of
fertility problems dates back to Litzenberg’s paper
in 1926, in which he states: “It has been known
for many years that marked disturbances of the
thyroid gland cause sterility, and the possibility
that the milder alterations of that function may
also effect the fecundity has been given scant
attention.”19 Fifty per cent of his infertile patients
had a basal metabolic rate of — 10 or less. Of
those treated with thyroid extract, 33 per cent
became pregnant within a short time. He con-
cluded that a normal basal metabolic rate is
apparently essential for conception and normal
gestation. Others have carried the work of Litzen-
berg much further, maintaining the need for, and
value of, thyroid extract, in the treatment of
infertility even when the basal metabolic rate,
cholesterol, protein-bound iodine and I131 tests are
within normal.
We must not forget, however, that we also have
innumerable examples of pregnancy after adop-
tion, wheat germ oil, tubal insufflation, bimanual
examination, estrogen and the passage of more
time. How are we to evaluate these results? It
has been shown that, in the case of primary steri-
lity, pregnancy followed within a year in about
1 7 per cent of patients, no matter what procedure
was used.23 In spite of the enthusiasm of many
authors, there is still no convincing evidence that
the euthyroid individual is benefitted by thyroid
extract in the treatment of sterility. I know it is
used by the ton, and one may say, “It can’t do
harm; why not use it?” Remember, it may sup-
press normal thyroid activity and actually may
lead to hypothyroidism. In conclusion, then, we
believe that thyroid extract probably is of no
value in the treatment of sterility in the euthyroid
patient. It is indicated in the treatment of infer-
tility in the hypothyroid patient.
What about the effect of hyperthyroidism on
fertility? Apparently mild degrees of hyperthy-
roidism do not interfere with conception. Preg-
nancy is best postponed until the thyroid problem
is completely solved. Should the two conditions
— pregnancy and hyperthyroidism — coexist, we en-
counter difficulties which will be discussed later.
The relationship of thyroid function and anoth-
er facet of ovarian activity, menstruation, is not
too clear. One of the most valuable contributions
856
JMSMS
THYROID GLAND— DECOSTA
to our understanding of this problem comes from
the work of Benson and Dailey.3 In reviewing the
clinical histories of 274 women with authenticated
hyperthyroidism, they were able to follow not only
the menstrual patterns associated with thyrotoxi-
cosis, but also the pattern after these patients were
treated. In some instances hypothyroidism fol-
lowed, then they were able to observe the effects
of hyperthyroid and hypothyroid function on men-
struation in the same patient.
From this report, we learn that 50 per cent of
women with mild toxic diffuse goiter and 74 per
cent with severe cases, experienced a decrease in
amount and duration of the menstrual flow, while
only 5.7 per cent (mild) and 7 per cent (severe)
noted an increase and 44 per cent (mild) and
18 per cent (severe) failed to observe any change
at all. This observation is important, because
throughout the years it has often been stated that
hyperthyroidism leads to increased menstrual flow.
Not so, apparently, but rather a decrease or no
change at all. Amenorrhea occurred in less than
5 per cent of patients, but where it did occur, the
patients were quite toxic, and all patients with
amenorrhea suffered unequivocal exophthalmos.
Turning to thirty-one patients who developed
hypothyroidism after the treatment of toxic diffuse
goiter, we learn that eighteen developed menor-
rhagia or polymenorrhea. The menstrual history
in the thirteen remaining patients did not change
from their pretreatment normal. The administra-
tion of thyroid extract to these hypothyroid bleed-
ing women led to prompt resumption of a normal
cycle in twelve out of fourteen patients.
Experiments with monkeys also indicate that a
relationship does exist between the thyroids and
gonads. Engel9 noted that amenorrhea occurred
in hypothyroid monkeys. Following thyroidectomy,
a single period of treatment with thyroid extract
would induce normal menstruation for several
cycles.
To summarize, hyperthyroidism is most likely to
be associated with a decrease in menstrual flow —
although there may be no change in menses at
all, while true hypothyroidism is often associated
with increased bleeding. But what about the
patient with subclinical or very mild degrees of
hypothyroidism or hyperthyroidism? Might not
she, too, manifest menstrual abnormalities? We
have no reason to believe so. The subclinical states
are still theoretical.
At this point I would like to discuss the relation-
ship of abnormal thyroid function and pregnancy
in the human. Here we may ask a series of ques-
tions which will focus attention on the major
problems. First let us consider hypofunction.
1. What is the effect of hypothyroidism on
pregnancy? We have seen that fertility is de-
creased with hypothyroidism of moderate degree,
but pregnancy does occur.14,18’20 If achieved,
hypothyroidism may lead to abortion or prema-
ture labor. Generally, true hypothyroid states are
recognized and treated prior to conception. Ob-
viously, therapy, which consists of thyroid extract,
should be maintained throughout pregnancy.
2. What effect will hypothyroidism have upon
the fetus? Apparently none, assuming that the
degree of hypothyroidism is not sufficient to inter-
rupt gestation.
3. What effect will thyroid therapy have upon
the fetus? Again, apparently none, although we
know that the placenta is permeable to thyroid
hormone.21 If there is suppression of endogenous
activity of the fetal thyroid- -which activity can
be recognized as early as the twelfth week of ges-
tation6’13 the suppression is transitory and not
recognizable by ordinary means.
4. What effect does the fetal thyroid have upon
maternal hypothyroidism? If the mother is taking
thyroid extract, the effect of fetal activity would
be difficult to recognize. If the mother is not on
therapy, pregnancy would be unusual in severe
cases. In mild cases, presumably fetal activity
could ameliorate the symptoms.
5. How do we treat hypothyroidism during
pregnancy? Just as we would treat hypothyroid-
ism in the non-pregnant woman. In true hypo-
thyroidism, small doses of /2 to 2 gr. of desiccated
extract daily usually suffice.
Turning to hyperthyroidism and pregnancy, we
can ask pretty much the same question, but the
answers are not quite as simple.
1. What is the effect of hyperthyroidism on
pregnancy? Severe hyperthyroidism leads to in-
fertility, abortion and premature labor, but not
to toxemia or post partum hemorrhage, as once
taught. If adequately treated, however, pregnancy
occurs and proceeds normally.
2. What effect will hyperthyroidism have upon
the fetus? There is no evidence that hyperthyroid-
ism per se causes fetal abnormalities (other than
problems already mentioned).
July, 1957
857
THYROID GLAND— DECOSTA
3. What effect will the treatment of hyperthy-
roidism have on the fetus? The answer to this
question will depend upon the therapy used, the
stage of gestation and the severity of the disease.
Answers to this question will be delayed until
therapy is discussed.
4. What effect does the fetal thyroid have upon
maternal hyperthyroidism? Apparently none. Hy-
perthyroidism generally progresses in severity so
any exacerbation might well be coincidental.
5. How do we treat hyperthyroidism? Obvious-
ly, if recognized before conception, it should be
treated at that time. Mild degrees of hyperthy-
roidism may be particularly difficult to recognize,
especially if the patient manifests anxiety. In
addition, we must remember that pregnancy in-
creases both the basal metabolic rate and protein
bound iodine.
The non-pregnant hyperthyroid patient is well
served by several orthodox therapies; long-term
use of antithyroid drugs, radioactive iodine or
surgery after adequate preparation. Each therapy
has its own staunch supporters, with most experts
less enthusiastic about I131 in the younger patient.
The reason for this still rests on the unknown
long-range harmful effects of internal radiation
on the body and genes, although I131 has now
been used for fifteen years without a single in-
stance of serious adverse developments.
With the pregnant patient, the problem is quite
different. Basically, thyrotoxicosis must be con-
trolled. but in such a manner as to avoid injury
to the fetus. Both the antithyroid drugs and I131
cross the placenta. While short term therapy with
antithyroid drugs does not harm the baby, long
term therapy may lead to goiter of the newborn.1
Even if the swelling is only transitory, it seems
best to avoid any medication which may affect
the future health of the child. Hence, during
pregnancy thiouracil and its related compounds
are not desirable except for preoperative prepara-
tion for subtotal thyroidectomy.
Radioactive iodine is contraindicated. It readi-
ly crosses the placenta and we know it may be
absorbed by the fetus as early as the twelfth week
of gestation. It has been shown to cause cretinism
in the experimental animal.24
Surgery can be performed during pregnancy
without much difficulty.22 Most patients can be
adequately prepared by the use of iodine alone.
Some few will also need an antithyroid drug.2
But we must not get the idea that all patients who
are pregnant must be operated upon — at least not
while they are pregnant. Some patients will do
well on ordinary iodine alone and may be carried
through childbirth. Afterward one may elect to
use I131 rather than to operate. The severity of
symptoms, duration of gestation, and response to
therapy will greatly determine the ultimate recom-
mendation.
In summary, then, we shall aim to carry the
patient medically until after delivery. If this can-
not be done safely, subtotal thyroidectomy will be
performed during pregnancy after adequate prepa-
ration.
One final question remains to be asked. What
effect does pregnancy save upon the genesis of
hyperthyroidism or upon the course of the disease?
We all have observed the onset of hyperthyroidism
during pregnancy or shortly after childbirth.
There does seem to be some relationship, but it
still remains obscure. The course of the disease,
however, is not affected by pregnancy. As already
mentioned, hyperthyroidism is usually a progres-
sive disease; the pregnancy is incidental. Cer-
tainly, the effect of pregnancy is no longer con-
sidered serious enough to warrant interruption.
Bibliography
1. Aaron, H. H., Schneierson, S. J., and Siegel, E.:
Goiter in newborn infant due to mother’s ingestion
of propylthiouracil. J.A.M.A., 159:848, 1955.
2. Bell, G. O.: Hyperthyroidism, pregnancy and thi-
ouracil drugs. J.A.M.A., 144:1243, 1950.
3. Benson. R. C. and Dailey, M. E. : The menstrual
pattern in hyperthyroidism and subsequent post-
therapy hypothyroidism. Surg., Gynec. & Obst.,
100: 19, 1955.
4. Buxton, C. L. and Hermann, W. L.: Effect of
thyroid therapy on menstrual disorders and sterility.
J.A.M.A., 155:1035, 1954.
5. Buxton, C. L. and Vann, F. H.: Thyroid therapy
in gynecologic abnormalities. New England J. Med.,
239:536, 1948.
6. Chapman, E. M., Corner, G. W., Jr., Robinson,
D. and Evans. R. D.: The collection of radioactive
iodine by the human fetal thyroid. J. Clin. En-
docrinol., 8:717. 1948.
7. Chu, J. P. : The influence of the thyroid on preg-
nancy and parturition in the rabbit. J. Endocrinol.,
4:109, 1944-46.
8. Chu, J. P., and You. S. S.: The role of thyroid
gland and oestrogen in the regulation of gonado-
trophic activity of the anterior pituitary. J. En-
docrinol., 4:115. 1944-46.
9. Engel, E. T.: The effect of hypothyroidism on
menstruation in adult rhesus monkeys. Yale J.
Biol.. 17:59. 1944.
10. Fredrikson, H. and Rvdin, H. : The thyroid-ovarian
correlation in the rabbit. Acta Physiol. Scand., 14:
136, 1947.
11. Gause, R. U.: Diagnosis and treatment of men-
strual irregularities. Bull. New York Acad. Med.,
31:59, 1955.
(Continued on Page 874)
858
1MSMS
Evaluation of Chlorpromazine and Reserpine in
Intensive Treatment of Chronic Psychotic Patients
VEN THOUGH there have been notable
changes wrought by chlorpromazine and re-
serpine in the mentally disturbed, the limitations
of the recovery process have become more
prominent when one reviews each new report.
How completely one can bring about the re-
covery of a chronically ill patient, and how much
that complete recovery is aided by hospital per-
sonnel, are questions still not satisfactorily an-
swered.
Hollister, et al,1 noted in their study that “both
drugs, reserpine and chlorpromazine, have been
equally effective in the most difficult group of
patients. It should be emphasized that it is the
practice to continue other forms of treatment
while the patients are treated with drugs. Thus,
these results represent more than the effects of
the drug alone.”
Bleuler and Stoll2 asked the question, “Are
treatments with chlorpromazine and reserpine as
effective as the older therapies in improving,
socializing and, in cases of curable schizophrenia,
accelerating and creating readiness for contact
and psychotherapy?”
It was not our purpose at first to attempt
to answer these important questions. For the past
year we have been measuring the therapeutic ef-
fects of reserpine and chlorpromazine, like so many
other hospitals and research centers throughout
the country. Due to an interruption in our drug
supply, we had a chance to note that even
minimal doses of the drugs seemed to have affected
the over-all therapeutic atmosphere of our chronic
treatment building.
By evaluating the year’s results, we hoped to
find the answers to several questions. Did these
drugs change the interaction between personnel
and patients, thereby improving the milieu therapy,
or did these drugs make the patient more acces-
From the Psychiatric Division, Wayne County General
Hospital — J. A. Belisle, Acting Clinical Director, S. B.
Jenkins, Assistant Psychiatrist, J. E. Carson, Psychiatric
Resident.
By J. A. Belisle, M.D., S. B. Jenkins, M.D.,
J. E. Carson, M.D., and C. Jones, R.N.
Eloise, Michigan
sible to milieu therapy? Which was more effec-
tive in treating chronic patients, reserpine or
chlorpromazine? Which gave the greater degree
of change? Did auxiliary therapies — electrocon-
vulsive therapy and group therapy- - help bring
about a greater improvement? What revision in
the treatment regime for chronic patients had been
suggested by the results from the study?
Kovitz3 found improvement in 53 per cent of
cases of severe chronic schizophrenics treated with
reserpine, in 58 per cent of such cases treated with
chlorpromazine and in 24 per cent of similar cases
treated with placebos.
In a public institution matters of cost are of
importance. Results with such apparent similar-
ity would cause one to ask why use a more expen-
sive medication? We therefore examined the de-
gree and quality of the improvement brought about
by the two drugs.
Ford and Jameson4 found chlorpromazine in
conjunction with electroconvulsive therapy short-
ened the course of treatment. When used on
treatment failures, a notable percentage recovered
sufficiently to be discharged home. Chlorpromazine
appeared to be both an adjunct and a last ditch
measure. Would it play a similar role in our
treatment program?
TABLE I. DIAGNOSIS IN 285 SUBJECTS
Diagnosis Number
Schizophrenia 245
Chronic brain syndrome 32
Manic depressives 4
Involutional psychotic reaction 4
Total— 285
Subjects
Those in the study consisted of 285 chronically
ill women of various diagnoses, white and colored,
ranging in age from twenty to sixty. Duration of
hospital stay was from one to fifteen years. Two
hundred forty-five were diagnosed schizophrenia,
thirty-two chronic brain syndrome, four manic-
depressive psychosis, and f®ur involutional psy-
chotic reaction.
July, 1957
859
CHLORPROMAZINE AND RESERPINE— BELISLE ET AL
One hundred seven received chlorpromazine and
auxiliary therapy.
Fifty-three received reserpine and auxiliary
therapy.
The chlorpromazine group consisted of 104
schizophrenics, one mental defective and two
manic depressives, totaling 107. Patients receiving
as little as 600 milligrams of chlorpromazine were
included.
TABLE II. SUBJECTS TREATED WITH
CHLORPROMAZINE AND OTHER THERAPIES
Diagnosis Number
Schizophrenia 104
Chronic brain syndrome — Mental deficiency 1
Manic depressives 2
Involutional psychotic reaction 0
Total— 107
The reserpine group contained forty-nine schizo-
phrenics and four diagnosed chronic brain syn-
drome.
TABLE III. SUBJECTS TREATED WITH RESERPINE
AND OTHER THERAPIES
Diagnosis Number
Schizophrenia 49
Chronic brain syndrome 4
Total — 53
The controls numbered 135 and contained all
the patients receiving no chlorpromazine, reserpine,
electroconvulsive therapy or group therapy. They
received milieu therapy, which consisted of oc-
cupational therapy, recreational therapy and cus-
todial care.
Method
Everyone was rated according to his recorded
and observed behavior for the three-month period
prior to the beginning of treatment. For the
month following a year of treatment, another
rating was made. Any change in rating could
be observed quantitatively by subtracting one from
the other. Table IV gives the scale used.
TABLE IV. RATING SCALE
1. Convalescent leave
2. Ground privileges or home visits every week
3. Adequate ward adjustment. Occasional visits (monthly)
4. Combative or untidy or withdrawn up to half of time
5. Combative or untidy or withdrawn over half of time
Several treatment categories were devised which
contained combinations of the available therapies.
To secure results for a group receiving what was
surmised from the literature to be a minimal
therapeutic trial, a category of chlorpromazine,
20,000 milligrams or more, was evolved.
TABLE V. THERAPY CATEGORIES
Type . Number
A. Chlorpromazine and auxiliary therapy 107
B. Reserpine and auxiliary therapy 53
C. Chlorpromazine alone 52
D. Chlorpromazine and reserpine alone 9
E. Chlorpromazine and group therapy 16
F. Reserpine and group therapy 8
G. Chlorpromazine and electroconvulsive therapy 3
H. Reserpine and electroconvulsive therapy 2
I. Chlorpromazine, ECT, and group therapy 4
J. Reserpine, chlorpromazine, ECT, and group therapy 7
K. Control group 135
L. Chlorpromazine, reserpine and ECT 2
M. Reserpine alone % 15
N. Chlorpromazine 20,000 mg. or more, other therapy .. . 49
O. Chlorpromazine 20,000 mg. or more alone 21
These groups were compared as to over-all im-
provement, quantitative improvement in behavior
and degree of improvement. All patients that
moved from one behavior category to a category
considered better were recorded as improved no
matter how many categories advanced.
The quantitative improvement was computed
by averaging the betterment and worsening of
behavior for each individual in a therapy com-
bination. An improvement of two points meant
an advance of two behavior categories. Since
the majority of the patients were in group III,
an advance of two points would have meant the
obtainment of convalescent leave. This was the
ideal for which we hoped. The quantitative rat-
ing showed which therapy combination came the
closest to the ideal two point improvement.
The degree of improvement was determined by
computing the percentage of patients in each
treatment combination that advanced the hoped
for two points or more.
The improvement in group V patients for com-
binations containing chlorpromazine and reserpine,
and for the control was computed.
TABLE VI. CONVALESCENT LEAVE
(April, 1955 to April, 1956)
Due to or aided by chlorpromazine 15
Due to or aided by reserpine 1
On neither drug 7
Total— 23
Results
There were twenty-three convalescent leaves is-
sued. In fifteen, chlorpromazine had played a
prominent part in their recovery and extramural
adjustment. Four were not in psychiatric remis-
sion but either they were able to tolerate their
860
TMSMS
CHLORPROMAZINE AND RESERPINE— BELISLE ET AL
environment better or their friends, relatives and
acquaintances found their behavior more accept-
able.
The over-all improvement computed showed
that about one-third of the controls improved in
behavior. The change brought about by chlor-
promazine was less than that of reserpine. Both
showed more improvement than would have been
expected from chance. When the chlorpromazine
result was limited to only those receiving 20,000
mg. or more, the improvement brought about was
significantly higher than that from reserpine.
TABLE VII. PERCENTAGE OF OVER-ALL IMPROVEMENT
Percentage
Category Number of Category
K.
Control
.46
34.8
A.
Chlorpromazine and auxiliary therapy
.60
56.1
B.
Reserpine and auxiliary therapy
.38
71.7
C.
Chlorpromazine alone
.26
50.0
M.
Reserpine alone
. 9
60.0
N.
Chlorpromazine 20,000 mg. or more and
other therapies
.40
81.6
O.
Chlorpromazine 20,000 mg. alone
.16
76.2
This pattern continued when quantitative im-
provement was determined. The difference be-
tween the two therapies was more marked when
larger amounts of chlorpromazine were used. The
chart shows that auxiliary therapies contributed
to the quantitative improvement but not enough
to allow two point improvement.
TABLE VIII. QUANTITATIVE IMPROVEMENT IN
BEHAVIOR
Average Point
Category Number Improvement
A.
Chlorpromazine and auxiliary therapy..
107
.97
K.
Control
135
.38
B.
Reserpine and auxiliary therapy
53
.96
C.
Chlorpromazine alone
52
.75
M.
Reserpine alone
.... 15
.80
D.
Chlorpromazine and reserpine alone ..
9
.55
E.
Chlorpromazine and group therapy
16
1.19
F.
Reserpine and group therapy
11
1.22
!■
Chlorpromazine, ECT, group, reserpine
.... 7
1.29
N.
Chlorpromazine 20,000 mg. or more
and
auxiliary therapy
49
1.29
O.
Chlorpromazine 20,000 mg. or more alone 21
1.14
Table IX shows that chlorpromazine is three
times as effective as reserpine in bringing about
two-point improvement. The findings indicated
that group therapy and electroconvulsive therapy
were valuable adjuncts in bringing about sought
for degree of improvement.
The Group V controls show a high percentage
of improvement. That particular rating is af-
fected by not only the behavior of the patient but
also by the response of the hospital personnel. If
the patient were either assaultive or withdrawn,
TABLE IX. PATIENTS ADVANCING TWO POSITIONS
OR MORE IN RATING
Percentage
Category Number of Category
K. Control 7 5.2
A. Chlorpromazine and auxiliary therapy 27 25.2
C. Chlorpromazine alone 10 19.2
B. Reserpine and auxiliary therapy 12 22.6
M. Reserpine alone 1 6.7
G. Chlorpromazine and electroconclusive
therapy .. 2 66.7
E. Chlorpromazine and group therapy 5 31.3
I. Chlorpromazine, ECT and group therapy 3 75.0
D. Chlorpromazine and reserpine 0 00.0
N. Chlorpromazine 20,000 mg. and
auxiliary therapy 6 28.6
he was restrained or ignored. More patient, posi-
tive contacts with a less apprehensive employe al-
lowed an improvement in rating.
TABLE X. PATIENTS IN GROUP V
Category
Number
Im proved
Number
Per
Cent
K.
Control
18
12
66.7
A.
Chlorpromazine and auxiliary therapy.
22
18
81.8
C.
Chlorpromazine alone
11
9
81.8
o.
Chlorpromazine, 20,000 mg. or more a
lone 6
4
66.7
B.
Reserpine and auxiliary therapy
13
12
92.3
M.
Reserpine alone
5
3
60.0
Total Group V
44
30
68.1
Complete blood counts were taken and recorded
for seventy of the patients receiving chlorproma-
zine. These showed that at least ten per cent of
the patients showed depressions of the white blood
count. There were no serious clinical manifesta-
tions.
TABLE XI. EVALUATION OF WHITE BLOOD COUNTS
Group Number Percentage
Counts before and after chlorpromazine 70 100.0
Depression of more than 2,000 8 11.4
Counts below 4,000 at end of treatment 4 5.7
Elevation of more than 2,000 6 8.5
Medical complications were seen in seven pa-
tients. Five broke out in rashes, one developed a
Parkinson-like condition which reversed itself
rapidly when the drug was discontinued, and one
developed convulsions which were spaced about
a month apart. These were easily controlled by
small doses of dilantin.
TABLE XII. COMPLICATIONS (CHLORPROMAZINE)
Type
Number
Percentage
Rash
5
4.7
Parkinsonism
1
0.9
Jaundice
0
0.0
Convulsions
1
0.9
Total
7
6.5
July, 1957
861
CHLORPROMAZINE AND RESERPINE— BELISLE ET AL
Discussion
Our results seem to support the findings of
Kovitz3 as to the relative effectiveness of both
drugs. But like Kinross- Wright5 we found chlor-
promazine to be significantly more effective when
used in high doses.
The ability of a drug to bring about a quan-
titatively greater degree of improvement is of pri-
mary importance in reducing inpatient treatment
in public hospitals. Our results seem to indicate
that these drugs both change the interaction be-
tween patient and personnel, enhancing milieu
therapy and the patient’s accessibility to milieu
therapy. The improvement of almost one-half
point in the control group indicates that the milieu
therapy does bring about some improvement.
Since our results show two-thirds of the Group V
improving, we can envision a more subdued, com-
municative and social atmosphere. This would
allow milieu therapy, group and individual psycho-
therapy to be brought into play more effectively.
We have found that catatonics after treatment
with electroconvulsive therapy can be kept from
relapsing by being placed on reserpine. Chron-
ically ill patients are showing more lasting im-
provement to electroconvulsive therapy when this
is combined with chlorpromazine. Two patients
advance from Group V to convalescent leave on
chlorpromazine. This did not happen on reser-
pine.
With these results, more social contact between
patients and personnel is inevitable. In the ab-
sence of sufficient individuals trained in develop-
ing positive interpersonal relationships, attendant
personnel should be trained to do this.
Milieu therapy must be administered swiftly,
intensely and persistently as soon as the patient
shows some response in order to maintain the
contact with reality and to enhance his recovery.
Our patients have been in the hospital an aver-
age of six years. We have found it necessary grad-
ually to reacquaint the improved patient with
extramural environment. More “half-way houses”
be( ;ome urgent. There a patient could gradually
get on his feet while still maintaining some ©f
his dependent ties with the hospital.
While checking white blood counts, it was noted
that those that had depressed white blood counts
showed a notable rise in their counts following
a. short course of electroconvulsive therapy.
Conclusions
1. On all dosage levels we found no significant
differences between the effectiveness of reserpine
and chlorpromazine.
2. When more than 20,000 milligrams of chlor-
promazine were used, not only was there greater
improvement but also the degree of improvement
was quantitatively larger.
3. Milieu therapy had a measurable effect upon
chronically ill patients, aiding their recovery.
4. Improvement was greater when both drugs
were used with auxiliary therapies.
5. The use of drug therapy created an atmos-
phere that allowed improvement of severely re-
gressed patients who had received none of the
drugs.
6. None of the therapies brought about sought
for “two point” improvement in the majority of
patients.
7. The percentage of patients treated with
chlorpromazine advancing two points was signifi-
cantly higher than the percentage of those treated
with reserpine.
Summary
Two hundred eighty-five, white and colored, fe-
male, chronically ill psychotics were treated with
drug, electroconvulsive, group and milieu therapy.
The results were analyzed to determine the per-
centage and the magnitude of improvement.
References
1. Hollister, L. E.; Jones, L. P. ; Brownfield, B. ; John-
son, F. : Chlorpromazine alone and with reserpine.
California Med., 83:118-221, 1955.
2. Bleuler, M., and Stoll, W. A.: Clinical use of
reserpine in psychiatry; comparison with chlor-
promazine. Ann. New York Acad. Sc., 61:167-173
(Apr. 13) 1955.
3. Kovitz, B.; Carter, J. T.; and Addison, W. P.: A
Comparison of Chlorpromazine and Reserpine in
Chronic Psychosis. Arch. Neurol & Psychiat., 74:
467-472 (Nov.) 1955.
4. Ford, H., and Jameson, G. K.: Chlorpromazine in
conjunction with other psychiatric therapies; a
clinical appraisal. Dis. Nerv. System, 16:179-185
(June) 1955.
5. Kinross-Wright, V.: Chlorpromazine and reserpine
in the treatment of psychoses. Ann. New York
Acad. Sc., 61 : 174-184 (Apr. 15) 1955.
862
JMSMS
The General Practitioner in Chronic Disease
and Disability in Industry
Seward E. Miller, M.D.
Ann Arbor, Michigan
T N CONSIDERING his role in the prevention
and amelioration of chronic disease and dis-
ability in industry, the general practitioner cannot
but sense an awesome responsibility. The chronic
ailments have greater social and economic import
than any other disease category. This is borne
out by the fact that about 60 per cent of all days
of disability is accounted for by chronic illness7
and that approximately seven-tenths of all deaths
are caused by chronic illness. We know that,
contrary to popular belief, chronic disease strikes
during man’s productive years. Thus, one case
out of every five involves a person under twenty-
five, and one out of every two involves a person
under forty-five. Chronic diseases are estimated
to cause three-fourths of a billion days of lost time
each year.7
Since it is the private physician who sees the
majority cf cases of chronic disease and disabling
accidents — both home and industrial, it is basi-
cally his responsibility to observe and recognize
those conditions which lead to disability and to
attempt to arrest their progress or mitigate their
effects. This tremendous burden on the private
physician can be eased by his utilizing the re-
sources available in the community and in indus-
try for the early detection, management, and,
where necessary, rehabilitation in chronic disease
and disability. These aids are available to him, in
greater or lesser degree, in four major areas:
( 1 ) the prevention of occupational exposures which
may lead to chronic disease; (2) the proper place-
ment of workers to avoid the aggravation of exist-
ing chronic diseases; (3) the provision of preven-
tive health services in industry for early detection
and diagnosis; and (4) the rehabilitation and
restoration of the disabled patient to as productive
and full a life as possible.
Presented at the 91st Aranual Session of Michigan
State Medical Society. Detroit, Michigan, September
26, 1956.
Dr. Miller is Director of the Institute of Industrial
Health, University of Michigan, Ann Arbor, Michigan.
Prevention of Occupational Chronic Diseases
Let us first consider the chronic diseases known
to be associated with specific occupational expo-
sures. These include various types of cancer,
diseases of the respiratory tract, diseases of the
cardiovascular system, and a large variety of
chronic poisonings or the resultant chronic dis-
ability from acute poisonings.
Cancerigenic exposures are found in diversified
occupations. Thus, the processing of chromates
has been associated with a many-fold increase in
the incidence of primary lung cancer. Ionizing
radiation from radon and its decay products has
been implicated in the extraordinarily high lung
cancer rates among European uranium miners.
In addition, ionizing radiation may be an etiologic
factor in leukemia and skin cancer; bone sarcoma
has also been related to deposition of radium.
Bladder cancers have been conclusively related to
beta naphthylamine and to benzidine exposure.
Arsenic and some of its compounds, as well as a
variety of fractions of petroleum, coal tar, and
pitch have been implicated as causing skin can-
cers. Finally, cancer may complicate other occu-
pational diseases; for example, lung cancer is sus-
pected of being secondary to asbestosis.
Respiratory diseases have been frequently asso-
ciated with the occupation. This disease group in-
cludes silicosis, silicotuberculosis, asbestosis, and
other pneumoconioses, and bagassosis.
Diseases of the cardiovascular system directly
traceable to the working environment are few.
Thus, disabling cor pulmonale may accompany
severe pneumoconiosis and chronic beryllium dis-
ease. Also, damage to the peripheral vascular
system may residt from the prolonged use of vi-
brating tools and from exposure to low tempera-
tures.
Chronic effects are also associated with expo-
sure to heavy metal poisons in industry. In this
category, lead poisoning wras the classic example.
Although disabling chronic industrial lead poison-
ing is no longer a major disease problem, opper-
July, 1957
863
GENERAL PRACTITIONER IN CHRONIC DISEASE— MILLER
tunities for exposure are widespread, temporary
overexposure is frequent, and only by great vigil-
ance can anemia, peripheral neuritis, and ence-
phalopathy be prevented. Organic damage to the
nervous system may result not only from lead expo-
sure but also from arsenic or mercury and its
compounds.
Cirrhosis of the liver can result from carbon
tetrachloride exposure, as well as exposure to the
chlorinated naphthalenes and diphenyls. Chronic
anemia from benzol is well recognized. Indeed,
in searching for the etiology of chronic disabilities
of the liver, kidneys, nervous system, and hemo-
poietic systems particularly, the possibility of
chronic or subacute poisoning should never be
overlooked.
Chronic dermatoses can be caused by numerous
irritant or sensitizing agents encountered occupa-
tionally. Because of their widespread occurrence,
frequency, and duration, industrial dermatoses are
of special importance to the general practitioner.
Often a worker who becomes sensitized to a par-
ticular substance, usually a chemical, may retain
this sensitivity long after he has left that specific
w'orking environment.2 For this reason, in cases
of chronic dermatitis, first consideration should be
given to the patient's occupational history in
attempting to establish the cause.
These examples serve only to illustrate the wide
variety of chronic diseases that may have their
origin in occupational exposures. Should the gen-
eral practitioner suspect that the patient’s job
may be the cause of certain symptoms, he can turn
to the industrial physician for expert consultation.
The industrial physician, with his intimate knowl-
edge of the materials and processes used in the
plant, frequently is able to provide readily the in-
formation needed for a differential diagnosis.
His information may either confirm the occupa-
tional disease diagnosis or lead the private physi-
cian to look elsewhere for the cause. A quick
check with him can save the busy general prac-
tioner much time and effort. For example, an
automobile spray painter who is losing weight and
developing a pallor may conceivably be suffering
from lead poisoning. Consultation with the indus-
trial physician, however, might reveal that the
paint with which the patient is working contains
no lead. Ruling out lead poisoning, one might
determine that the patient has a primary anemia
of nonoccupational origin.
If a particular plant does not have an indus-
trial physician, the general practitioner may call
upon the official occupational health agency in his
State to help establish the nature of the materials
and conditions to which his patient is exposed.
By availing himself of the services of his official
agency, the physician is not only enabled to diag-
nose with greater certainty the patient’s condition,
but may also be instrumental in preventing other
workers from being similarly affected.
Placement of Workers
The general practitioner’s co-operative bonds
with the industrial physician extend beyond the
diagnosis of occupationally related chronic diseases
and encompasses other aspects of the total chronic
diseases problem. A particular opportunity for
mutual helpfulness is presented by the preplace-
ment examination.
In general, there is no great difficulty about
such non-disqualifying ailments as infected tonsils
and ailments causing temporary disqualifications,
such as hernia. Both are referred to the private
physician for correction. Problems exist, however,
where more severe permanent disabling conditions
are involved. Such a situation calls for complete
agreement by the industrial physician and the
individual's personal physician. In cases of epilepsy
or serious heart disease, for example, the family
physician upon request should make known to
the industrial physician his opinion of the patient’s
physical condition and prognosis. It then becomes
the industrial physician’s responsibility to recom-
mend proper placement of the applicant in a posi-
tion which will not aggravate his disease state or
constitute a hazard to himself or his fellow
employes.
Differences of opinion can be resolved by full,
free exchange of information on the part of both
physicians, based upon recognition and respect of
each other’s knowledge and scope of responsi-
bility. Mutual respect is built on the premise that
the general practitioner knows far more about the
applicant’s medical history and physical condition,
while the industrial physician knows far more
about the physical requirements of the job and
the working environment.6
Detection of Chronic Disease
In the detection of chronic disease, the general
practitioner may again look upon the industrial
physician as a valuable ally. An opportunity for
productive co-operation is afforded by the periodic
864
TMSMS
GENERAL PRACTITIONER IN CHRONIC DISEASE— MILLER
:xamination, screening tests, and by visits made
)y the worker to the plant medical department.
Observing the worker at these times, the alert
ndustrial physician frequently recognizes chronic
lisease in its incipient stages and refers the worker
o you for treatment. This type of co-operation
lolds great promise for minimizing the disability
rom chronic diseases.
The significance of the early detection of chronic
lisease through periodic examinations in indus-
ry, with prompt referral to the private physician
before irreparable harm is done, is illustrated in
he following report of Dr. E. P. Luongo5 of the
General Petroleum Corporation:
By regular examination, healthy employes are reas-
ured against doubts as to their physical condition and
lypochondriasis is reduced. Through advice given to
mployes regarding physical defects which may be found,
mployes are assisted in maintaining their health. The
rnpact of disabling organic disease is reduced by early
letection, and employes are encouraged to seek treat-
nent from their private physicians before irreparable
larm is done.
In General Petroleum, the following has been experi-
nced, with due consideration given to other influencing
actors including age of employe population:
1. The incidence of disabling and fatal cardiovascular
leart disease has been decreased 15 per cent since 1948.
2. There have been no disabling consequences among
liabetics since 1950.
3. The incidence of overweight has been reduced
rom 25 per cent of employe population in 1951 to 15
ler cent of employe population in 1954.
4. Mortality from malignant lesions of internal organs
n male patients has dropped 33 per cent since 1948.
5. Disabling diseases of the digestive tract have
Iropped 20 per cent from 1948 to 1954.
6. In female patients, the mortality from breast and
lelvic malignant disease has decreased 50 per cent
ince 1948.
Where industrial health services are not avail-
ible, health departments, together with voluntary
Lgencies, in a few places are conducting so-called
nultiphasic screening examinations of employed
groups. Since screening tests are designed to cull
rom an apparently healthy population those indi-
viduals with incipient disease, such tests result in
ubstantial numbers of referrals to the private phy-
icians. It is in the private physician’s office, how-
:ver, where the synthesis of the art and science of
nedicine establishes a definite diagnosis of disease
>r its absence.
The health education activities of official health
igencies, the publicity campaigns of voluntary
uly, 1957
health associations, and the health literature of
insurance companies and other agencies likewise
serve to alert many individuals who may be
harboring the seeds of a chronic disease. All of
these are sources of assistance to the doctor in the
early detection of chronic disease. Through indus-
trial periodic physical examinations and health
counselling, and through community screening
procedures and educational activities, the patient
is not only guided early to the private physician
for any necessary care but in many instances is
also emotionally prepared for the diagnosis of a
chronic disease.
It must not be overlooked, however, th?t, while
these aids have an important place, their scope
and impact are limited. Thus, by far the most
direct and far-reaching contributions to adult
health maintenance must come from the private
physicians, in their day-to-day contacts with their
patients. There is no substitute for repeated coun-
selling and reminder to patients to discard bad
health practices, to adopt healthful habits, and to
report to the physician at regular intervals or
upon the development of any unusual symptoms.
Rehabilitation and Restoration
Once a chronic disability has been diagnosed,
medical rehabilitation should start immediately
and continue as long as the patient can benefit
from such services. Various types of specialized
assistance are required, depending on the disa-
bility. The wide range of supportive personnel in-
cludes medical social workers, medical specialists
such as physiatrists and psychiatrists, physical and
occupational therapists, public health nurses, and
welfare workers. All of these specialized personnel
have some contribution to make to the solution of
the varied health and social problems of the
individual. It is the responsibility of the general
practitioner and the industrial physician to utilize
fully the available professional resources of the
community that must make up the rehabilitation
team.
The key role of the general practitioner is
apparent from the outset when the diagnosis is
first made. Because of his relationship with the
patient, he is in the position to captain the team
most effectively, to guide the therapy, and to make
the necessary interpretations to the patient and
family. It has been amply demonstrated, for
example, that many persons with heart disease are
able to continue to perform a wide variety of jobs
865
GENERAL PRACTITIONER IN CHRONIC DISEASE— MILLER
with no adverse effects. Motivation, anxiety,
taboos, and prejudices play as great a part in the
disability as the type of work to be done.3 Thus,
in the case of a myocardial infarct, the problem of
cardiac neurosis is well known. The private physi-
cian can avert such a complication by starting
psychotherapy soon after the infarct, while the
patient is still convalescing.
The American Heart Association1 has reported
that “under no circumstances should the patient
be told that he can never again do regular work,”
and that although the young patient having
cardiac disease usually can cope with changes in
his environment, “drastic reorganization of the
life of an elderly cardiac is emotionally undesir-
able; return to the same job on a limited basis is
preferable to a marked change in occupation or
attempts to learn a new skill.”
In determining what job the cardiac patient
can safely perform within his actual limitations,
the private physician can turn for assistance to
work evaluation clinics now being developed in
many localities. If none exists in his area, the
private physician, in consultation with the indus-
trial physician and a vocational counsellor, may
judiciously have to prescribe a job trial to truly
evaluate the patient’s work capacity, as recently
described by Dr. John J. Thorpe of the New York
University-Bellevue Post Graduate Medical
School.8 In any case, the patient’s entire physical
activity during a twenty-four-hour period should
be evaluated, with emphasis placed on frequent
follow-up examinations to determine the influence
of his total activities upon his cardiac status.4 The
American Heart Association makes available to all
physicians various publications which serve as
guides in the evaluation of physical capacity and
as a reference to existing community resources
which may be utilized.
Another major area of disability involves mental
health and emotional problems. The physician
may expect to find himself increasingly concerned
with such problems among workers. It has been
estimated that about 25 per cent of the nation’s
labor force suffer from some form of emotional
disturbance. Whether these disturbances have
their roots in the job situation or not, the private
physician can achieve a greater insight into his
patient’s difficulties by working closely with the
industrial physician. Co-operation of this type
is particularly important if it is suspected that the
job is contributing significantly to the emotional
disturbance. If there is no industrial physician in
the patient’s place of employment, the private
physician will need to consult with the supervisor
or an appropriate management representative to
help resolve the difficulties that may be causing
the disorder. In addition, many communities are
developing specialized mental health clinics and
facilities which can be of great service to you in
the management of these cases.
According to Dr. Ralph T. Collins, chairman of
the Committee on Industrial Psychiatry of the
American Psychiatric Association, in the care of
neuropsychiatric cases, anxiety causes the greatest
problems. He advises that patients with mild
neuropsychiatric conditions stay on the job. Dr.
Collins further reports that patients with acute
schizophrenic reactions frequently recover in ten
to twelve weeks, and that returning them to their
job is important in their rehabilitation.8
The rehabilitative aspects of such other chronic
diseases as vascular lesions affecting the central
nervous systems, arthritis, neuromuscular disorder,
and diabetes are equally important in preventing
the progression of these diseases and in helping
the patients learn to live and, where possible, to
work with their handicaps and disabilities.
In a number of communities, a broad variety of
rehabilitative services are available for the patient
in the home as well as in the hospital. These
services are provided by what are known as “home
care programs.” Some of these programs are
hospital based and represent an extension of the
hospital service into the community. Other similar
programs have been developed in official and
voluntary health agencies. Experience has shown
that home care is not a substitute for hospital
care. However, home care programs fill a real
need for medical service in a surprisingly large
percentage of long-term cases, especially those
requiring specialized treatment. In the handling
of patients with long-term illness or disability,
home care can be as helpful to the general prac-
titioner as hospital care. The development and
use of this new technique may well be one of the
more important health service developments of the
past several years.
Since restoration of the patient as nearly as
possible to economic independence is the ultimate
(Continued on Page 870)
866
TMSMS
ACTH and Cortisone in Trichinosis
By Geoffrey L. Brinkman, M.D.,
and Laslo Koos, M.D.
Detroit, Michigan
'T'RICHINOSIS is a common but rarely recog-
nized infection in the United States. Autopsy
studies show that up to 30 per cent of the popula-
tion is infected,1 but symptoms are manifested in
only 5 per cent of cases. There is no known
curative agent and up till recently it was not pos-
sible to alter the natural course of the illness
which may be prolonged for many weeks and had
a mortality varying between 5 to 30 per cent.
However, treatment with ACTH and cortisone
has markedly altered the picture. It is now pos-
sible to obtain complete symptomatic relief with-
in forty-eight hours and so far no deaths have
been reported in patients receiving steroid therapy.
Although these drugs have been freely avail-
able for eight years, only seventeen cases of tri-
chinosis treated by steroid therapy have been
reported2'11 in the American and Canadian litera-
ture. Review of the foreign literature discloses
a further twelve cases,12'14 giving a total of twenty-
nine cases in all. In every case there has been
a dramatic symptomatic response. Three further
cases are reported here.
Case Reports
Case 1. — P.B., a forty-five-year-old Hungarian man,
was admitted on December 25, 1955. Nine days prior
to admission he had diarrhea for three days, following
which he became constipated. For six days previous
to admission he had fever with shaking chills, during
which time he had been given penicillin and streptomy-
cin without effect. His past history was noncontribu-
tory.
At the time of admission he complained of fever,
malaise and constipation. His temperature was 103.6
F. and his pulse 100/min. There were no abnormal
physical signs. Laboratory investigations showed:
Hemoglobin 14.2 grams; red blood count 4.86 million;
white blood count 9,400, 86 per cent polymorphonu-
clears, 4 per cent eosinophils; Urine: albumin trace,
6 to 8 leukocytes, otherwise normal. Three blood
cultures as well as urine and stool cultures were nega-
tive. Liver function tests showed: Thymol turbidity
3 units, thymol flocculation 1+, cephalin cholesterol
negative, direct bilirubin 0.13 mg., total 0.63 mg.
From Pulmonary Division, Henrv Ford Hospital, De-
troit, Michigan.
July, 1957
On the fifth hospital day his personality changed
and he became anatagonistic and complained constantly
of feeling “crazy.” At this time, he first developed
muscle pain. A history was now obtained of his
Fig. 1. Temperature chart of Case 1, showing the
response to therapy.
having eaten uncooked bacon just prior to his present
illness. Despite muscle pain, muscle tenderness was
not a prominent feature at any stage. The only
fresh abnormality found on physical examination was
one small fundal hemorrhage. A trichinosis skin test
gave a strongly positive immediate reaction. A repeat
white blood count was 11,300, with 59 per cent
polymorphonuclears and 16 per cent eosinophils. A
diagnosis of trichinosis was made, and this was con-
firmed (on the eighteenth hospital day) by a biopsy
of the deltoid muscle, which showed encysting larvae.
On the sixth hospital day he was started on steroid
therapy as shown in Figure 1. Within forty-eight hours
his temperature was normal, and by the fourth day
his muscle pains were gone. The personality change
persisted up to the time of discharge, but cleared before
he finally stopped steroid therapy. He was discharged
after thirteen days of treatment to continue on Acthar
Gel, 20 units a day for a total of six weeks. Two days
after discharge, he was readmitted with a thrombosis
of the left femoral vein which responded satisfactorily
to routine anticoagulant therapy. The Acthar Gel was
stopped, as intended, on February 4, 1956, with no
subsequent relapse.
867
ACTH AND CORTISONE IN TRICHINOSIS— BRINKMAN AND KOOS
Case 2. — M.B., the thirty-two-year-old Hungarian
wife of the patient in Case 1, was admitted to the
hospital on December 31, 1955. Fifteen days prior to
admission and within a few days of having eaten some
1-10-56 1-26-56
Fig. 2. Electrocardiographic changes in Case 2,
showing the inversion of the T-wave in S III, V2 and
V3, with return to normal in sixteen days.
uncooked bacon, she had a brief episode of diarrhea,
followed by malaise. Eight days later, she noticed
periorbital edema which spread rapidly to involve the
whole face. Soon generalized muscle pains developed
so that even breathing became painful. The day be-
fore admission, she had fever for the first time.
On physical examination her temperature was 100.4
F, pulse 76/min. She was lethargic, apprehensive and
very emotional. Besides the facial swelling and muscle
tenderness, it was noticed that the flexor muscles of
the right forearm were swollen. The trichinosis skin
test gave a strongly positive immediate reaction. The
white blood count was 13,000, with 28 per cent eosino-
phils. On January 10, 1956, an electrocardiogram
showed inversion of the T-waves in Standard lead 3
and in precordial leads Vi, V2 and V3. These changes
persisted until January 26, 1956, when the electro-
cardiogram showed reversion of the above changes to
normal (Fig. 2). In spite of the electrocardiographic
evidence of myocardial involvement, the patient never
exhibited any subjective evidence of myocarditis.
She was started on Acthar Gel, 40 units a day. There
was a less dramatic response to treatment than in the
first case, but she made steady improvement and at no
time had a fever over 99.4 F. She did, however, re-
main very depressed for about three weeks, but this
cleared before stopping the Acthar Gel, which therapy
was maintained for a total of six weeks.
Case 3. — K.B., the fifteen-year-old-son of the family,
was admitted to the hospital on January 7, 1956.
Twelve days previously, he had developed a con-
tinuous fever of up to 104.0 F. Three days prior
to admission, facial and periorbital edema developed,
associated with pain in the muscles of the arms and
legs. He also had eaten of the same uncooked bacon
as his mother and father.
Fig. 3. Temperature chart in Case 3, showing the
response to therapy.
On physical examination, his temperature was 103.0
F. and the pulse 88/min. He was a well developed
boy with marked swelling of the face and considerable
tenderness of the limb muscles. There was a small
hemorrhage in the left fundus. The trichinosis skin
test gave a strongly positive immediate reaction. White
blood count was 17,300, with 27 per cent eosinophils.
For the first three days, he was treated with aspirin,
20 to 60 gm. per day, and Benadryl,® 50 mg. three
times daily in order to compare such a regime with
steroid therapy, but he had no relief of his symptoms
nor of his temperature. On the fourth hospital day,
he was therefore started on Acthar Gel, 20 to 40 units
daily, with a prompt and sustained improvement in
his condition (Fig. 3). He was discharged on the
thirteenth hospital day, but continued on Acthar Gel
20 units daily, for a total of six weeks. His con-
valescence was uneventful.
Infection with the Trichinella spiralis occurs as
the result of eating improperly cooked pork, al-
though rare cases have occurred from eating bear
and even walrus meat. The disease has three
stages. The first is due to invasion of the in-
testinal wall by the female worm and is char-
acterized by irritative gastrointestinal symptoms.
After five days, the worm is so well embedded in
the submucosa that purgatives will no longer dis-
lodge her. The second stage lasts fourteen to
twenty-one days as the larvae migrate from the
intestine by way of the blood stream. Every organ
is infected, but in particular, the striated and
cardiac muscles and the brain. It is during this
868
TMSMS
ACTH AND CORTISONE IN TRICHINOSIS— BRINKMAN AND KOOS
period that symptoms are most prominent and
the patient may present with a combination of
fever, periorbital or facial edema, muscle pain
and tenderness, encephalitis or psychosis. The
final stage may be characterized by fatigue as the
larvae encyst in the striated muscles.
The diagnosis was first suspected in these three
cases as the result of being aware of the Hun-
garians’ habit of eating uncooked meat. Muscle
biopsy of the father confirmed the diagnosis. In
the mother and the son the diagnosis was pre-
sumptive, but both had eaten the same uncooked
bacon as the father, and both had the typical
clinical features and showed the same response
to therapy. The diagnosis of trichinosis is, there-
fore, felt to be safely established in these last two
cases.
Discussion
These three cases, together with the twenty-
nine cases reported previously, all showed a rapid
response to cortisone and ACTH. These drugs
have no parasiticidal effect and the mode of
action is still undecided. Fortier9 suggests that
they alter the host’s defense mechanisms, in which
case a change in the cellular reaction about the
encysting larvae would be expected. Further-
more, the cyst wall, which represents a host re-
action, also would be expected to show change
under steroid therapy. Davis and Most6 did
serial sections in one case of human infection and
found a change in the inflammatory response,
but this has not been confirmed by others, nor
was it apparent in the muscle biopsy in the case
reported here. Most observers agree that the
symptoms and signs of this infection represent
an allergic response on the part of the host and
that these drugs merely modify this reaction.
Contrary to clinical experience, where the re-
sponse to ACTH and cortisone has been invari-
ably favorable, animal work shows that these drugs
may be actually harmful in trichinosis. Coker15
showed that in mice infected with Trichinella spi-
ralis and treated with cortisone, the adult worms
lived longer and so produced more larvae. This may
account for Stoner and Goodwin’s16 finding that
both these drugs increased the susceptibility of
mice to this parasite. Luongo et al1 found that
ACTH would protect infected guinea pigs while
therapy was maintained, but if the onset of treat-
ment was delayed the mice died despite ACTH.
Although experimental work in animals does not
support the use of these drugs, in humans there
is no doubt that if given in sufficient dosage,
ACTH and cortisone are always effective in re-
lieving symptoms.
A further reason for using ACTH and cortisone
is that it probably protects the patient against the
serious complication of myocarditis, which is the
commonest cause of death in these patients. Al-
though the larvae invade the myocardium, en-
cystment does not normally take place. However,
areas of focal necrosis and inflammation occur
often proceeding to fatty degeneration, with death
from myocardial failure resulting between the
fourth to eighth week of the illness.17 Clinically,
the only demonstrable evidence of myocardial in-
volvement may be a change in the electrocardio-
gram. The commonest abnormalities are inver-
sion of the T-wave or prolongation of the PR-
interval or QRS-complex. On this basis, electro-
cardiographic evidence of myocarditis has been
found in 21 to 75 per cent of patients. Whereas
Solarz18 and Spink2 found the highest incidence
of electrocardiogram change in the second week
of illness, Reiman (quoted by Solarz) found that
the peak occurred in the fifth week. Of the
thirty-two cases cited here, seven showed electro-
cardiographic evidence of myocarditis, one of
whom developed congestive heart failure. This
gives an incidence of 22 per cent.
The myocarditis in trichinosis is presumably a
toxic reaction resulting from the destruction of
the larvae within the myocardium. Because of
their anti-inflammatory effect, ACTH and corti-
sone probably modify the myocarditis, although
due to the complete lack of pathologic material
in steroid treated cases, this must remain an as-
sumption in the meanwhile. Nevertheless, there
is considerable justification for maintaining ther-
apy until the danger of myocarditis is past and,
for this reason, six weeks would appear to be a
minimum period during which these drugs should
be given.
Summary
The literature is reviewed and three cases of
trichinosis treated with ACTH or cortisone are
reported. Twenty-nine similarly treated cases are
cited from the literature. The mode of action
of these drugs is briefly reviewed and the reason
for maintaining therapy for at least six weeks
is given.
July, 1957
869
ACTH AND CORTISONE IN TRICHINOSIS— BRINKMAN AND KOOS
References
1. Faust, E. C.: Animal agents and vectors of human
disease. Philadelphia: Lea & Febiger, 1955.
2. Spink, W. W.: Adrenocorticotrophic hormone and
adrenal steroids in the management of infectious
diseases. Ann. Int. Med., 43:685-701 (Oct.) 1955.
3. Rosen, E.: Cortisone treatment of trichinosis. Am.
J. M. Sc., 223:16-19 (Jan.) 1952.
4. Luongo, M. A.; Reid, D. H.; and Weiss, W. W.:
Effect of ACTH in trichinosis; Clinical and ex-
perimental study. New England J. Med., 245:757-
760 (Nov. 15) 1951.
5. Roehm, D. D.: Trichinosis: Report of case manifest-
ing myocarditis, encephalitis and radial neuritis. Re-
sponse to ACTH. Review of literature regarding
the erythrocyte sedimentation rate. Ann. Int. Med.,
40:1026-1040 (May) 1954.
6. Davis, W. M., and Most, H.: Trichinosis. Case
report with observations of effect of adrenocorti-
cotrophic hormone. Am. J. Med., 11:639-644
(Nov.) 1951.
7. Wertheim, J. M., and Cohen, S.: Case of trichino-
sis treated with cortisone. New York J. Med.,
55:1908-1909 (July 1) 1955.
8. Rothenberg, F.: Treatment of trichinosis with cor-
tisone. J. M. Soc. New Jersey, 48:517 (Nov.) 1951.
9. Fortier, J. J.: ACTH and cortisone in trichinosis.
Report of three cases. Canad. M. A. J. 72:298-301
(Feb.) 1955.
10. Scott, R. A.; Johnson, R. E.; and Holzman, D.:
Trichinosis with neurologic and mental manifesta-
tions. New England J. Med., 247:512-514 (Oct. 2)
1952.
11. Solomon, C., and Seligman, B.: Response of tri-
chiniasis to adrenocorticotrophic hormone (ACTH)
therapv. New York State J. Med., 52:1444-1446
(June 1) 1952.
12. Faiguenbaum, J.: Triquinos y cortisona. Bol. Inform.
Parasit. Chilenas, 8:9-11 (Jan. -Mar.) 1953.
13. Buylla, P. A.; LLavona, J. A.; and Villarroya,
P. F.: Trichinose et A.C.T.H. Gaz. Med. France,
60:1 171-1172 (Nov.) 1953.
14. Perez-Bryan, M.; Reyes Tellez, J. C.; and Rod-
riquez Navarrete, A.: Consideraciones clinicas y
terapeuticas con motivo de un brote epidemico de
triquinosis. Estudio de siete casos. Rev. Clin.
Espan., 52:264-271 (Feb. 28) 1954.
15. Coker, C. M.: Effects of cortisone on trichinella
spiralis infections in non-immunized mice. J. Para-
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16. Stoner, R. D., and Godwin, J. T.: Effects of
ACTH and cortisone upon susceptibility in mice.
Am. J. Path., 29:943-950 (Sept.-Oct.) 1953.
17. Saphir, O.: Myocarditis. A general review, with
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Path., 33:88-137 (Jan.) 1942.
18. Solarz, S. D.: An electrocardiographic study of one
hundred fourteen consecutive cases of trichinosis.
Am. Heart J., 34:230-240 (Aug.) 1947.
THE GENERAL PRACTITIONER IN CHRONIC DISEASE
(Continued from Page 866)
goal of rehabilitation, the private physician should
be niindlul of opportunities to help his patient
become a productive member of society. One
such opportunity is presented in his contacts with
the owner-managers of business that he numbers
among his patients. By allaying baseless fears on
the part of the management group regarding the
ability of persons with chronic diseases to work
successfully in jobs for which they are physically
and emotionally suited, the physcian can further
open the doors of industry to chronic disease
patients. Such a contribution completes the cycle
of medical and rehabilitative care which the
private physician has provided and directed. Until
the whole course of this cycle can be altered by
the discovery of the causes and thus the primary
prevention of chronic diseases, restoring the chron-
ically disabled to useful productive lives, it affords
the private physician his greatest satisfaction in a
job well done in today’s complex medical picture.
References
1. American Heart Association: Returning Cardiacs to
Work: A Guide for Private Physicians. New York:
American Heart Association, 1952.
2. Chronic Disease Commission: Chronic Disease in
Industry. Public Health Service, U. S. Department
of Health, Education, and Welfare. Statement for
inclusion in report on prevention of chronic diseases
(To be published).
3. Katz, Louis N. : What stress does to the heart.
Indust. Med. & Surg., 23:267-269 (June) 1954.
4. Kuhn, Paul H. : Observations on Cardiovascular
Patients in Industry — Results of a Six-year Study in
a Small Industrial Plant. Indust. Med., 17:2
(Dec.) 1948.
5. Luonoo, E. P.: The Evaluation of Periodic Exami-
nations of Employes. M. Ann. District of Columbia,
24:183-188 (Apr.) 1955.
6. Lutz, Earl E.: Relationship between the general
practitioner and the industrial physician. AMA
Arch. Indust. Hyg. & Occupational Med., 8:4
(Oct.) 1953.
7. President’s Commission on Health Needs of the
Nation: Building America’s Health. A report to
the President. Washington, D. C.: Government
Printing Office, 1953.
8. Unsigned Article: Job trial is only way to evaluate
work capacity of cardiac patients. Scope Weekly,
1:12 (May 23) 1956.
870
JMSMS
Ecthyma Contagiosum (Orf) in Sheep and Man
A Summary of the Literature and Report
of Three Cases
William B. Taylor, M.D.
and Walker A. Lea, Jr., M.D.
Ann Arbor, Michigan
T7 CTHYMA contagiosum in man is an acute
■*—J vesicular and pustular disease acquired by
contact with an infected sheep, goat or labora-
tory material. It is well known among sheep-
raisers and veterinarians and in sheep-raising
areas, rural physicians frequently see the disease.
Since it is a self-limiting process and of a banal
nature, it is probably more common than pub-
lished reports would indicate. Many synonyms
have been used to describe ecthyma contagiosum
in sheep. Laymen are more familiar with the
synonyms scabby mouth or sore mouth of sheep
than with such terms as orf, contagious ecthyma,
ovine pustular dermatitis or infectious pustular
dermatitis of sheep. The disease is found in
sheep-raising areas throughout the world.
Although it is not generally recognized, sheep-
raising in Michigan appears to be steadily in-
creasing. According to the 1954 census of the
Department of Agriculture, there were approxi-
mately 675 sheep breeders with a total of more
than 66,000 sheep in Washtenaw County alone.*
It is evident from these figures that more than
an academic interest in the disease is necessary
among physicians in Michigan.
Ecthyma Contagiosum in Sheep
The infection in animals usually appears in the
spring soon after the sheep are put to pasture.
The usual sequence of events are that a few ani-
mals become infected from dried crusts which
have remained scattered over the pasture from
the previous year. The infection then is rapidly
From the Dermatology Service, St. Joseph Mercy
Hospital, Ann Arbor, Michigan, and Department of
Dermatology, University Hospital, Ann Arbor, Michigan.
William B. Taylor is on the Staff at St. Joseph Mercy
Hospital and is Assistant Professor of Dermatology,
University of Michigan Medical School.
Walker A. Lea, Jr., M.D., is Resident Physician in
Dermatology, St. Joseph Mercy Hospital and Univer-
sity Hospital, Ann Arbor. Michigan.
*Coagriculture Agent. Co-operative Extension Service,
Department of Agriculture: Personal communication to
the authors, July, 1956.
July, 1957
spread by way of contaminated feed or water or
by direct spread, i.e., when an infected lamb
suckles a ewe. Sheep of any age are highly sus-
ceptible and the process may quickly reach epi-
demic proportions. About three days following
exposure, typical lesions begin to appear.24 These
may continue to appear for several days. The
lesions occur on portions of the animal devoid
of wool ; namely, the gums, lips, nose, eyelids,
teats and genitalia. The original papulovesicular
eruption becomes pustular and ulceration occurs.
The bases of the ulcerated areas become papil-
lomatous and covered with heavy crusts. This
produces swollen, painful lips and the typical
“sore mouth.”
The process is usually over in about three to
four weeks. However, the infection is important
from an economic standpoint because the animal
fails to grow and gain weight properly. Although
it is seldom fatal, if the disease is complicated by
pyogenic organisms, screw worms or other para-
sites, the mortality rate may be very high.
In an attempt to protect the flock, many sheep-
breeders vaccinate their lambs at about three
weeks of age. The vaccine consists of one part
of ground dried infected scab and one hundred
parts of a diluent composed of fifty parts of glyc-
erine and fifty parts of physiologic saline.3 Al-
though vaccination results in an immunity suf-
ficient to provide effective protection on the range,
Wheeler et al24 have shown that a complete im-
munity did not exist unless the animal had re-
ceived two inoculations of the virus. Partially
immune animals had a much milder form of the
disease.
Ecthyma Contagiosum in Man
Ten reports were found in various medical
journals in this country concerning human cases
of ecthyma contagiosum.4’7,8’10’15’16 19’20>21’23 One
of the best clinical descriptions of the disease was
reported by the Australian authors, Pask et al,17
871
ECTHYMA CONTAGIOSUM (ORF)— TAYLOR AND LEA
who produced the disease experimentally in hu-
man volunteers.
Infection usually occurs when a person attempts
to medicate or feed an infected lamb. In four to
six days following inoculation, the process begins
as an erythematous macule. Papules form quickly
and these become vesicular or bullous and then
pustular in a few days. The pustules rupture and
heavy crusts form over the area. Frequently, a
typical lesion will resemble a smallpox vaccination
with the formation of an umbilicated pustule sur-
rounded by an erythematous halo. Pruritus may
be intense in the area of involvment. Regional
adenopathy usually occurs but it is generally of
a mild nature. Constitutional symptoms are mild
to absent unless a secondary bacterial infection
occurs. As one would expect, the sites of predilec-
tion are the fingers, hands and wrists. If infected
material on the fingers is inoculated into the skin
of the face and neck, these areas may also become
involved. The entire process, if uncomplicated,
lasts about three weeks. Healing occurs without
scarring.
Virology
The virus of ecthyma contagiosum has been
studied by many workers.1'4’6’14’22’24 Blakemore
et al2 reported observing the virus with the elec-
tron microscope. Its appearance was not de-
scribed. The organism can pass through Berke-
feld V, Chamberland L2 Mandler No. 7 filters,
and membranes having pore diameters of 600 to
900 millimicrous.1’4’5’6,9’14’24 It is resistant to both
drying and freezing and may remain viable at
room temperature for many months. Wheeler
et al24 have shown that tissue and crusts from
lesions are usually infectious in dilutions up to
1 : 50,000. Inoculation of the chorio-allantoic
membrane of the chick embryo has failed to
produce evidence of the disease.24 Several work-
ersi3,23,24 ]iave reported unsuccessful attempts to
produce lesions on the scarified cornea of a
rabbit. Wheeler et al produced a very mild disease
with almost inconspicuous lesions in the skin of
rabbits.24
Histopathology
Histologic changes occurring as part of the
disease have been described by several au-
thors.10,17,18 Wheeler and Cawley25 have recent-
ly described these changes in great detail.
The pertinent microscopic findings usually con-
sist of ballooning degeneration with intraepider-
mal vesicle formation, edema of the dermis with
dilated blood vessels and lymphatics, a dermal
infiltrate of lymphocytes, reticuloendothelial cells
and a varying number of polymorphonuclear leu-
kocytes and plasma cells. Increased blood vessel
formation is a prominent feature and pseudoe-
pitheliomatous hyperplasia may occur.
Ecthyma contagiosum has been classified with
the dermatropic viruses, herpes simplex, herpes
zoster, vaccina, variola and varicella. There are
other findings in the dermis, however, which are
associated with chronic granulomas and it is this
tendency of the lesion that sets it apart from the
usual pock disorders.
Several authors have been unable to demon-
strate inclusion bodies in biopsy material from
humans or animals.10,12’17 Percival has described
intracytoplasmic eosinophilic droplets in biopsy
material from humans but he failed to designate
these as inclusion bodies.18 Two authors have re-
ported the presence of elementary bodies in cyto-
logic preparations made from the vesicles of
human patients.2’12
Treatment
Because the disease is self-limiting and of short
duration, no specific therapy is indicated. Care
should be directed toward preventing transmis-
sion of the infection and preventing secondary
bacterial infection. Vaccination of sheep handlers
and laboratory workers against the virus may be
the most satisfactory way to control the infection.
Case Reports
Case 1. — A thirty-six-year-old farmer was referred to
us for diagnosis. About three weeks previously he had
assisted a veterinarian inoculate a flock of sheep, in
which there had been an outbreak of ecthyma conta-
giosum. Subsequently, he had treated some of the in-
fected lambs. This consisted of removing crusts from
lesions about the nose, lips and gums and applying
topical preparations to these areas.
About five days prior to his first examination, he noted
the appearance of erythema and swelling at the site of
a burn which he had incurred on the left index finger.
About twenty-four hours after the onset of redness and
swelling, a vesicle had appeared and this had become
pustular. Although he opened the pustule, he was unable
to express purulent material from the lesion. Examina-
tion revealed two circular lesions with sharply demarcated
borders on the left index finger. The surfaces were
covered by thick crusts. A straw-colored serum could
be expressed from the lesions. Epitrochlear and axillary
872
JMSMS
ECTHYMA CONTAGIOSUM (ORF)— TAYLOR AND LEA
nodes were present and painful. Constitutional symp-
toms were absent.
Case 2. — The second patient was a thirty-two-year-old
woman. The first patient had given her some orphan
lambs immediately preceding the outbreak of ecthyma
Fig. 1. (above) Case 1. Crusted secondarily infected
lesions of seven days’ duration.
Fig. 2. (below) Case 3. An early lesion showing sharp-
ly demarcated inflammatory papule with central vesi-
culation.
contagiosum in his flock. As soon as she realized that
her sheep had been exposed, she vaccinated them. Al-
though many of her flock developed the disease and
required local treatment, it was her observation that the
disease had been much milder in her flock.
She developed two erythematous macules which soon
became papulovesicular and then pustular on the dorso-
lateral aspect of the left index finger. These lesions
developed in superficial skin breaks that the patient had
incurred while working in her garden. When first seen
the lesions were secondarily infected. Lymphadenitis
and lymphangitis were present, and she had had fever,
malaise and headaches.
Case 3. — The third patient was a fifty-three-year-old
engineer and part-time farmer who helped vaccinate
and treat a flock of infected sheep. Approximately five
days following his initial exposure to the sheep, he
developed erythema and swelling on the dorsum of the
right middle finger in its distal portion and on the
dorsum of the proximal phalanx of the right thumb.
His lesions occurred in the sites of small abrasions and
developed in the characteristic manner. Epitrochlear
adenopathy was minimal. Constitutional symptoms were
absent.
Comment
An important aspect of the disease in man is
its recognition and differentiation from other
diseases. Nomland16 has aptly called attention to
the fact that ecthyma contagiosum does not re-
semble the usual vesicular eruptions of the hands.
In the differential diagnosis, one must include
pyogenic bacterial infections, vaccina, pyogenic
granuloma, Milker’s nodule, tularemia, primary
inoculation tuberculosis, anthrax, extragenital
chancre, infected verruca vulgaris and sporotrich-
osis.
Ecthyma contagiosum begins as an inflamma-
tory papule, on which is superimposed a vesicle
which may or may not be hemorrhagic. Central
umbilication is frequently present, and pustulation
occurs following vesicle formation. The primary
lesion in a deep impetigo, or bacterial ecthyma,
is a pustule which later develops into a crusted
pyogenic ulcer. In addition, the two processes
differ from each other in distribution, history and
duration. Milker’s nodules are acquired from
cattle and not sheep. The microscopic features of
Milker’s nodule and ecthyma contagiosum are dis-
similar. A history of exposure to infected sheep or
laboratory material, plus the clinical appearance
of the lesion is usually sufficient for a diagnosis.
Sheep pox and ecthyma contagiosum are not
synonyms.4’11 Sheep pox is a virus disease, but
it is a systemic infection and involvement of the
skin is only part of the generalized process.
Summary
1. Three cases of ecthyma contagiosum are re-
ported.
2. Attention is called to the fact that ecthyma
contagiosum is more common than is generally
recognized.
3. The salient aspects of the disease in sheep
and man are reviewed.
References
1. Aynaud, M.: La stomatite pustuleuse contagieuse
des ovins (chancre du mouton). Ann. Inst. Pasteur,
37:498 (May) 1923.
2. Blakemore, F.; Adleussalam, M., and Goldsmith,
W. N. : A case of orf (contagious pustular derma-
titis) : identification of the virus. Brit. J. Dermat.,
60:404 (Dec.) 1948.
July, 1957
873
ECTHYMA CONTAGIOSUM (ORF)— TAYLOR AND LEA
3. Blank, H., and Rake, G.: Viral and Rickettsial
Diseases of the Skin, Eye, and Mucous Membranes
of Man. P. 193. Boston: Little, Brown and Co.,
1955.
4. Boughton, I. B., and Hardy, W. T. : Contagious
ecthyma (sore mouth) of sheep and goats. J. Am.
Vet. M. A.. 85:150 (Aug.) 1934.
5. Came, H. R. ; Wickham, N. ; Whitten, W. K., and
Lockley, R. P.: Infection of man by the virus of
contagious pustular dermatitis of sheep. Australian
J. Sc., 9:73 (Oct.) 1946.
6. Glover, R. E.: Contagious pustular dermatitis of
the sheep. J. Comp. Path. & Therapy, 41:318
(Dec.) 1928.
7. Gray, E. H. : Contagious ecthyma in man. Cali-
fornia Med., 70:417 (May) 1949.
8. Hollister, A. C.: Infectious ecthyma, morbidity and
mortality. Weekly Report, 2:38 (Oct. 2) 1953.
9. Howarth, J. A.: Infectious pustular dermatitis of
sheep and goats. J. Am. Vet. M. A., 75:741 (Dec.)
1929.
10. Kingery, L. B., and Dahl, J.: Ecthyma contagiosum
in man. Arch. Dermat. & Syph., 51:359 (June)
1945.
11. Krai, F., and Novak, B. J.: Veterinary Derma-
tology. P. 154. Philadelphia: J. B. Lippincott Co.,
1953.
12. Lloyd, G. M.; MacDonald, A., and Glover, R. E.:
Human infection with the virus of contagious pus-
tular dermatitis. Lancet, 1:720 (March) 1951.
13. Lyell, A., and Miles, J. A. R.: Orf in man. Brit.
M. J., 2:1119 (Nov.) 1950.
14. Marsh. H.. and Tunnicliff, E. A.: Stomatitis in
young lambs involving actinomyces necrophorus and
the virus of contagious ecthyma. J. Am. Vet. M. A.,
91:600 (Nov.) 1937.
15. Newsom, I. E., and Cross, F. : Sore mouth in sheep
transmissible to man. J. Am. Vet. M. A., 84:799
(May) 1934.
16. Nomland, R. : Human infection with ecthyma con-
tagiosum, a virus disorder of sheep : Report of two
cases. Arch. Dermat. & Syph., 42:878 (Nov.)
1940.
17. Pask, J. M. ; Mackerras, I. M.; Sutherland, A. K.,
and Simmons, G. C.: Transmission of contagious
ecthyma from sheep to man. M. J. Australia, 2 : 628
(Nov.) 1951.
18. Percival, G. H.; Drennan, A. M., and Dobbs, T.
C.: Atlas of Histopathology of the Skin. P. 187.
Edinburgh: E. and S. Livingstone, Ltd., 1947.
19. Price, D. A.: Contagious ecthyma in man. Texas
Rep. Biol. & Med., 11:530 (Fall) 1953.
20. Price, D. A.: Human infection with contagious
ecthyma of sheep. Southwestern Vet., 5:344, 1952.
21. Schock, A.: Sheep-pox infection in man. Arch.
Dermat. & Syph., 39:1040 (June) 1939.
22. Selbie, F. R. : Properties and pathogenicity of a
virus derived from sheep dermatitis. Brit. J. Exper.
Path., 26:89 (Apr.) 1945.
23. Wheeler, C. E. ; Cawley, E. P., and Johnson, J. H. :
Ecthyma contagiosum (Orf). Arch. Dermat. &
Syph., 71:481 (Apr.) 1955.
24. Wheeler, C. E.; Potter, M., and Cawley, E. P. :
Experimental ecthyma contagiosum (Orf). J. In-
vest. Dermat., 26:275 (Apr.) 1956.
25. Wheeler, C. E., and Cawley. E. P. : The microscopic
appearance of ecthyma contagiosum. Am. J. Path.,
32:535 (May-June) 1956.
THYROID GLAND IN OBSTETRICS AND GYNECOLOGY
(Continued from Page 858)
12. Green, M. A.: The effect on endogenous thyroid
activity of feeding desiccated thyroid to normal
human subjects. New England J. Med., 244:385,
1951.
13. Hodges, R. E., Evans, T. C., Bradbury, J. T., and
Keettel, W. C. : The accumulation of radioactive
iodine by human fetal thyroids J. Clin. Endocrinol.,
15:661, 1955.
14. Hodges, R. E., Hamilton, H. E., and Keettel, W. C.:
Pregnancy in myxedema. Arch. Int. Med., 90:863,
1952.
15. Krichesky, B.: The influence of thyroidectomy on
the period of gestation in the rabbit. Am. J. Phys.,
126:234, 1939.
16. Krohn, P. L.: The effect of thyroidectomy on re-
production in the female rabbit. J. Endocrinol.,
7:307, 1950-51
17. Krohn, P. L., and White, H. C.: The effect of
hypothyroidism on reproduction in the female al-
bino rat. J. Endocrinol., 6:375, 1949-50.
18. Lister, L. M., and Ashe, J. R., Jr.: Pregnancy and
myxedema. Obst. & Gynec., 6:436, 1955.
19. Litzenberg, J. C.: The relation of basal metabolism
to sterility. Am. J. Obstet. & Gynec., i2:706, 1926.
20. Parkin, G., and Greene, J. A.: Pregnancy occurring
in cretinism and in juvenile and adult myxedema.
J. Clin. Endocrinol., 3:466, 1943.
21. Peterson, R. R., and Young, W. C.: The problem
of placental permeability for thyrotrophin, propyl-
thiouracil and thyroxine in the guinea pig. En-
docrinology, 50:218, 1952.
22. Piper, J., and Rosen, J. : The management of
hyperthyroidism during pregnancy. Acta Medica
Scand., 150:215, 1954.
23. Sharman, A.: Therapeutic experiments in female
infertility. J.A.M.A.. 148:603, 1952.
24. Smith, C. A,. Oberhelman, H. A., Jr., Storer, E.
H., Woodward, E. R., and Dragstedt, L. R. : Pro-
duction of experimental cretinism in dogs by the ad-
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63:807, 1951.
25. Zieve, L., Skanse, B., and Schultz, A. L.: Compara-
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104 S. Michigan Avenue
Chicago 3, Illinois
874
JMSMS
Indications for the Treatment of Hemorrhoids
Norman D. Nigro, M.D.
and George L. Walker, M.D.
Detroit, Michigan
\T7 HEN should hemorrhoids be treated? This
’ ’ question has become a frequent one for a
variety of reasons. First, there are an increasing
number of people who are in the older age group
where hemorrhoids are common. Secondly, we are
doing more routine health examinations at the
request of the patients themselves or their employ-
ers; the primary purpose of these procedures being
to exclude cancer or potential cancer. During the
rectal portion of the survey, hemorrhoids are often
an incidental finding, especially in people over
forty. Finally, we have to deal with a large group
of patients who consult us because of rectal symp-
toms. In such cases, the determination of the
amount of hemorrhoidal tissue present is depen-
dent upon a thorough rectal examination. If we
make an inadequate examination, we may find
little evidence of internal hemorrhoids even though
they may be large. In such a situation the ten-
dency is to discount the complaint, dismissing the
patient without effective treatment. It is not sur-
prising that some of these people turn to irregular
practitioners for help.
In order to arrive at a useful set of indications
for therapy, it is necessary to consider some of the
basic facts involved. Hemorrhoids are masses of
varicose veins of the anorectal area. Internal
hemorrhoids are varicose veins which originate in
the rectum above the anorectal line and are there-
fore covered with mucous membrane. External
hemorrhoids are those that arise distal to that
line, and are covered with skin. These veins are
distensible and vary greatly in size depending upon
the intrarectal pressure. This pressure depends
upon the position of the patient and upon whether
or not he is bearing down as in the act of defeca-
tion. Hemorrhoids are subject to trauma, and are
in close proximity to potentially infected struc-
tures, the anal glands. In spite of this, we doubt
From the Department of Surgery, Wayne State Uni-
versity, College of Medicine, Detroit, Michigan.
Presented at the Fall Postgraduate Clinic of the Mich-
igan Academy of General Practice, Sheraton-Cadillac
Hotel, Detroit, November 6, 7, and 8, 1956.
July, 1957
that hemorrhoids are frequently the focus of any
serious infection. We are certain that hemorrhoids
are not a precancerous lesion. Since there is no
etiologic relationship between hemorrhoids and
cancer of the rectum, the mere presence of hemor-
rhoids is no indication for treatment. All patients
who are found to have anatomic evidence of piles,
but without symptoms, are advised against any
form of therapy.
If a patient without symptoms is told that he
has hemorrhoids, it should be made clear to him
that cancer will not develop from them. On the
other hand, he should understand that if rectal
symptoms occur, he must not assume that they
are hemorrhoidal in origin. A re-examination is
mandatory, because a malignant lesion could de-
velop coincidently but unrelated to the hemor-
rhoids.
A significant proportion of patients with large
hemorrhoids or with smaller hemorrhoids asso-
ciated with infection of the perianal tissues, will
have annoying complaints. Large hemorrhoids,
because of their size, are more liable to trauma
and thus more likely to cause symptoms. Hemor-
rhoids of any size associated with perianal infec-
tion cause symptoms because of the inflammatory
reaction. These symptoms are rectal bleeding, dis-
comfort often described as a feeling of fullness
or lack of complete emptying of the rectum, actual
pain, pruritus, protrusion, and soiling. These com-
plaints occur in varying degrees, and it is essential
to carefully evaluate their severity.
Complete examination includes the use of in-
struments which will allow internal visual inspec-
tion. Rectal cancer, which in its early stages pro-
duces symptoms often attributed to hemorrhoids,
must be searched for and eliminated as a possi-
bility. External examination alone will fail to note
the presence of internal hemorrhoids, and the all
too common practice of simple inspection with
the patient bent over, spreading the buttocks, is
woefully inadequate. With this kind of examina-
tion, patients having annoying symptoms may be
875
TREATMENT OF HEMORRHOIDS— NIGRO AND WALKER
denied therapy because the examiner sees nothing
and concludes that the complaint must be exag-
gerated. Furthermore, hemorrhoids, unless throm-
bosed, are not palpable. They must be visualized.
It is not difficult to make an accurate appraisal
of the amount of hemorrhoidal tissue present. This
is done by examining the patient in the left lateral
position with the right thigh flexed. A suitable
anoscope, such as the Hirschman anoscope, is
inserted, and an adequate light is directed through
the scope into the rectum. The patient is asked
to bear down during the inspection of each of the
three principle hemorrhoidal areas: right anterior,
right posterior and left lateral, and again during
the removal of the instrument. The scope must
be inserted several times in order to visualize the
entire circumference of the anal canal. The size
of the hemorrhoids becomes evident only when the
pressure within the veins is maximal. With the
removal of the scope, the hemorrhoids, if very
large, will prolapse to the outside. The variation
in the size of these veins is similar to that of vari-
cose veins of the leg in different degrees of depen-
dency.
We may conclude then, that the need for treat-
ment depends upon the symptomatology, and upon
the size of the hemorrhoids as determined by ade-
quate examination. Asymptomatic hemorrhoids
require no treatment. Minimal symptoms indicate
either no therapy or palliative treatment, while
long standing, annoying complaints usually indi-
cate surgery'.
Acute External Thrombotic Hemorrhoid
This common lesion is characterized by the sud-
den appearance of a painful lump near the anus.
It is a bluish, tender mass covered with skin
located at the anal opening, and it represents
a clot of blood recently formed from the rupture
of an external vein. It is not necessarily associated
with internal hemorrhoids.
Treatment, for the most part, is indicated to
relieve pain. If the patient is seen early, he will
complain of pain, and the clot should be removed.
This is done as an office procedure. If the patient
is seen late when the pain has subsided, and if
there is no infection or erosion of the skin, then
no treatment is indicated. The clot will absorb.
In this latter situation, the discomfort resulting
from treatment would be greater than the origi-
nal complaint.
External Hemorrhoids
We include in this group the common anal
skin tags which most often result from healed
fissures and resolved external thrombotic hemor-
rhoids. They are very common in women who
have borne children. External hemorrhoids alone
and these anal tags seldom cause symptoms.
Rarely, when very large, they may become irri-
tated. Occasionally, they cause soiling and efforts
to cleanse the parts after defecation may be a
factor contributing to pruritus. Conservative mea-
sures such as the use of moistened cotton for
cleansing will often control such a complaint. If
not, simple excision under local anesthesia is
indicated.
Internal Hemorrhoids
It is useful to classify symptomatic internal
hemorrhoids into three groups.
1 . Internal hemorrhoids which do not protrude.
2. Internal hemorrhoids which protrude on de-
fecation but reduce spontaneously.
3. Internal hemorrhoids which protrude on de-
fecation but require replacement.
Internal hemorrhoids which do not protrude. —
Patients in this group whose only complaint is
rectal bleeding are suitable for injection therapy.
This treatment will control bleeding. It is well
to emphasize that only internal hemorrhoids should
be injected. External piles are never injected with
a sclerosing solution because such an extra vascu-
lar injection would be extremely painful.
If there is considerable discomfort or actual
pain associated with bleeding, it indicates the
presence of a complication such as a fissure or
infection. If of recent occurrence, relief may be
obtained from such palliative measures as hot sitz
baths, correction of constipation, and the use of a
small oil enema or a bland suppository rectally.
If the complaint is of long duration, or if conser-
vative measures fail, then hemorrhoidectomy is
indicated.
Internal hemorrhoids which protrude, but which
reduce spontaneously. — This is the group most
difficult to evaluate. As indicated above, if there
are no symptoms, no treatment is necessary. If
symptoms are minimal, conservative measures
mentioned above may be effective. If complaints
are marked, especially when present over a long
period of time, hemorrhoidectomy is advised. If
surgery is inconvenient, injection therapy may be
876
TMSMS
TREATMENT OF HEMORRHOIDS— NIGRO AND WALKER
tried. However, these patients should be told that
relief probably will be temporary and that if symp-
toms recur, surgery would be the treatment of
choice. If the patient is young, the need for sur-
gery is somewhat clearer. In older or poor risk
patients, the tendency should be toward conserva-
tive treatment. The guiding principle here, as in
all elective surgery, should be to weigh the risk,
however slight, and the inconvenience of surgery
as against the benefit to be expected.
Internal hemorrhoids which protrude and re-
quire replacement. — All patients who have hemor-
rhoids requiring replacement after bowel move-
ments should have a hemorrhoidectomy if their
general condition permits. The chances of annoy-
ing, even disabling complications such as acute
thrombosis developing in this situation are so
great that surgery is well advised even in the
absence of marked symptoms. We consider the
necessity for replacement of hemorrhoids follow-
ing bowel action a symptom requiring surgical
correction.
Strangulated Internal Hemorrhoids
Acute thrombosis of internal and external
hemorrhoids associated with prolapse of the anal
lining is an emergency. There are two schools of
thought concerning the management of this com-
plication. One is conservative treatment of the
acute phase followed by hemorrhoidectomy. The
other is immediate operation. We prefer the im-
mediate operation because it quickly relieves pain
and cures the patient in a much shorter time.
The actual surgery is not too difficult. Strangu-
lated internal hemorrhoids following child birth
is an exception to this rule. We treat them conser-
vatively with hot compresses.
Hemorrhoids During Pregnancy
Women who have mild to moderate symptoms
only during pregnancy should be treated conserva-
tively. If symptoms are severe, or if they persist
between pregnancies, hemorrhoidectomy is indi-
cated. This may be done either between preg-
ancies or during the first two trimesters. Exter-
nal thrombotic hemorrhoids, if painful, should be
relieved by excising the clot as in the nonpregnant
patient. Internal hemorrhoids which bleed should
be injected. We hesitate to do a hemorrhoidectomy
in the immediate post partum period because the
surrounding tissues are apt to be extremely edema-
tous and healing may be slow and difficult.
Summary
When to recommend treatment of hemorrhoids
is a common problem. It is common because we
are dealing with an increasing number of people
in the older age group and we are doing more
routine health examinations. Contributing to the
confusion is the too frequent incomplete exami-
nation which fails to note the presence of internal
hemorrhoids. Under such circumstances, patients
with symptoms may be inadequately treated.
Hemorrhoids, being masses of varicose veins of
the rectum, are not precancerous. Their mere
presence without symptoms is not an indication
for treatment. In other words, the treatment of
hemorrhoids is based largely upon symptomatology.
The kind of treatment depends upon the
severity of the complaint and upon the amount
and type of hemorrhoid present. An internal
inspection of the rectum under direct vision is
essential to determine the presence of internal
hemorrhoids. Furthermore, the patient must bear
down in order to fill the hemorrhoidal veins. Mini-
mal symptoms indicate palliative treatment. Long
standing, annoying complaints usually indicate
hemorrhoidectomy. But before undertaking the
treatment of hemorrhoids, one must be sure to
exclude cancer of the rectum or colon.
HEART AND CIRCULATORY DISORDERS
Although heart and circulatory disorders cause more
deaths than all other diseases combined, great progress
has been made against certain forms of heart disease,
according to Health Information Foundation. Thanks
to new methods of fighting rheumatic fever and rheu-
matic heart disease, for example, the number of heart
disease deaths among children aged one to fourteen has
decreased by 95 per cent since 1900.
July, 1957
Heart disease is apparently more prevalent among
women than men, Health Information Foundation points
out, but it causes 75 per cent more deaths among the
men in this country. One possible explanation of the
excess male mortality: men are thought to be particularly
subject and vulnerable to the strains and pressures of
modern life.
877
The Economic Royalist in Medicine
Jackson Livesay, M.D.
Flint, Michigan
/^\N a cliff towering over the city of Edinburgh,
Scotland, is the famous old Edinburgh castle
which, for generations long since gone, was a
fortification for the Scots during their wars with
the English, ft was fitting that the courtyard of
this castle be chosen as the site of one of the
world’s most lavish war memorials.
As we entered this building and our eyes ac-
commodated to the dim lighting, a sense of awe
overcame us at the grandeur and splendor dis-
played. The walls are a gleaming marble and are
inscribed liberally with gold. There are life-sized
statues of soldiers in field battle dress. And there
are many crypts off the main room, each for a
regimental tribute with the gold inscription on
the wall ; “To the Glory of God and the Men of
the 38th Regiment who gave their Lives for King
and Country.” And beneath would be a large
leather bound parchment book with the names
of the fallen heroes of that regiment. The next
crypt would proclaim “To the Glory of God and
the Men of the 42nd Regiment who gave their
lives for King and Country.” And so it went until
we were just ready to leave and near the exit
door f noticed a little brass plate, not more than
a foot square, with simple black letters printed
on it. ft was even placed so that one had to
stoop to read it. It said, “To the Glory of God
and the Men of the Royal Medical Corps who
gave their lives in the service of their fellow men.”
It was after we stepped outside, I think, that we
began to appreciate how different that last little
plaque had been. It was so plain and simple in
contrast to the ornateness of the other tributes, as
if a nation had purposely felt a quiet, humble
gratitude for their medical corps; in fact, had
made the distinction quite emphatic. For it had
not said. "To the Glory of God and the men who
gave their Lives for King and Country,” but
Presented to the Senior Class, University of Michi-
gan College of Medicine, Ann Arbor, May, 1956 and
November, 1956.
Published at the request of the Committee on Courses
on Medical Economics and Ethics, R. W. Teed, M.D.,
Chairman.
rather, “To the doctors who gave their lives in
the service of their fellow men.”
I have been asked to discuss the economic
royalist in medicine. I think I have worried more
over the organization of this presentation than any
I have ever given. For in reality, we are to dis-
cuss some of the basic principles of medical prac-
tice in relation to money. It is extremely difficult
to keep one’s thoughts totally objective on these
matters and so easy to dwell on ideals and philo-
sophical points that defy any practical outline for
a talk. I shall try my best to keep this from sound-
ing like a sermon; but if you should consider it
such, I shall not be too apologetic.
I purposely began with my experience in Edin-
burgh to point up in an emotional way, the ideal
side of a life in medicine lived in the service of
your fellow men. I hope that by the end of this
discussion I have made this the attractive goal of
your professional life that lies just ahead of you.
But at the same time, I am not blind to the
realities of our modern world and hope to show
how these problems must be integrated into the
ideal pattern of a doctor’s life.
Suppose we get down to the case in point and
define the economic royalist. In short, he is the
doctor who trys to impress people with the acqui-
sition of too much of the world’s costliest goods.
He has the biggest house in town, he has the
biggest and best automobile, he sports a luxury
boat, he dresses in the finest clothes and often
overdresses. He will be the first with a color
television, he gives lavish parties, his chief topic
of conversation will be his investments and his
newest gadget that he has bought. Mostly he is
talking about money or taxes or what money will
buy. He may or may not be a good doctor as far
as scientific medicine goes.
What are the effects of this man? The public
will not take kindly to this doctor because they
instinctively say that because of his appearance
of affluence, he charges too much and is making
too much money. What about this influence on
medicine in general? The public says therefore
878
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ECONOMIC ROYALIST IN MEDICINE— LIVESAY
all doctors make too much money. It is sur-
prising how one ostentatious doctor can over-
shadow the good works of dozens of his more
moderate colleagues. That is his danger to medi-
cine in general.
Now let’s talk about the individual and not
medicine in general. How does a man get this
way? Let me suggest that there are two ways.
First, we must recognize the personality deficit
of a few individuals who must compensate by
displaying their worldly goods to prove their suc-
cess. I noticed an ad for an automobile recently,
the first line of which read, “Some men must
prove their success, others simply live theirs.”
This puts the matter quite simply, I think. It
would be difficult to analyze the background that
created this need in a person, but I suppose any
remedy would have to start there. The usual
pattern of this man is that he is a merchant. The
Bible says, “Where a mans’ treasure is, there is
his heart also.” So it goes with this doctor. He
is unscrupulous in his charges, he often takes
cases beyond his ability, he uses every legal way
to make money out of medicine such as unneeded
surgery, unnecessary shots once a week, etc. He
is known to his colleagues early in the game, but
unfortunately, the public is not so discriminating.
But the peculiar thing about him is that after he
has gained the whole world in material things
and lost his professional soul, he suddenly switches
and his soul becomes more important for now
the ultimate in success is respectability and he
will begin in a pitiful way to court the respect of
his colleagues. I have seen it happen several times,
and I might add that he is seldom successful in
this and passes on an unhappy, frustrated and still
unsuccessful doctor, even in his own eyes.
The second way a doctor gets this way is per-
haps the more important to a group of students
about to embark on a career, and is more insidious
and may happen before he is aware of it. Aristotle
said, “In the case of our habits we are only mas-
ters of the beginning, their growth by gradual
stages being imperceptible like the growth of
disease.”
Let’s take Dr. Doe who is a typical new doctor
in our town. He is married like so many of the
young ones these days, and has two children.
Mamma has seen daddy through some pretty
rough years when there was hardly money enough
to buy food, let alone any of the luxuries common
to the better social class to which their minds and
social background entitle them. For years they
have dreamed of the day when things would be
different and finally that day seems to have ar-
rived. Mamma wants a really important house
right away and daddy thinks she deserves it. She
must dress in a way fitting her new station in
life and comparable to the other doctor’s wives
(even though their husbands have been in practice
for many years). Of course the doctor should
have a new car so that he will look prosperous
to his patients and pretty soon mamma has made
friends with a few gals who have their own cars
and so a second car is added to the family. In-
cidentally, there must be money to equip a new
office which is no small item. Finally, when all
this is added up, Dr. Doe is overwhelmed by the
shock of financial burdens and he suddenly sees
$50 in Johnny’s throat rather than a pair of
pretty good tonsils, and Mrs. Jones neurosis turns
into a $5 a week shot. And although he had
never done any real surgery, Mr. Black’s torn
hand could be fixed in the office rather than refer
him to a competent surgeon. The habit of the
first step is perhaps not easy, because Dr. Doe
once thought of medicine as a great calling with
pretty fixed habits and ideals, but as Aristotle
said, we control only the beginning of our habits,
their growth after that is imperceptible. And on
just such a weak beginning under stress is born
the economic royalist of medicine.
If I could leave you with just one word of
advice it would be to plan to start your life in
practice on a scale of living commensurate with
your early income. Build first a sound layer
of good will and service and you will not be
troubled with the economic side of medicine nor
with your scale of living from then on. If mamma
is the helpmate you and she think she is, she will
be content to let time take care of material things
in its own way and be happy in the sharing of
a great service to a community.
I know of no smooth way to make a transition
to my next line of thought, so in the parlance of
sailboating, “prepare to come about” and we will
take a new tack. We will start with a fishing
story.
Several years ago a bunch of us went to the
Thousand Islands in the St. Lawrence river for
some muskie fishing. We got hold of an old Nova
Scotia schooner and a ferry boat operator to
run it for us. Because there were too many fish-
ermen to permit us all to troll at once, we towed
July, 1957
879
ECONOMIC ROYALIST IN MEDICINE— LIVESAY
along a dinghy with an outboard. So when we
reached the fishing grounds several miles down
river, two fellows we'll call Jim and Joe took off
by themselves. Joe had brought his young Lab-
rador retriever on the trip to teach him tricks in
the water, so we must add him to the list of oc-
cupants of the boat.
It was a very hot, still day in September — but
not calm enough for the dog because he promptly
became seasick and vomited all over the little
boat. The heat of the sun soon made the stench
quite potent. The river there is perhaps eleven
miles wide and because of distance it was not
prudent to return to the mother ship. So they
had to endure the odor and keep fishing.
They had made a bet. It was to be one dollar
for the first fish and two dollars for the largest
fish caught. But fishing was not good that day,
and finally after three hours of sun and heat,
stench and frustration Joe caught a perch min-
now hardly larger than the flat fish lure he was
using. As he tossed the illegal fish back he said,
“Okay, we’ll go in now, pay me three dollars.”
Thereupon, a heated argument ensued over the
technicality of counting an illegal fish at all and
the deadline for quitting.
By the time they had returned to the schooner,
a fine friendship was fraying at the edges, and
Joe was so upset he refused to come aboard the
schooner but chose to be towed home in the dinghy
with his sick dog for company.
The sequel to this story took place eight years
later when Jim and Joe finally went fishing to-
gether again. They repeated their bet for one
dollar for the first fish and two dollars for the
largest. But this time they had learned their les-
son, though, and agreed on all the rules in ad-
vance. It was any fish this time and a time limit
of two hours.
I don't have to remind you that disagreement
over money can break up friendships. The same
thing is true of doctor and patient. It is therefore,
very wise to discuss fees in advance, especially for
extensive procedures. As our fishermen finally
learned, the rules, too, should be talked over in
advance.
But doctors as a rule don’t do this because
there has been preached a doctrine of humani-
tarianism in medicine in which money is just a
nasty word and remuneration an evil thought.
But when the patient sees his bill he knows other-
wise and classifies his humanitarian a hypocrite.
He preaches “holier than thou” humanity but
acts like a businessman.
I think I can explain why most doctors practice
this way.
The author of the first treatise on medical
ethics in 1860 or thereabouts, plainly stated that
“fee for service” was a part of medical practice.
He did not ignore the money side of medicine.
But by the turn of the century, this country has
so many diploma mills in operation that profiteers
in medicine were threatening to outnumber the
conscientious men who were doing a good job.
So about 1912-1914 the AMA wrote a code of
eithics deploring the profit motive in medicine and
setting forth an idealogic code painting medicine
as a completely selfless calling.
In the 1920s the Rockefeller Foundation
cleaned house on our medical schools; the diploma
mills vanished and the legitimate schools took
over. This country slowly but surely became the
world leader in medical education. But the doc-
trine of humanitarianism from this background
has persisted until just recently Dr. Elmer Hess,
when president of the AMA allowed himself to
be quoted in the Saturday Evening Post as saying,
“We spend too much time talking about what
great humanitarians we are. I have made as
much as $100,000 a year in medicine and I am
not ashamed of it.” This might be classed as
a history-making statement because it is such a
sharp departure from the usual public relations
remarks of the AMA.
I feel it is high time wTe began talking more
about the business side of medicine. I am not
ashamed, either, to admit that I make a very
good living in the practice of medicine. Why
should I be? I think I work hard, charge just
an average fee, I have a large investment in my-
self and in my equipment. On pure business prin-
ciples I deserve a just return on my investment,
as well as my labor. But I do not think nor act
like a merchant selling a product. When my
customer can’t pay, he gets the service anyway.
But when he can, I have to be doctor and busi-
nessman as well. I have four kids to clothe, feed
and educate; I have office help to pay and rent,
and finally, my own security to consider wrhen
the day comes that I can't keep up the pace any-
more.
Now if my remarks have left you wondering
about the paradox between my opening theme and
my recent remarks, let me try to explain:
880
TMSMS
ECONOMIC ROYALIST IN MEDICINE — LIVES AY
Last fall I spent my time in a deer blind read-
ing Marjorie Moringstar by Herman Wouk. The
central male character is an irresponsible rake
of a playwright. Marjorie can’t see him as a
good financial risk for matrimony so she talks
him into the security of an office job and he makes
some good money. One day they spend in the
Fifth Avenue shops and then are lunching at the
Swank Plaza Hotel when he says, “You know,
Marjorie, I like having money. Sure it’s fun. Of
course I like what it will buy. I would like to
wear gold cuff links, dine in these fine places
and buy you things from the Fifth Avenue Shops.
But I could stand it only — and only if both my
wife and I agreed that it was nothing but a comic
mask to be put on or taken off as we wish. That
having money is not the real thing at all.” And
then he tells her he has found out what the real
thing is— “The Hit.”
You will remember he is a playwright and he
has found out that creating a hit play is the fiber
on which his being is suspended. It is not the
money he can make from the play, but as he
puts it, “the externalizing of one’s ego” — being
able to create something tangible and external
that you can see or sense. This is the real thing
in life we seek — and such a hit can nourish the
personality for a long period of time.
With the doctor it is the deep satisfaction of
knowing he has done a real service. It is not
found alone in the glory of spectacular surgery
but may be just as real in a tiny office without
the glare of spotlights and without any stirring
background music.
Let’s say for example, that it is late in the
afternoon of a busy day in your office. You are
rushing, perhaps, because you and your wife
have a little anniversary celebration planned for
the dinner hour. There is one more patient and if
you wish, you can rush her through in a hurry.
But your conscientious nature and good habits
prevail and you do a real examination, including
a pelvic — and there it is — small, but it’s there —
an early and curable carcinoma of the cervix.
She is the mother of four children who depend
on her. She doesn't know anything about medi-
cine and so will never be able to appreciate how
much you have done for her. But you know —
you know that her chance for cure rests on your
early discovery of her disease. And you know in
your own mind that in this simple, routine exami-
nation you have created a hit show equal to any
spectacular on Broadway and inside you feel good.
For years you see this patient around your town
and feel good that you had a big part in her still
being there. And the day comes that her son,
Johnny, is awarded a scholarship to the univer-
sity as an outstanding student, and you again feel
good living this event with this family for even
this day depended upon Johnny having a normal
home life and a mother to help.
So you forget the patient dying of stomach can-
cer and the cardiac invalid you can’t do anything
about, and you feel good that you are a doctor
doing something worthwhile in your community.
And certainly you can’t remember what you
charged this woman nor if she paid her bill. The
“Hit” is the real thing.
So now we are ready to put our story together.
Medicine is without question a great humanity.
It is of necessity also, a business for profit. The
big difference in doctors depends entirely upon
which he emphasizes. “Where your treasure is,
there will your heart be also,” the Bible says.
It also says that God knows humans have need of
food and raiment and material things, but says
“Seek ye first the Kingdom of God and all these
things shall be added unto you.” If we could
paraphrase this slightly we would say, “Seek ye
first the service of your fellowmen and all these
other things shall be added unto you.” But the
important word is “first.” That’s what makes the
difference.
In conclusion, may I suggest that you ask your-
self what you really want out of a life in medicine.
Are you the one who wants a life-sized statue set
up in a marble palace all resplendent in gold art
work? If so, you are to be the ecomomic royalist
and merchant of medicine.
Or, are you content with humility in material
things? Are you willing, at the end of the road,
to settle for a monument of gratitude in the
hearts of a community and a little brass placque
not more than a foot square?
July, 1957
881
Lente Insulin*. A Clinical Evaluation
T T IS now well over a year since Lente insulin
was made generally available in this country.
In that time, its value as an insulin of intermediate
action has become evident. Because of the resem-
blance of its effect to that of NPH, globin, and
certain protamine zinc mixtures, some observers
are of the opinion that this new insulin is not
needed at this time. This study was undertaken
in order to aid in determining whether, because
of its individual characteristics, there is a place
for Lente.
A brief review of some of its pertinent chemical
facets are of interest. As Hallas-Moller1 has
pointed out, at the ph of blood, zinc and insulin
form a relatively insoluble and slowly absorbable
compound. Zinc, of course, has been utilized for
some years in our familiarly used insulin prepara-
tions. However, this slowing effect was not evident
as long as phosphate buffers were used. Using an
acetate buffer allows the zinc to remain in close
contact with the insulin rather than be preci-
pitated out as a zinc phosphate which probably
occurs when a phosphate buffer is present. Under
the latter circumstance, foreign proteins such as
protamine, globin, or histone must be added to
create a slowly absorbed product.
The degree of slowness of action of the zinc
insulin preparation is dependent primarily on its
physical state. Amorphous zinc insulin (semi-
Lente) is relatively fast acting, and its duration
is slightly longer than regular insulin (eight to
twelve hours). The crystalline suspension (ultra-
Lente), obtained at a different ph, has an effect
not unlike PZI. This difference in action is re-
tained when mixed and varying stable mixtures
- v'v*
Dr. Jaffe is Assistant Professor of Internal Medicine,
Wayne State University College of Medicine; Chief,
Department of Internal Medicine Highland Park Gen-
eral Hospital; Physician, Harper Hospital.
Dr. Leach is Assistant Professor of Internal Medicine,
Wayne State University College of Medicine.
Dr. Salem is a Jennie Jospey Fellow in Medicine,
Wayne State University College of Medicine.
From the Diabetic Clinic, Detroit Receiving Hospital
and the Department of Medicine, Wayne State Uni-
versity College of Medicine, October, 1955.
Lente insulin was supplied by Eli Lilly and Company.
Louis Jaffe, M.D., Robert B. Leach, M.D.,
and Edward S. Salem, M.D.
Detroit, Michigan
can be used. Lente, which is the only mixture
available in this country is a 3 to 7 mixture of
semi-Lente and ultra-Lente.
Eighteen patients considered well controlled
with various other insulins, were given a similar
dose of Lente before breakfast. Blood sugars were
taken before meals, including 9 o’clock at night
and again the following morning at 8 o’clock. In
all cases, the diet distribution for each meal, in-
cluding an evening feeding was 20-30-40-10 per
cent. Daily insulin dosage ranged from 28 to 68
units, and in most cases (fourteen) between 32
and 56. These were all hospitalized patients, some
with other diseases not considered as affecting the
course of the diabetes at the time of the study.
Individual graphs are shown (Figs. 1 and 2).
Most of the curves with a low point at 4 P.M.
are in Figure 1, and those with a low point at 12
noon in Figure 2. The average daily insulin dos-
age in Figure 1 was 44 units, and in Figure 2, 40
units. The two highest doses in the latter were 52
and 56. Higher dosage, therefore, was not a
factor in creating the 12 o’clock drop noted here.
Although fasting levels are lower than usually
seen, it was not felt that the response pattern
would be appreciably altered. The lowest curves
in Figures 1 and 2 were associated with mild
hypoglycemic symptoms before supper and lunch,
respectively, but no extra carbohydrate was added.
The individual with the high F B S (240) had
been well controlled until the day of the test.
However, he was included in our series and
exhibited a marked fall to the 4 P.M. level.
As expected, most of the patients (eleven) have
a 4 P.M. low point. However, an important per-
centage (33 per cent) exhibit a 12 o’clock (before
lunch) low point indicating greater sensitivity to
the semi-Lente component of the mixture. In
general, these patients had somewhat higher fast-
ing levels the next morning indicating that in these
circumstances a higher percentage of ultra-Lente
in the insulin mixture administered would have
been desirable. Some of the patients with the low^
est 4 P.M. levels were later given a 20-40-30-10
882
TMSMS
LENTE INSULIN— JAFFE ET AL
per cent diet distribution of carbohydrate with
avoidance of hypoglycemic levels in the late after-
noon.
Four patients had a burning sensation at the site
of injection, not noted with previous insulins,
which were NPH and PZI : regular mixtures. In
none of these was it of sufficient intensity to dis-
continue prolonged use. No allergic reactions
were noted.
Five “brittle” diabetic patients, considered un-
controlled by all previous methods, were given
equivalent Lente doses and followed for forty-
eight hours. Two remained grossly uncontrolled
and three exhibited distinct improvement. How-
ever, the inherent variability of control in these
cases made the duration of study too short to lead
to significant conclusions.
Discussion
In our series, Lente fulfills the requirements for
classification as an intermediate insulin, with, in
most cases, its maximum effect at eight hours,
but with a strong immediate effect within four
hours in a substantial fraction of our group. On
the whole, control was adequate, and it was not
thought necessary to add regular insulin to Lente
for more rapid effect. When this is done, regular
is apparently converted into amorphous zinc in-
sulin and, if used immediately, has almost the
same effect as if given separately. This is not true
if allowed to stand, since it will then become con-
verted into a longer acting insulin and its effects
are not accurately calculated.
If semi-Lente and ultra-Lente were readily
available, stable individualized mixtures could be
formulated for daily use. For example, the 9 P.M.
rise in blood sugar, as well as that seen in some
cases the following morning at 8 o’clock might
well be avoided by an increase in the percentage
of ultra-Lente in thev mixture. Alteration of the
percentage of carbohydrate in the various meals
throughout the day, as noted above, would also
“flatten” the twenty-four hour curve and tend to
prevent hypoglycemic and hyperglycemic levels.
Another potential advantage is the absence of the
foreign proteins — protamine and globin. This, ad-
mittedly, is an empiric advantage, since there is no
(Continued on Page 918 )
Fig. 1. Fig. 2.
July, 1957
883
Editorial
THIRTY-THREE MILLION, FIVE
HUNDRED AND SIXTY-NINE THOUSAND
Such is the number of persons in the United
States who are eligible for part or full medical
(health) care at government expense right now.
That is almost one out of every four in our popu-
lation. The number includes 22,599,000 veterans
and, as of January 1, 1957, 5,200,000 military
personnel and their families who last year were
voted into Medicare, 5,100,000 public assistance
rolls, 370,000 Indians and Alaskans, and 300,000
other dependents of U. S. Public Health Service.
The United States has assumed responsibility for
increasing numbers each year.
The need and urge for benefits and security has
always been present when and if government was
able and especially willing to “help” in the one
service which is so often a calamity to such a
large proportion of people — health care. No mat-
ter what the income level may be — $2,500, $5,000
or $7,500, or more — much more — the relative
purchasing value of the dollar does not increase.
Social need for medical care has always been
with us and always will be. The stress and strain
of the 1930’s brought “Compulsory Health Serv-
ice” to England. Bismarck plus the First World
War had brought it to France, Germany — many
nations. Only the genius of our home town medi-
cal men to diagnose a trend and find an answer
prevented America from adopting the “Beveridge
Plan” — care from “womb to tomb” — the com-
pulsory prepayment medical service, which en-
gulfed so many other nations.
Individual citizens deserve the best and ade-
quate medical care. What they could not buy in-
dividually, our pioneer leaders found could be
supplied collectively and at a price they could
afford to pay.
New problems, largely economic conditions,
actions of pressure groups, demanding of extend-
ed services, more security from extra charges,
lower purchasing value of our money and the
ever-present willingness of government to increase
its list of eligible patrons have forced the medical
profession especially its Blue Shield to take a
new look.
MICHIGAN MEDICAL SERVICE
What is Michigan Medical Service? What is
Blue Shield? To the younger medical members
of our Michigan State Medical Society who have
graduated since the translation of the theory of
prepayment into an operative fact and to the
older ones who may have forgotten: Michigan
Medical Service is really the Michigan State Med-
ical Society, part and parcel organized to meet a
need and do a job which seemed to be impractical
to the Medical Society itself. It was organized in
Michigan to meet Michigan needs. Because simi-
lar organizations grew up independently in differ-
ent states and at different times is sufficient evi-
dence of the correct basic theory. Michigan Medi-
cal Service is actually an arm of the Society. Its
Board of Directors is elected by the House of
Delegates, who constitute the membership of the
corporation. Michigan Medical Service makes
reports to The Council and the House of Dele-
gates, the same as other committees. Every mem-
ber of the Society is just as much involved in the
creation, maintenance and government of Michi-
gan Medical Service as in any other activity of
the Michigan State Medical Society. He is repre-
sented in the governing body by elected delegates.
After the movement became sufficiently extended
and accepted by the profession in general, national
associations, state, and community groups accept-
ed the term Blue Shield as representing a basic
philosophy. Michigan Medical Service is also an
outgrowth and extension of a socio-medico-eco-
nomic trend which has served the profession many
times and for many years.
Other Serving Groups
A bit of history which the current legislature
could have seriously impaired, is worth recalling.
During the late 1920’s and the 1930’s, the years
when medical care for the indigent and the
medically indigent was so impractical there were
many different plans for partial payment, none
in any way satisfactory or suitable. We do not
know who was first, but many county medical
societies were involved. The Ingham County
Medical Society, under a very special committee.
(Turn to Page 886)
884
TMSMS
Our Number One Problem
It is my personal opinion that the present staggering num-
ber of mental patients can be, and must be, reduced. This is
the responsibility of the entire medical profession. I am con-
vinced that a large percentage of these cases need never have
reached the acute stage if we had recognized their early
symptoms of emotional and mental disturbances in our offices.
Pressures, both internal and external, usually have become
severe before the patient goes to his doctor for help. This
patient comes with the fear that the doctor will not under-
stand, that his problems will seem trivial, when in truth they
are very real and serious to him. The effect of tins fear is
an increase in his desire to hide his problem. He withdraws
and builds up an unnatural defense. The physician must
convince him that he considers the problems as very real
and most of all that he is on the patient’s side. The art of
listening is at its best when we first see such a patient. List-
ening to what he says and what he does not say can develop
an early diagnosis.
Statistics of the National Committee against Mental Illness
should be enough to make us realize we have failed some-
where. An estimated 16,000,000 people in the United States
are now suffering from some form and degree of mental
illness — that is one in every ten people. More than one out
of every two hospital beds in the United States is now oc-
cupied by a mental patient. Each year averages another
290,000 new patients in mental hospitals. During the past
year, 2 Yz million people were treated in mental hospitals for
some form of mental disorder. Only 2.2 per cent of these
were in private hospitals.
Of the hospitalized general medical and surgical cases, 30
per cent were diagnosed as neurotic. Isn’t that significant?
The doctor who sees the patient for the first time can give
him a great deal of practical and simple psychiatric treatment.
The recognition of early problems can be unlimited, and
preventative mental hygiene is our duty to our patients. A
doctor’s office can be the first line of defense against mental
illness.
All we need to do is spend more time and dispense far
more understanding and kindness. Since our previous meth-
ods apparently have proven inadequate, it appears to me it
is worth a new try.
President, Michigan State Medical Society
f^reAldent
e
July, 1957
885
EDITORIAL
(Continued from Page 884)
contracted with the City of Lansing and the
County of Ingham to care for the medical and
surgical needs of the indigent and needy at a
stipulated amount which was deposited in a spe-
cial fund. Their doctors agreed to care for these
patients and make no personal charge. This fund
is used for certain agreed expenses and benefits
to the members of the Ingham County Mdical
Society. It has accumulated into a fund which
has established an outstanding annual clinic and
other professional activity. Muskegon County
made a similar bargain and has kept the work
going, has met the needs of the county, has sat-
isfied their doctors and people, and is justly to be
congratulated. Similar programs were adopted
in many counties. We believe plans of a some-
what similar nature are in effect in Kent, Genesee
and Monroe Counties.
The Calhoun County Medical Society attempt-
ed a similar arrangement with the City of Battle
Creek but finding difficulties established the Battle
Creek Academy of Medicine — later added Den-
tistry. The Battle Crek Academy bargained with
the city and the county to care for the indigent.
Soon every item of a medico-economic nature was
referred automatically to this bargaining group,
which was led by the same men who over the
years worked out a plan and were ready to sell
prepaid medical care to the citizens in 1935. They
were stopped by representation from Lansing,
and accused of violating insurance laws. The
group functioned for many years in medico-
economic matters but became inactive during the
war. Its affairs were finally settled, and a small
treasury amount was put into a needed relief.
Jackson County Medical Society met with the
Battle Creek group and established the Jackson
Academy of Medicine for the same purpose. They
appealed to The Council of the Michigan State
Medical Society about two years ago for a method
of disbanding, as the need had long since passed.
State Department of Social Welfare
Approximately ten years ago the State Depart-
ment of Social Welfare asked the Michigan State
Medical Society to nominate doctors of medicine
for an advisory committee to discuss and solve
many problems affecting the practice and what
to do. Among these problems was the very un-
satisfactory method of paying for medical care
for certain categories of persons. Doctors were
complaining about not being paid, yet the De-
partment was expending what apparently was
sufficient money.
A program was evolved, and Calhoun County
agreed to be the guinea pigs using the same money,
but having Michigan Medical Service administer
the distribution. The Society believed it would give
the medical care, and make its own payments
direct, through Michigan Medical Service and
probably save money. When the program was
ready for action, the Washington office disap-
proved. For the past year or more, the Depart-
ment has adopted a method of operation by which
the patient must submit a certificate from the
doctor before more money is allowed. It was
found there is a saving of nearly 25 per cent.
Organized Sabotage?
The Department of Social Welfare, in order to
accept certain additional grants from Washington,
and for other reasons, requested some amendments
to their control act — House Bill No. 586 of the
69th Legislature. The administrators had con-
sulted with the Medical Advisory Committee and
had agreed upon a bill which seemed satisfactory.
However, before the bill was introduced, we
were informed some Detroit interests insisted on a
certain restricting sentence: Section 14B “The
State Department shall not contract with any
corporation or other private agent for furnishing
of any type of medical service to recipients of
old age assistance, aid to the blind, aid to the per-
manently and totally disabled or aid to dependent
children on a prepayment or insurance basis.”
This would have cancelled the programs just
described in Ingham, Muskegon, Kent, Monroe
and Flint, also it would have ruled out Blue
Cross and Blue Shield. With this step in the
door, one can imagine that the same pressure
group, or one equally unfriendly, might add a
push here and there and ultimately legally ter-
minate the prepayment plans in government pro-
grams. Luckily, Michigan State Medical Society
was alert, and the legislators granted its request
to delete this clause in committee. Was this
section deliberately planted?
During the years, Michigan has furnished
leadership in many medical problems and has
made medical history. We developed many plans
to relieve the suffering and stress of our people.
We were also the first Medical Service plan to
undergo a governmental inquisition from the
Governor’s Commission. We underwent a year
886
TMSMS
EDITORIAL
of vicious publicity, and now we have had an
attempt by legislation to stymie our functioning.
More Adequate Care for Needy
For several years, the President in his messages
has advocated reinsurance or subsidy to assure
more care for persons otherwise uninsurable. He
has even advocated modifying the anti-monopoly
features to allow prepayment or smaller insurance
groups to pool their resources in order to provide
prepayment care. The Federal Government has
also recognized the prepayment plans of the medi-
cal profession through usage over ten years in
the Veterans Administration service-connected dis-
abilities program, and has now established the
program for dependents of the military-Medicare.
This is a direct reversal of their actions a few
years ago when we might have started in Michi-
gan in cooperation with the Department of Social
Welfare and the Calhoun County Medical So-
ciety. Neither does it correspond with an attempt
in our 1957 Michigan state legislature to put in
a prohibitory clause.
Privately, some of our doctors may class this
attempt with other activities which seem too
strong and persistent, but do not convince some
of our well-disposed doctors who believe the
threat of socialized medicine is a bugaboo.
Michigan Medical Service is part of us — it is
Michigan State Medical Society. It is ingrained
in each of us with our traditional duty to render
good medicine to our people.
INVESTIGATIONS AND REPORTS
The request of Michigan Blue Cross Admin-
istration for an increase in its rates about a year
and a half ago, plus the prompt organized objec-
tion from pressure groups including certain labor
officials, necessitated a delay in granting and a
curtailment of the request. At the suggestion of
many, the Governor appointed a Study Commis-
sion to investigate Blue Cross, and “incidentally
Blue Shield because the two services cannot readi-
ly be separated.” Extensive reports and articles
began appearing in the Detroit Free Press on
February 20, 1956 and almost daily until May
22, 1956. In the main, the doctor who cares
for the patient received extremely unfriendly
blame for every fault and act that could be con-
jured by ungrateful patients who mainly objected
to costs, which incidentally have never increased
in the same proportion as general costs of living,
or of labor.
The Governor’s Commission authorized a com-
plete detailed survey of Blue Cross and Blue
Shield and arranged with a certain bureau at
the University of Michigan to make the study
which was to cost up to $200,000 and take eight-
een to twenty-four months. This survey never
started, our profession being accused of blocking
it because we asked that the study be done by
an impartial group instead of by an oft-quoted
prejudiced source.
The House of Delegates at its September 1956
meeting, instructed The Council to conduct a
survey to determine what services the public
wants and is willing to pay for, and what the
profession wants and is willing to provide. The
Speaker was directed to appoint a study com-
mittee to accomplish the following: “(1) meet
with the representatives of Michigan Medical
Service to study and develop details and mechan-
isms, (2) initiate as a joint endeavor and in co-
operation with Michigan Medical Service, neces-
sary studies to ascertain what would best serve
the public and (3) prepare a complete report for
presentation to the House of Delegates at its
meeting in 1957 with the proviso that copies of
this report shall be sent to each member of the
House of Delegates by August 15, 1957.
Separate extended conferences were held by
this committee with many and qualified repre-
sentatives of Michigan Hospital Association,
Michigan Medical Service, Industry, Manage-
ment, Farm Bureau, Labor, and various study
groups from the medical profession. The com-
mittee devoted one whole day to restudy and in
preparation of its report which is at this writing
being typed for proofing and final form to be
submitted to the House.
Surveys
In conformity with instructions of the House
of Delegates (Special Session, April 27, 1957)
and just as soon as working details and specifica-
tions could be worked out, The Council ordered a
survey through the facilities of Michigan State
University to determine: (1) what the public
wants in the nature of extended or additional
medical care, whether they want home and office
calls rather than outpatient and office diagnosis,
or both, (2) what and how they are willing to
pay, if they want full coverage, limited coverage,
indemnity type or co-insurance, and (3) what
the doctors want from Blue Shield.
July, 1957
887
EDITORIAL
This study is in progress and will be completed
in time for the House of Delegates in September.
■Sr vr "X*
At the May meetings of the Michigan Blue
Cross and Blue Shield Boards authority and funds
were provided for a preliminary outline study by
the Science Research Group at Ann Arbor, look-
ing to a complete and comprehensive study of
administration, plans, programs, history, efficiency,
and prospects of both plans. If approved, this will
be even more comprehensive than the plan of the
Governor’s Commission. It will be absolutely
unbiased, the four interested groups giving assur-
ance of no interference or hindrance and with
complete approval — Michigan State Medical So-
ciety, Michigan Medical Service, Michigan Hos-
pital Association, and Michigan Hospital Service.
The investigators are to be free to outline their
procedure once the fundamental objectives have
been agreed upon. If and when ordered, this sur-
vey will require at least eight to ten months.
Michigan Medical Service has authorized man-
agement to provide a complete surgical service in
office, out-patient department, home, wherever
necessary, beginning July 1, 1957. This is to be
a liberalization, not an extended service; it is to
be in the nature of a study and survey to deter-
mine certain fundamental costs and usages. This
is on a temporary basis, the same as the twenty-
one liberalizations now allowed.
To begin at the same time, if it can be ar-
ranged, Michigan Medical Service will send to
each subscriber whom it has served a return
sealed post card reporting payments that have
been made for services, and asking the subscriber
to fill out and return answers to certain questions,
as to satisfaction in the Plan, and/or suggestions
and other desires.
Several months ago Michigan Medical Service
management completed studies which would offer
us extended benfits; office and out-patient sur-
gery; therapeutic and diagnostic radiology and
x-ray; consultations; out-patient and office labor-
atory procedures such as blood tests; electrocardio-
grams, basal metabolism rate, electroencephalo-
grams, and assistance in certain surgical proce-
dures, amounting to quite complete coverage —
this to be sold as a rider or second contract in
addition to the basic contract. This service will
be made available as soon as the Michigan State
Medical Society is ready to accept it and help
administer certain features guaranteeing that con-
tracts will be served as written.
Complete home, office, and hospital care could
be made available and sold to groups on demand,
thus rectifying one of the criticisms that our plan
is not comprehensive. Management has deter-
mined the rates that would be needed, and could
write such a contract, if need be.
Summary
Just what do the pressure groups or the doctors
want? What extra extended service do our sub-
scribers want and are willing to bargain for on
a prepayment basis? Who and how many want
to discontinue Blue Shield? (There must be some
judging by the arguments). The Federal Gov-
ernment’s intense interest in medical problems and
its constant willingness to extend medical care is
proven by the 82nd Congress which had 250 mea-
sures of medical interest introduced. In the 83rd,
there were 407 introduced, and in the 84th, there
were 571. That shows a trend which should prove
to our members who believe the “compulsory
health insurance ogre is dead,” that it is very
much alive.
Voluntary medicine, prepayment insurance (ad-
ministered by medical men) has made astounding
advancement ; it must now realign and change
some features to correspond with new crises and
new needs. Fundamentally, our plan of cohesive
and co-operative work by independent advisors
without government supervision or any group
dictation is right.
Studies are being made to determine the weak
spots, the needed splints, the new ideas, and how
to apply them as a solid united unit of action.
No one can defeat this next step in medical
sociai evolution.
Editor's Note: We realize many items have been
repeated and emphasized, but the immediate future of
medicine’s prepayment program is so vital we have pub-
lished every detail to give more adequate information
to our members. We sincerely hope everyone will com-
pletely inform himself. He must help make the final
decision, the final choice.
WHAT IS A HOSPITAL?
Did you know that except for maternity homes
there is no law in the State of Michigan which
regulates, defines or accredits hospitals?
There are and have been a number of volun-
tary nationwide hospital accrediting organizations,
such as the College of Surgeons, the American
888
TMSMS
EDITORIAL
Hospital Association and the American Medical
Association. The latter has been interested in the
educational features only. Most of the national
organizations concerned with the hospitals have
now merged under a single organization known as
the Joint Commission on Accreditation.
It seems that the time is ripe for the Michigan
State Medical Society and the Michigan Hospital
Association jointly to sponsor an official or quasi-
official definition of the minimum standards for
the organization of a hospital. All of us know
that there is a great deal of difference between a
converted house with a few beds for relatively
minor surgical procedures and a large hospital or
hospital center with unlimited facilities of all
types. Yet every shade between these two extremes
exists in the State of Michigan. To be sure, each
and every one is performing a service and has
evolved as a response to a need. Nevertheless,
doctors, patients, government agencies and insur-
ance organizations, including Blue Cross, have no
standard method of evaluation. The public espe-
cially lacks discrimination and is frequently inter-
ested in almost every other factor about a hos-
pital than its intrinsic medical value.
If action is not taken soon by those people who
run and use these workshops of doctors, it would
seem that we shall have something thrust upon
us from outside sources or something will evolve
that we shall neither like nor relish.
Clarence I. Owen, M.D.
JOURNAL COVER STOCK
Have you noticed that the cover of The Jour-
nal is now composed of much heavier stock?
MSMS ANNUAL MEETING
September 25-26-27, 1957
Civic Auditorium, Pantlind Hotel
Grand Rapids
— » Make your hotel reservation now <—
HOUSE BILL 586
(Continued from Page 818)
ability. Each month the Social Welfare Depart-
ment will receive a statement from the county
showing expenditures for hospital care, indicat-
ing who received it and how much. From the
medical assistance fund, the State will reimburse
the county up to 90 per cent of its expenditures.
“LTp to” means that any collections made by the
county toward the costs of hospital care will be
applied first.
The 90 per cent reimbursement applies only to
expenditures for care in a hospital. If the reci-
pient is in a county medical facility or a private
convalescent home, the maximum amount which
can be paid for his care is $90.00 per month.
A section of the bill which would have pro-
hibited the Department from entering into any
plan for prepaid medical care for recipients, such
as Blue Shield or Blue Cross might provide, was
stricken before the bill passed the legislature. Also
removed was the provision that would have pro-
hibited the Department from entering into agree-
ments with County Medical Societies for the care
of eligible patients.
Since the bill is an extremely complicated one,
it is impossible to predict what problems may
arise when the law takes effect in July. Because
of this, the legislature amended the original bill
to provide that the act terminate in December,
1958, for purposes of re-evaluation at that time.
ROLE OF MEDICAL ASSISTANTS
(Continued from Page 842)
3. Organize or assist in organizing refresher courses
in medical office administration for the employed
medical assistant.
4. Persuade individuals currently employed as medical
secretaries to increase their effectiveness on their
jobs through additional training in school and/or
on the job.
5. Point out to physicians the importance of em-
ploying well-qualified medical assistants and re-
munerating them adequately.
MSMS was one of the original and leading
supports of medical assistants organizations which
are designed to increase the effectiveness, quality
and training of its members. The Michigan State
Medical Assistants Society, now nearing the thou-
sand-member mark, is growing with the support
and assistance of local county medical societies —
the local sponsorship is a part of MSMS “Win-
ning Friends for Medicine” PR Program.
Mickelson will be a featured speaker at the
MSMAS annual meeting in Grand Rapids, Tues-
day, September 24, 1957. His talk will be on
“The Division of Duties in the Doctor’s Office.”
July, 1957
889
L. H. Bartemeikk,
M.D.
O. J. Becker, M.D. Samvel Bellet, M.D
T. I. Boileau, M.D.
P. A. Bowers, M.D.
J. W. Burks, Jr.,
M.D.
O. Theron Claggett
M.D.
1957
Guest
Speakers
Max Cutler, M.D. D. C. Dahlin, M.D.
D. T. Davidson, Jr.,
M.D.
S. M. Finch, M.D. Leon Goldman, M.D. E. Keith Hammond,
M.D.
R. J. Jackman, M.D.
C. T. Javert, M.D.
Benjamin Jeffries,
M.D.
P. C. Kronfeld, M.D.
Adelaide M. Johnson,
M.D.
Ormand C. Julian,
M.D.
Don W. McLean, R. L. Now, M.D \y. L. Palmer. M.D. John D. Porterfield.
M.D. M.D.
890
TMSMS
Men With New Messages— For You
The men pictured on these pages have a mes-
sage of personal value to you — and for your
patients.
These experts will converge on Grand Rapids
September 25-26-27 to bring to you in three com-
pact days a “refresher course” featuring the latest
techniques in medical treatment and surgical pro-
cedures as well as the results of day-by-day ex-
periments with the newest drugs and equipment.
They will bring to you at the MSMS Annual
Session today’s information on today’s Medicine
for your every-day, clinical use. In the six assem-
blies, fifteen section meetings and the three dis-
cussion conferences you, the practicing M.D., will
find a rare opportunity to avail yourself of the
medical advances of the past 365 days.
All meetings will be held in the Pantlind Hotel
and the Civic Auditorium. C. Allen Payne, M.D.,
of Grand Rapids, is General Chairman of the
Committee on Arrangements.
More than a dozen ancillary groups will also
meet in Grand Rapids the same week.
The General Practice Section will meet Thurs-
day afternoon at 5:00 o’clock.
The Woman’s Auxiliary to the Michigan State
Medical Society will convene in its thirty-first
annual meeting, and the Michigan State Medical
Assistants Society will hold its eighth annual meet-
ing during the same period.
Foremost nonscientific feature during the week-
long business and scientific program is the Offic-
er’s Night address Wednesday bv Michigan Gov-
ernor G. Mennen Williams. Also included in that
evening’s activities in the Pantlind Ball Room is
the induction of new MSMS officers, the annual
address of 1956-57 MSMS President Arch Walls,
M.D., Detroit, and a report of the House of
Delegates by Secretary L. Fernald Foster, M.D.,
Bay City.
This year’s Biddle Lecture will be delivered by
UAW President Walter P. Reuther on Wednesday
afternoon. Mr. Reuther will speak on “The Simi-
lar Problems of Labor and Medicine in These
Changing Times.”
The two-day House of Delegates session preced-
ing the scientific meetings will hear the results of
a state-wide survey, instituted by MSMS to reveal
public opinion of present-day medical-surgical
prepayment plans and to solicit suggestions for
possible changes in MSMS-sponsored Blue Shield.
A bigger and better State Society Night is
planned for Thursday. Top flight entertainment
has been booked for registrants and their ladies.
One hundred forty-four exhibits set up in the
Civic Auditorium will provide you with valuable
additional information on the latest scientific and
technical advances. All physicians are invited to
make full use of this opportunity to talk with
people who are interested in you and your prac-
tice.
Grand Rapids will see in September the largest
MSMS meeting ever. Be safe. Make your res-
ervations now. It’s your meeting, Doctor. Get
the message these experts have for you — and your
patients.
Walter P. Reuther
R. J. Schneck, M.D.
H. E. Schmitz, M.D.
Gerald A. Wilson,
M.D.
T. O. Winship, M.D.
July, 1957
891
Michigan State Medical Society
Past Presidents, 1866-1955
1866 — *C. M. Stockwell, Port Huron
1867 — *J. H. Jerome. Saginaw
1968 — *Wm. H. DeCamp, Grand Rapids
1869 — *Richard Inglis, Detroit
1870 — *1. H. Bartholomew, Lansing
1871 — *H. O. Hitchock, Kalamazoo
1872 — * Alonzo B. Palmer, Ann Arbor
1873— *E. W. Jenk, Detroit
1874 — *R. C. Kedzie, Lansing
1875 — *Wm. Brodie, Detroit
1876 — * Abram Sager, Ann Arbor
1877 — *Foster Pratt. Kalamazoo
1878 — *Ed. Cox, Battle Creek
1879 — *George K. Johnson. Grand Rapids
1880— *J. R. Thomas. Bay City
1881 — *J. H. Jerome, Saginaw
1882 — *Geo W. Topping. DeWitt
1883 — *A. F. Whelan. Hillsdale
1884 — *Donald Maclean, Detroit
1885 — *E. P. Christian, Wyandotte
1886 — ^Charles Shepard, Grand Rapids
1887 — *T. A. McGraw, Detroit
1888 — *S. S. French, Battle Creek
1889 — *G. E. Frothingham, Detroit
1890 — *L. W. Bliss, Saginaw
1891 — *George E. Ranney, Lansing
1892 — *Charles J. Lundy, Detroit
(Died before taking office)
*Gilbert V. Chamberlain. Flint
(Acting President)
1893 — *Eugene Boise, Grand Rapids
1894 — *Henry O. Walker. Detroit
1 895 — ^Victor C. Vaughan. Ann Arbor
1896 — *Hugh McColl, Lapeer
1897 — ^Joseph B. Griswold. Grand Rapids
1898 — *Ernest L. Shurly. Detroit
1899 — *A. W. Alvord, Battle Creek
1900 — *P. D. Patterson, Charlotte
1901 — *Leartus Connor. Detroit
1902 — *A. E. Bulson, Jackson
1903 — *Wm. F. Breakey, Ann Arbor
1904 — *B. D. Harison, Sault Ste. Marie
1905 — *David Inglis, Detroit
1906 — *Charles B. Stockwell, Port Huron
1907 — *Hermon Ostrander, Kalamazoo
1908 — *A. F. Lawbaugh. Calumet
1909 — *J. H. Carstens, Detroit
1910 — *C. B. Burr, Flint
1911 — *D. Emmett Welsh. Grand Rapids
^Deceased.
1912 — ‘Wm. H. Sawyer, Hillsdale
1913 — *Guy L. Kiefer, Detroit
1914 — *Reuben Peterson. Ann Arbor
1915 — *A. W. Hornbogen, Marquette
1916 — * Andrew P. Biddle, Detroit
1917 — * Andrew P. Biddle, Detroit
1918 — * Arthur M. Hume, Owosso
1919 — ^Charles H. Baker, Bay City
1920 — *Angus McLean, Detroit
1921 — *Wm. J. Kay, Lapeer
1922 — *W. T. Dodge, Big Rapids
1923 — *Guy L. Connor, Detroit
1924— *C. C. Clancy, Port Huron
1925 — *Cyrenus G. Darling, Ann Arbor
1926 — *J. B. Jackson. Kalamazoo
1927 — ^Herbert E. Randall, Flint
1928 — Louis J. Hirschman. Detroit
1929 — *J. D. Brook. Grandville
1930 — *Ray C. Stone, Battle Creek
1931— *Carl F. Moll, Flint
1932 — J. Milton Robb, Detroit
1933 — *George LeFevre, Muskegon
1934 — *R. R. Smith, Grand Rapids
1935 — Grover C. Penberthv, Detroit
1936 — *Henry E. Perry, Newberry
1937 — Henry Cook, Flint
1938 — *Henry A. Luce, Detroit
1939 — Burton R. Corbus, Grand Rapids
1940 — Paul R. Urmston. Bay City
1941 — Henry R. Carstens, Detroit
1942 — H. H. Cummings. Ann Arbor
1943 — *C. R. Keynort, Grayling
1944 — *A. S. Brunk. Detroit
1945 — *V. M. Moore, Grand Rapids
(Died before taking office)
1945 — R. S. Morrish, Flint
1946 — Wm. A. Hyland, Grand Rapids
1947 — *P. L. Ledwidge, Detroit
1948 — E. F. Sladek, Traverse City
1949 — Wilfrid Haughey, Battle Creek
(PVesident-for-a-Day, Sept. 21, 1949)
1949 — *W. E. Barstow, St. Louis
1950 — C. E. Umphrey, Detroit
1951 — Otto O. Beck, Birmingham
1952 — R. L. Novy, Detroit
(President-for-a-Day, Sept. 22. 1952)
1952 — R. J. Hubbell. Kalamazoo
1953— L. W. Hull, Detroit
1954 — L. Fernald Foster. Bay City
(President-for-a-Day, Sept. 28, 1954)
1954 — *R. H. Baker. Pontiac
1955 — W. S. Jones, Menominee
892
JMSMS
Michigan State Medical Society
The Ninety-second Annual Session
PANTLIND HOTEL, GRAND RAPIDS
SEPTEMBER 25-26-27, 1957
ANNUAL SESSION INFORMATION
DIRECTORY
Headquarters — Pantlind Hotel and Civic Auditorium,
Grand Rapids
Registration — for House of Delegates: Pantlind Hotel.
For Scientific Session: Civic Auditorium (see hours
below) .
House of Delegates — Monday-Tuesday, September 23-24
(Ballroom, Pantlind Hotel).
Exhibits — Wednesday-Thursday-Friday, September 25-
26-27, Civic Auditorium.
Press Room — for House of Delegates: Parlor A, Pant-
lind Hotel; for Scientific Session: Room F, Civic
Auditorium.
Woman’s Auxiliary Headquarters — Pantlind Hotel,
Grand Rapids
Michigan State Medical Assistants Society Headquarters
— Manger Rowe Hotel, Grand Rapids.
• REGISTER- -as soon as you arrive.
Hours:
House of Delegates: Sunday, September 22, Lobby
of Pantlind Hotel, 8:00 to 10:00 p.m. and Mon-
day, September 23, 8:30 a.m.
Scientific Session: Tuesday, September 24, 1:00 to
5:15 p.m.; Wednesday, September 25, 7:30 a.m.
to 5:15 p.m.; Thursday, September 26, 8:30 a.m.
to 5:15 p.m.; Friday, September 27, 8:30 a.m.
to 3:30 p.m.
• NO REGISTRATION FEE FOR MEMBERS OF
MSMS AND OTHER STATE MEDICAL ASSO-
CIATIONS, AMA AND CANADIAN MEDICAL
ASSOCIATION.
Admission will be by badge only to all Scientific
Assemblies, Section Meetings, Discussion Conferences
and the Exhibition. Please present your MSMS or
other State Medical Association, AMA or CMA
Membership card to expedite your registration. We
wish to save your time.
• MICHIGAN DOCTORS OF MEDICINE, in prac-
tice but who are not members of MSMS, if listed in
the American Medical Directory, may register as
guests, upon payment of $25.00. This amount will be
credited to them as dues in the Michigan State
Medical Society FOR THE BALANCE OF 1957
ONLY provided they subsequently are accepted as
members by the County Medical Society in whose
jurisdiction they practice.
• DOCTOR, register Tuesday! Registration of physi-
cians will be held Tuesday afternoon from 1:00 to
5:00 p.m. — as well as on Wednesday-Thursday-Fri-
day, during the 1957 MSMS Annual Session. The
Tuesday afternoon registration hours are arranged
so that physicians may avoid waiting in line Wednes-
day morning before the opening Assembly.
We recommend to Grand Rapids physicians — and
those who arrive in Grand Rapids on Tuesday —
that they register Tuesday, September 24, from 1:00
to 5:00 p.m., Civic Auditorium, Grand Rapids.
July, 1957
C. Allen Payne, M.D., Grand
Rapids, General Chairman of Ar-
rangements for the 92nd Annual
Session.
• TELEPHONE SERVICE — Special lines to handle
local and long distance telephone service for regis-
trants at the MSMS meetings are available in the
Civic Auditorium just outside the Black and Silver
Room: Glendale 1-9213, Glendale 1-9751, Glendale
1-9156. To contact the Exhibit Hall, call: Glendale
1-9145, Glendale 1-9403, Glendale 1-0738. The tele-
phone number at the Pantlind Hotel is Glendale 9-
7201.
• GUEST ESSAYISTS are very respectfully requested
not to change time of their lecture with another
speaker without the approval of the Assembly Chair-
man. This request is made in order to avoid con-
fusion and disappointment on the part of members
of the audience.
SECTION MEETINGS
WEDNESDAY, SEPTEMBER 25
5:00 to 6:00 p.m. Occupational Health
Obstetrics-Gynecology
Pediatrics
Radiology
Urology
THURSDAY, SEPTEMBER 26
5:00 to 6:00 p.m. Gastroenterology-Proctology
General Practice
Ophthalmology
Otolaryngology
Public Health and Preventive
Medicine
Surgery
FRIDAY, SEPTEMBER 27
5:00 to 6:00 p.m. Anesthesiology
Dermatology and Syphilology
Medicine (starting at 4:00 p.m. )
Nervous and Mental Diseases
Pathology
(starting at 3:00 p.m.)
893
ANNUAL SESSION INFORMATION
THREE DISCUSSION CONFERENCES
A. C. Furstenberg, M.D.
Ann Arbor
Leader on Wednesday,
September 25, 1957
Perry C. Gittins, M.D.
Detroit
Leader on Friday,
September 27, 1957
Three quiz periods will be
held Wednesday- Thursday -
Friday, September 25-26-27,
Black and Silver Ballroom,
Civic Auditorium, 12:00
noon to 1:00 p.m., with all
the guest speakers of the
day on the platform.
An opportunity to ask ques-
tions concerning the pres-
entations of the guest speak-
ers, or to discuss an in-
teresting case with them, is
C. Allen Payne, M.D. provided at these Discus-
Lea£ranodnRThuSday, sion Conferences.
September 26, 1957
• CHECK ROOM — Both in Civic Auditorium and
Pantlind Hotel.
• OFFICERS NIGHT DINNER DANCE— Wednesday,
September 25, 1957, will be a gala occasion for
MSMS members and their ladies. Sponsored by
MSMS and its Woman’s Auxiliary, this dinner dance
will begin with cocktails at 7:00 p.m. in the beautiful
Continental Room of the Pantlind Hotel. Dinner will
follow at 8:00 p.m. in the Ballroom. Dancing during
the dinner to a famous name band. The Governor of
the State of Michigan, G. Mennen Williams, will ad-
dress the group at 9:00 p.m.
Arch Walls, M.D., Detroit and Mrs. A. C. Stander
of Saginaw are Co-chairmen of this Officers Night
gala dinner dance.
NEW INFORMATION IN THE EXHIBIT
Many items of interest or education will be
found in the large exhibit of 126 technical and
1 1 scientific displays. The Exhibit Section
at MSMS Annual Sessions is as important and
desirable to most doctors of medicine as the
scientific papers presented in the Assembly room.
Doctor, stop at every booth — you’ll be sur-
prised how much you’ll learn! No high-pressure
salesman but a courteous well-informed exhibitor
will greet you and supply you with some valu-
able information helpful to your patients.
INFORMATION OF PRACTICAL VALUE IN
DAILY PRACTICE will be found at the Michi-
gan State Medical Society Annual Session. All
subjects on the MSMS Annual Session Program
are applicable to clinical medicine. They stress
diagnosis and treatment in everyday practice.
• POSTGRADUATE CREDITS ARE GIVEN TO
EVERY MSMS MEMBER who attends the Annual
Session.
• TRANSPORTATION- — The C & O Streamliners af-
ford a convenient means of transportation to the
MSMS Annual Session in Grand Rapids for hundreds
of physicians located in the southeastern and central
parts of the State.
• PARKING — Metered parking on the streets surround-
ing the Pantlind Hotel and Civic Auditorium. Out-
side lots are available as follows:
1. Rear of Rowe Hotel (two blocks from Pantlind
Hotel) .
2. Campau Avenue parking lot (one and one-half
blocks from Civic Auditorium).
3. Opposite Civic Auditorium.
• CABARET-STYLE DANCE AND FLOOR SHOW,
with the compliments of the Michigan State Medical
Society, will be held in the Ballroom of the Pantlind
Hotel at 10:30 p.m., Thursday, September 26. All who
register, and their ladies, are cordially invited to
attend.
• THE SCIENTIFIC PRESS RELATIONS COMMIT-
TEE is composed of: P. W. Kniskern, M.D., Grand
Rapids, Chairman; H. G. Benjamin, M.D., Grand
Rapids; F. C. Brace, M.D., Grand Rapids; G. E.
Braunschneider, M.D., Grand Rapids, and A. B.
Gwinn, M.D., Hastings.
• THE HOUSE OF DELEGATES PRESS RELA-
TIONS COMMITTEE is composed of: K. H. John-
son, M.D., Lansing, Chairman; L. Fernald Foster,
M.D., Detroit; J. J. Lightbody, M.D., Detroit; D. W.
Thorup, M.D., Benton Harbor; and C. L. Weston,
M.D., Owosso.
• THE MSMS HOUSE OF DELEGATES convenes
Monday, September 23, at 10:00 a.m.. Ballroom,
Pantlind Hotel; it will hold three meetings on Monday,
September 23, at 10:00 a.m., 2:00 p.m. and at 8:00
p.m.; also two meetings on Tuesday, September 24, at
9:30 a.m. and at 8:00 p.m.
MICHIGAN MEDICAL SERVICE
MEMBERS’ SCHEDULE
Pantlind Hotel, Grand Rapids
Tuesday, September 24, 1957
Coincident with MSMS Annual Session
1:00 p.m. Luncheon — -Continental Room
2:00 p.m. MMS Annual Meeting — Ballroom.
All MSMS Delegates are members of Michigan
Medical Service corporation and are expected to
attend the MMS Luncheon and Annual Meeting.
The MMS Annual Meeting is open to ALL mem-
bers of the medical profession, who are cordially
invited to attend.
894
JMSMS
ANNUAL SESSION INFORMATION
• PAPERS WILL BEGIN AND END ON TIME—
Believing there is nothing which makes a scientific
meeting more attractive than by-the-clock prompt-
ness and regularity, all meetings will open exactly on
time, all speakers will be required to begin their
papers exactly on time and to close exactly on time
in accordance with the schedule in the program. All
who attend the meeting, therefore, are requested to
assist in attaining this end by noting the schedule
carefully and being in attendance accordingly. Any
member who arrives five minutes late to hear any
particular paper will miss exactly five minutes of
that paper!
• THE FIFTH BEAUMONT LECTURE OF THE
MICHIGAN STATE MEDICAL SOCIETY will be
presented by Raymond J. Jackman, M.D., Rochester,
Minnesota, on Thursday, September 26, 2:00 to 2:30
p.m. Doctor Jackman’s subject will be “The Adenoma
Carcinoma Sequence in Cancer of the Lower Bowel.’
• THE TECHNICAL AND SCIENTIFIC EXHIBITS
will open daily at 8:45 a.m. and close at 5:15 p.m.
Frequent intermissions to view the educational ex-
hibits have been arranged before, during, and after
Assemblies.
• A CONCENTRATED THREE-DAY POSTGRADU-
ATE COURSE— A CAPSULE OF GREAT VALUE
TO THE MICHIGAN PRACTITIONERS OF
MEDICINE— THE MSMS ANNUAL SESSION OF
1957.
• THE HOLDER OF A HOTEL RESERVATION who
fails to show up . . . and fails to cancel his reservation
. . . causes gastric hyper-peristalsis, hyper-secretion of
the hydrochloric acid, and rubus of the gastric mucosa
to the hotel manager.
When convention reservations fill a hotel to the
capacity, a room not occupied is a loss in $$$ that
cannot be reclaimed.
The MSMS Annual Session always means a capacity
house in the headquarters hotel.
Be kind to the hotel manager ... be good to MSMS
... be generous to your patients ... be a friend
to yourself — by showing up at the Pantlind Hotel,
Grand Rapids for the three days of the MSMS
Annual Session, September 25-26-27.
DOCTOR, YOUR PHOTOGRAPH
Joseph Merante, Jr., portrait photographer of
New York — the official photographer for the
Michigan State Medical Society — will be in at-
tendance at the Michigan State Medical So-
ciety Annual Session at the Pantlind Hotel,
Grand Rapids, the week of September 23. Mr.
Merante, of 475 Fifth Ave., New York 17,
will be available for service to MSMS members
and their guests on the Mezzanine of the Pant-
lind Hotel between the hours of 9:00 a.m. and
4:30 p.m.
The Michigan State Medical Society’s desire
is to have a photograph in its files of everyone
of its members. Mr. Merante will help achieve
this ambition of your State Society, with your
kind cooperation. It will take but one minute
of your time in Grand Rapids.
ADVANCE REGISTRATION OF DELEGATES
Sunday, September 22, 1957
8:00 to 10:00 pan.
Lobby of Pantlind Hotel
HOTEL RESERVATIONS
MICHIGAN STATE MEDICAL SOCIETY
92nd Annual Session
Grand Rapids, September 25-26-27, 1957
The reservation blank below is for your convenience
in making your hotel reservations in Grand Rapids.
Please send your application to the Committee on Hotels
for MSMS Convention, Pantlind Hotel, Grand Rapids,
Michigan. Mailing your application now will be of
material assistance in securing hotel accommodations.
As very few singles are available, registrants are
requested to co-operate with the Committee on Hotels
by sharing a room with another registrant, when con-
venient.
Committee on Hotels,
Michigan State Medical Society
c/o Pantlind Hotel
Grand Rapids, Michigan
Please make hotel reservation (s) as indicated below:
Single Room(s) persons
Double Room(s) for persons
Twin-Bedded Room(s) for persons
Arriving September hour A.M P.M.
Leaving hour A.M P.M.
Hotel of First Choice:
Second Choice:
Names and addresses of all applicants including per-
sons making reservation :
Name Address City State
Date Signature
Address — City.
July, 1957
895
Michigan State Medical Society
The Ninety-second Annual Session
PANTLIND HOTEL-CIVIC AUDITORIUM,
GRAND RAPIDS
SEPTEMBER 25-26-27, 1957
Program of Assemblies and Sections
WEDNESDAY MORNING
September 25, 1957
First Assembly
Black and Silver Ballroom, Civic Auditorium
Chairman: J. H. Beaton, M.D., Grand Rapids
Secretary: C. E. Booher, M.D., Grand Rapids
A.M.
9:00 “MANAGEMENT OF HABITUAL ABOR-
TION”
Carl T. Javert, M.D., New York, New York
Professor of Obstetrics and Gynecology , College of Phy-
sicians and Surgeons, Columbia, University; Director,
Obstetrics and Gynecology, Woman s Hospital, Division
of St. Lukes; arid Attending Obstetrician and Gynecolo-
gist, New York Hospital
A systematic program of preconceptional, prenatal care
including psychosomatic therapy has been found to be
effective in the prevention of habitual abortion. The pre-
ventive program resulted in the delivery of viable off-
spring in 80 per cent of the habitual abortion patients.
They had previously aborted 92 per cent of their preg-
nancies. While this approach has not been used in a large
obstetrical population, it can be expected to reduce the
presently accepted abortion rate of 10 per cent to a
lower figure, since a study of 2,000 abortion specimens
indicated that one in five was salvageable at the time of
the abortion. It was conjectured that measures begun
early enough should salvage some of the remaining 80
per cent that were dead at the time of the abortion. Any
programs devoted to an improvement in fetal salvage
should consider reducing fetal wastage resulting from
spontaneous abortion.
9:30 “DIAGNOSIS OF PRECLINICAL CANCER
OF THE CERVIX”
Herbert E. Schmitz, M.D., Chicago, Illinois
Professor and Chairman, Department Obstetrics and
Gynecology, Stritch School of Medicine of Loyola Uni-
versity; Director, Mercy Hospital Institute of Radiation
Therapy
The successful outcome of the treatment of cervix car-
cinoma is directly proportional to the clinical stage of the
disease at the time therapy is instituted. It follows, there-
fore, that the greatest single contribution to be made in
reducing the death rate of this disease is early diagnosis.
Since the diagnosis of cervix cancer is made by the micro-
scope, two main procedures are available to the clinician
to screen properly his female patients, namely, cervical
biopsy and vaginal cytology. These two diagnostic aids
complement each other and may be considered technical
adjuncts. Each has its place of greater value and when
employed to best advantage will disclose many cases which
would otherwise be missed in the early stages.
The obtaining of specimens, either bv biopsy or smear,
while remaining the simplest of procedures, nevertheless,
requires certain diligence to avoid false negative reoorts.
It is important, for example, that material be obtained
for smear from both the vault and cervical canal by
abrasive swabbing and the slide fixed immediately. Biop-
sies should consist of generous fragments and in addition
to the obvious site of pathology should include specimens
from adjacent areas as well, the so-called four quadrant
biopsy. The use of electrocoagulation or actual cautery
to secure tissue specimens may so distort the histological
pictures as to make the interpretation imnossible. While
the acquisition of material initiates the diagnostic inves-
tigation, the interpretation can be a matter of contention.
In some instances this is of grave prognostic importance
and a number of opinions should be sought. Take, for
example, the problem posed by the report of carcinoma-
in-situ. Here is a lesion which, by definition, is confined
to the epithelium and should lend itself to complete erad-
ication. However, several questions immediately arise.
Is this actually carcinoma or is it basal cell hyperactivity?
If it is carcinoma, is it certain that the biopsy does not
merely represent a superficial fragment of a lesion which
is actually malignant? Are there other areas which might
show the disease in a more advanced stage? Are the
changes seen in the glandular lumina truly neoplastic or
are they merely epidermoidization? Similar problems arise
when biopsies are taken during pregnancy and the varied
cellular responses incident to the influence of gestation
are interpreted as neoplastic. Reversion of these cellular
aberrations to normal after delivery has occurred often
enough to cast considerable doubt on any diagnosis of
malignancy during pregnancy. This is not to imply that
such occurrences are so rare they may be dismissed as too
improbable, but it does serve to warn the clinician that
every effort must be made to establish the diagnosis with
certainty before treatment is undertaken.
It should be remembered that any technical procedure
is subject to a certain degree of error and a report of
nonmalignant condition in a case which does not show
clinical improvement under treatment may be misleading.
Follow-up examinations by smears may reveal persistent
abnormal cells despite negative biopsies and thus demon-
strate the need for repeat or more thorough tissue inves-
tigation. Conization of the endocervix with the cold
knife may be the ultimate outcome when indicated by
clinical symptoms or persistent abnormal cytology.
10:00 INTERMISSION TO VIEW EXHIBITS
11:00 “ACCIDENTAL POISONING IN CHILD-
HOOD”
Edward Press, M.D., New York, New York
Field Director, American Public Health Association;
Chairman, American Academy of Pediatrics Sub-Com-
mittee on Poisoning; Member, American Medical As-
sociation Committee on Toxicology
A discussion of the major points in the treatment and
prevention of poisoning in children and a summary of
the extent and type of Poison Control Centers in the
United States, including a brief resume of the sample
operation of a typical Poison Control Center.
11:30 “RECENT ADVANCES IN TREATMENT OF
URINARY STONE”
Edwin L. Prien, M.D., Brookline, Massachusetts
Assistant Clinical Professor of Urology, Boston Uni-
versity School of Medicine ; Urologist, Newton Wellesley
Hospital, Newton; Visiting Urologist , St. Elizabeth’s
Hospital; Senior Consultant in Urology, West Roxbury
Veterans Administration Hospital.
Urolithiasis is a recurrent disease in many people. We
do not know the cause of the great majority of urinary
calculi. Certain predisposing factors in stone formation
are recognized but cannot be considered causal because
stone may occur without them or be absent when they
are present. Despite this, it is believed that it may still
be possible to prevent recurrence of stone.
Surgical treatment alone will not suffice. Medical
regimens to prevent recurrence have been unsuccessful
896
JMSMS
PROGRAM OF ASSEMBLIES AND SECTIONS
2:00
because they were often inadequate, they were too
stringent to insure prolonged cooperation of the patient,
or were often casually applied without a proper knowl-
edge of (or interest in) the stone and the environment
in which it grew. Accurate analysis of all parts of a
calculus is important because it provides information on
factors of causation and on regimens of value in pre-
venting recurrence.
Except in the occasional heavy milk drinker who may
make calcium stone, there is little in dietary therapy
to prevent stone recurrence. A liberal fluid intake is
indicated in all. For cystine and uric acid stone only
alkalinization of the urine is of major value. Measures
to prevent calcium stone (accounting for 90 per cent of
all cases in North America) include — eradication of
urea-splitting urinary infection, mobilization of recum-
bent patients to prevent bone demineralization with its
attendant hypercalcinui ia, surgical ablation of hyper-
parathyroidism, diversion of calcium from the urine by
administration of sodium phytate, diversion of phos-
phate from the urine by administration of aluminum
gels, acidification of the urine to increase the solubility
of calcium salts and salicylate therapy to chelate cal-
cium to render it unavailable for stone formation.
END OF FIRST ASSEMBLY
WEDNESDAY NOON
September 25, 1957
12:00 noon to 1:00 p.m.
Discussion Conference
Black and Silver Ballroom, Civic Auditorium
Leader: A. C. Furstenberg, M.D., Ann Arbor
Participants : Thornton I. Boileau, M.D.,
Detroit, Michigan; Paul A. Bowers, M.D.,
Philadelphia, Pennsylvania; Max Cutler, M.D.,
Beverly Hills, California ; Douglas T. Davidson,
Jr., M.D., Philadelphia, Pennsylvania; Stuart
M. Finch, M.D., Ann Arbor. Michigan; Carl T.
Javert, M.D., New York, New York; Edward
Press, M.D., New York; Edwin L. Prien,
M.D., Brookline, Massachusetts; Mr. Walter
P. Reuther, Detroit, Michigan; Herbert E.
Schmitz, M.D., Chicago, Illinois.
HOTEL RESERVATIONS
for the
91st ANNUAL SESSION
MSMS
should be made
NOW
WEDNESDAY AFTERNOON
September 25, 1957
Second Assembly
Black and Silver Ballroom, Civic Auditorium
Chairman: F. C. Brace, M.D., Grand Rapids
Secretary: A. M. Hill, M.D., Grand Rapids
P.M.
2:00 “PRACTICAL THERAPY OF CONVUL-
SIVE DISORDERS”
Douglas T. Davidson, Jr., M.D., Philadelphia,
Pennsylvania
Associate in Neurology, University of Pennsylvania;
Assistant Neurologist , Children’s Hospital of Philadelphia
This presentation deals with therapy for all symptoms
arising from abnormal and excessive electrical discharges
of the brain’s nerve cells. These symptoms, both con-
vulsive and non-convulsive, reflect a wide variety of
intracranial and systemic disorders. As a general prin-
ciple, correction of the cause or causes for seizures is
considered before purely symptomatic suppression of the
attacks themselves. Sodium Phenobarbital, for example,
is equally effective in controlling “febrile convulsions”
associated with purulent meningitis and the garden va-
riety of “febrile convulsion.” A convulsive tendency sec-
ondary to a brain tumor also responds to the dose of
Dilantin appropriate for post-traumatic seizures. Chron-
icity of recurrence rather than cause or clinical sympto-
matology seems the more valid distinction among “epi-
leptic” convulsions and others at the present state of
our knowledge. The clinical seizure pattern of chronic
attacks as well as the age of onset greatly influences
prognosis and choice of treatment. The significance of
heredity, of social-emotional adjustment, the value of
various diagnostic procedures, including electroencepha-
lography, the role of surgical treatment, and the char-
acteristics of the most efficient anti-epileptic drugs will
be discussed. An optimistic outlook for most cases seems
justified in view of the effectiveness of modern therapy
and the improvement in community attitudes toward
the patient handicapped by recurrent seizures.
2:30 “MEDICINE AND LABOR IN THESE
CHANGING TIMES”
Mr. Walter P. Reuther, Detroit, Michigan
President , United Automobile Workers of America; Vice
President , AFL-CIO ; President, Industrial Union Depart-
ment, AFL-CIO; President , Community Health Associa-
tion of Detroit
3:00 INTERMISSION TO VIEW EXHIBITS
4:00 “PHYSIOLOGICAL OBSTETRICS”
Paul A. Bowers, M.D., Philadelphia, Pennsyl-
vania
Assistant Professor of Obstetrics and Gynecology, Jeffer-
son Medical College
July, 1957
897
PROGRAM OF ASSEMBLIES AND SECTIONS
4:30 ‘CANCER OF THE BREAST”
Max Cutler, M.D., Beverly Hills, California
Surgical Staffs, Cedars of Lebanon and St. John’s
Hospitals , Los Angeles ; formerly Director of the Chicago
Tumor Institute
Cancer of the breast is not only the most important
of the major forms of cancer, it is also one of the most
treacherous. Fortunately, however, the disease lends it-
self to a reasonable degree of prevention and early diag-
nosis. Although radical mastectomy with or without
postoperative radiation is the accepted method of treat-
ment for presumably operable mammary cancer, this view
has been challenged in recent years. It has been sug-
gested that simple mastectomy followed by a special type
of radiotherapy has certain advantages. This subject is
in a state of controversy.
Another development in recent years has been the ex-
tension of the surgical procedure to include removal of
mediastinal lymph nodes. This development also is at
present in a controversial state. There is an increasing
tendency to avoid the use of prophylactic postoperative
radiation as a routine procedure. Efforts to control ad-
vanced and metastatic carcinoma of the breast with
steroid hormones have been partially successful and form
a subject of active research.
The most interesting and perhaps the most important
phase of the problem of mammary cancer is related to
the so-called precancerous lesions. Cystic disease of the
breast, papillomata and so-called Schimmelbusch’s dis-
ease— commonly regarded as precancerous lesions — require
clarification. An effort is made in this presentation to
interpret the significance of these lesions and to indicate
the proper course of treatment.
5:00 END OF SECOND ASSEMBLY
OFFICERS NIGHT DINNER DANCE
Wednesday, September 25
Sponsored by the
Michigan State Medical Society
and the
Woman’s Auxiliary
Grand Ballroom, Pantlind Hotel
Grand Rapids
— Limit of 125 couples —
— Program of Sections —
WEDNESDAY AFTERNOON
September 25, 1957
SECTION ON OBSTETRICS AND GYNECOLOGT
Meeting — 5:00 to 6:00 p.m. — Black and Silver Ballroom
Civic Auditorium
Chairman: J. H. Beaton, M.D., Grand Rapid
Secretary: R. W. McClure, M.D., Detroit
“TREATMENT OF RADIO-RESISTANT
CERVIX CANCER”
Herbert E. Schmitz, M.D., Chicago, Illinoi
Modern radiotherapy is producing good end results ii
approximately half of the patients treated. The failur
of the treatment is caused by a variety of factors, on
of the most important of which is the intrinsic radio
resistant character of an individual lesion. When thi
feature of a given case has been demonstrated by clinica
observation, cytological smear or tissue biopsy, a mor
radical approach to tumor control may be indicated
Since many of these cases have extension of considerabl
magnitude, the technical difficulties in management ar
heavily exaggerated. The patient’s condition is likewis'
compromised by damage to the upper urinary tract am
poor liver physiology secondary to her protracted illness
One hundred twenty cases from the material seen in th
Mercy Hospital Institute of Radiation Therapy were sub
jected to extensive surgery for recurrent or resistant dis
ease. Slightly more than half had radical hysterectomie
and lymphadenectomies performed. The remaining case
had complete or partial pelvic exenterations. The com
plications, morbidities and mortality were evaluated t«
determine whether radical surgery had any additional bene
fit to offer in the treatment of radio-resistant lesions.
Evidence is presented to show what factors have th
greatest influence on the successful outcome of these pro
cedures. The marked contrast in salvage rates betweei
radical hysterectomy and pelvic exenteration serves t<
emphasize the seriousness of a decision to employ ultra
radical methods.
SECTION ON OCCUPATIONAL HEALTH
Meeting — 5:00 to 6:00 p.m. — Sadler Lounge, Pantlim
Hotel
Chairman: O. J. Johnson, M.D., Bay City
Secretary: P. B. Rastello, M.D., Warren
“SMALL PLANT PROGRAMS”
Thornton I. Boileau, M.D., Detroit, Michigai
SECTION ON PEDIATRICS
Meeting — 5:00 to 6:00 p.m.; Reception — 6:00 to 6:30 p.m
Schubert Room, Pantlind Hotel
Chairman: C. E. Booher, M.D., Grand Rapid:
Secretary: A. M. Hill, M.D., Grand Rapids
“PRACTICAL MANAGEMENT OF BE
HAVIOR PROBLEMS IN CHILDREN”
Stuart M. Finch, M.D., Ann Arbor, Michigar
Director , Children’s Psychiatric Hospital; Associate
Professor of Psychiatry , University of Michigan Medica
School
Essential to the practical management of any syndromi
in medioine is the proper understanding of the etiology
The physician seeing a child with a pain in his abdomei
898
J MS Ml
PROGRAM OF ASSEMBLIES AND SECTIONS
must discover the cause before he can proceed with in-
telligent management. If the child has appendicitis, one
course of action is suggested. If the child has a mild
general gastroenteritis, another course is advisable. It is
equally important that the child with a behavior problem
be really understood before any therapeutic program is
planned and initiated.
The adequate evaluation of a child’s misbehavior re-
quires a certain knowledge of his development and of
his family situation. Most children suffer behavior prob-
lems because of various environmental difficulties to
which they have been exposed. Prominent on the list
of environmental influences is parental psychopathology.
Parents usually try to do the best they can but are
often handicapped by problems within themselves of
which they are at best only dimly aware. The child
reacts to unconscious problems in his parents and they
in turn counterreact to the behavior problem he de-
velops. There ensues a vicious cycle in which parent
and child contribute to further problems.
Each child, if normally endowed, goes through a
series of emotional phases in his development. During
each stage he has certain emotional characteristics. If
the parents are mature and if they understand the
child, they will meet his needs and he will continue
to grow emotionally. If the parents, by virtue of their
own inner problems, do not understand or cannot meet
the child’s needs, the youngster may develop a behavior
problem. It is important for the physician to know
where and how such needs have not been met and thus
how the behavior problem developed. If he has this
basic knowledge he can then better outline an effective
theraputic regime.
This presentation will attempt to outline and discuss
some of the salient features of emotional development
and parental roles. Special attention will be given to
the management of various common behavior difficulties
with particular reference to the handling of parents.
SECTION ON RADIOLOGY
Meeting — 5:00 to 6:00 p.m. — Room G, Civic Auditorium
Chairman: E. O. Pearson, M.D., Kalamazoo
“INDICATIONS AND LIMITATIONS OF
RADIOTHERAPY IN CANCER”
Max Cutler, M.D., Beverly Hills, California
Certain forms of cancer by virtue of site, extent, gross
and microscopic features and unknown biological factors
are amenable to radiotherapy whereas other forms are not
suitable to this method of treatment.
Although some progress has been made with increase
in x-ray voltage and the use of large quantities of radium
and radioactive cobalt, the over-all results have not been
greatly improved by the introduction of these new tech-
niques. One reason for this is that most cancers treated
by radiotherapy are advanced and inoperable. It is ob-
vious that the results to be expected in these categories
are at best limited.
A discussion of the progress that has been made with
supervoltage x-rays, telecurietherapy and cobalt therapy is
presented. Special indications for interstitial radiation in
the form of removable platinum radium needles are dis-
cussed and some late results presented.
SECTION ON UROLOGY
leeting — 5:00 to 6:00 p.m. — Room 222 Pantlind Hotel
Chairman: R. P. Lytle, M.D., Detroit
Secretary: J. F. Harrold, M.D., Lansing
“MECHANISMS OF STONE FORMATION
AND PREVENTION”
Edwin L. Prien, M.D., Brookline, Massachusetts
The urinary stone is a product of its environment.
Predisposing factors in this environment are known;
causes still elude us. Therapeutic alterations in the en-
vironment may prevent stone growth. A simple straight-
forward exposition of the mechanisms which may promote
or inhibit calculus formation, discussed from both the
laboratory and clinical standpoints with the aid of
lantern slides.
WEDNESDAY EVENING
September 25, 1957
Officers Night
P.M.
6:30 Reception — Continental Room, Pantlind Hotel
7:15 Officers Night Dinner Dance — Ballroom, Pant-
lind Hotel
8:30 1. Announcements and brief report of House
of Delegates actions by L. Fernald Foster,
M. D., Secretary.
2. Induction of New Officers.
3. President’s Annual Address by Arch Wallis,
M.D.
Hon. G. Mennen
Williams
4. Address by Honorable G. Mennen Wil-
liams, Governor of the State of Michigan.
9:45 Adjournment.
Speakers like to hear from their audiences. If
you especially enjoy certain presentations, write
the lecturers and tell them. Obtain addresses from
the MSMS Press Room.
uly, 1957
899
PROGRAM OF ASSEMBLIES AND SECTIONS
THURSDAY MORNING
September 26, 1957
Third Assembly
Black and Silver Ballroom, Civic Auditorium
Chairman: O. J. Johnson, M.D., Bay City
Secretary: R. P. Lytle, M.D., Detroit
A.M.
9:00 “THE DIAGNOSIS AND TREATMENT OF
THE LESS OBVIOUS CARCINOMA OF
THE THYROID”
Theodore O. Winship, M.D., Washington,
D. C.
Pathologist , Garfield Memorial Hospital , Children s
Hospital , Episcopal Eye, Ear, Nose and Throat Hospital
The teTm “less obvious carcinoma” restricts this dis-
cussion to the consideration of the malignant tumors
measuring less than 2 cm. in diameter. Approximately
18 per cent of thyroid cancers fall into this category.
Because of the small size of the primary tumor, carcin-
oma is frequently unsuspected until cervical lymph
nodes become enlarged by metastatic carcinoma.
During the past decade the incidence of thyroid car-
cinoma has shown a marked increase. The increase is
mainly in the type of carcinoma which is “less obvious.”
This reflects a growing tendency to investigate solitary
thyroid nodules and to excise for diagnosis persistent
painless cervical lymph nodes. Most of the “less ob-
vious carcinomas” are papillary in type and are known
to be the least aggressive of all thyroid cancers with
the first metastases often appearing in the cervical nodes.
The treatment of patients must be individualized;
however, a safe general rule is to recommend the
removal of all single nodules in women, and all nodules
in men and children. The removal of a nodule infers
lobectomy. When cervical nodes are present without a
palpable nodule in the thyroid gland a lymph node
should be removed for frozen section. If this is found
to contain thyroid tissue, a total thyroidectomy and neck
dissection should be performed immediately. When a
nodule in the thyroid gland is suspected of being malig-
nant, in the absence of cervical nodes, a lobectomy should
be performed and the specimen submitted for frozen
section. If this proves to contain a carcinoma, a total
thyroidectomy should be performed. In this situation a
neck dissection should await histologically proved cervical
node metastases.
9:30 “PRESENT-DAY TREATMENT OF CAR-
CINOMA OF THE BREAST”
O. Theron Claggett, M.D., Rochester, Min-
nesota
Head of Section, Division of Surgery, Mayo Clinic,
Professor of Surgery, Mayo Foundation, Graduate School,
University of Minnesota
For approximately sixty years radical mastectomy has
been accepted by most surgeons as the best treatment
available for carcinoma of the breast. In recent years
some doubts have arisen regarding this procedure. It
has been suggested by some statisticians that any treat-
ment of breast carcinoma is futile. Some surgeons have
suggested more extensive surgical procedures than the
classic radical mastectomy, while simple mastectomy with
intensive irradiation therapy has been advocated by
others as the preferable treatment for carcinoma of the
breast. The problem of what constitutes the best pos-
sible treatment of carcinoma of the breast at the present
time has been complicated further by increasing evi-
dence of the influence of changes in hormonal environ-
ment on carcinoma of the breast and by the develop-
ment of a variety of means of altering hormonal bal-
ance.
It is very appropriate that the treatment of carcinoma
of the breast should be subjected to a critical reappraisal.
Carcinoma of the breast is a common disease and its
proper treatment is a matter of great importance. The
rationale of the various methods of treating carcinoma
of the breast will be discussed and the results of each
compared.
11:00 “THE EARLY AND LATE TREATMEN"
OF NASAL FRACTURES”
Oscar J. Becker, M.D., Chicago, Illinois
Assistant Professor of Otolaryngology, University of 1
linois ; Director of Plastic Surgery Clinic. University i
Illinois Eye and Ear Infirmary; Attending Surgeon at Un.
versity of Illinois Research and Educational Hospital. I
The etiology, pathology, mechanics, and managemer
of recent and late fractures will be discussed in detai
and complications and their treatment will be includec
11:30 “OUTPOSTS OF MEDICAL RESEARCH”
John D. Porterfield, M.D., Washington, D. C
Assistant Surgeon General. Public Health Service, De \
partment of Health, Education, and Welfare
12:00 END OF THIRD ASSEMBLY
THURSDAY NOON
September 26, 1957
12:00 noon to 1:00 p.m.
Discussion Conference
Black and Silver Ballroom, Civic Auditorium
Leader: C. Allen Payne, M.D., Grand Rapid:
Participants: Oscar J. Becker, M.D., Chicago
Illinois; O. Theron Claggett, M.D., Roch-
ester, Minnesota; Kieffer D. Davis, M.D.
Bartlesville, Oklahoma; Leo S. Figiel, M.D.
Detroit, Michigan; Raymond J. Jackman, M.D.
Rochester, Minnesota; Benjamin Jeffries
M.D., Detroit, Michigan; Ormand C. Julian
M.D., Chicago, Illinois; Peter C. Kronfeld
M.D., Chicago. Illinois ; Don W. McLean, M.D.
Detroit, Michigan; C. Allen Payne, M.D.
Grand Rapids, Michigan; John D. Porter-
field, M.D., Washington, D. C.; Gerald A
Wilson, M.D., Detroit, Michigan; Theodore
O. Winship, M.D., Washington, D. C.
MUCH THAT IS NEW— AND
USABLE— WILL BE FOUND
IN THE MSMS EXHIBIT!
10:00
900
INTERMISSION TO VIEW EXHIBITS
JMSMS
PROGRAM OF ASSEMBLIES AND SECTIONS
THURSDAY AFTERNOON
September 26, 1957
Fourth Assembly
Black and Silver Ballroom, Civic Auditorium
Chairman: J. M. Kaufman, M.D., Detroit
Secretary: B. C. Wildgen, M.D., Muskegon
>.M.
2:00 WILLIAM BEAUMONT, M.D., LECTURE
(Sponsored by the Michigan Foundation for
Medical and Health Education, Inc.)
“CANCER OF THE LOWER BOWEL: THE
ADENOMA CARCINOMA SEQUENCE”
Raymond J. Jackman, M.D., Rochester, Min-
nesota
Head of the Section of Proctology , Mayo Clinic, and
Associate Professor of Proctology, Mayo Foundation,
Graduate School, University of Minnesota
Considerable convincing evidence has accumulated that
most, if not all, adenocarcinomas of the large intestine
originate as polyps (adenoma). The factors which sup-
port this assumption will be presented, in company with
a discussion of those measures which must be taken to
prevent the final evolution of polyp-to-cancer.
2:30 “GLAUCOMA”
Peter C. Kronfeld, M.D., Chicago, Illinois
Professor of Ophthalmology, University of Illinois
School of Medicine
Despite all recent progress in general medicine and
ophthalmology it still happens that chronic simple
glaucoma is not recognized until it has reached too ad-
vanced a stage to be treated effectively. The principal
reason for the late detection of the disease is the in-
sidiousness of its onset and the inconspicuousness of its
early, subjective as well as objective, symptoms. These
features plus the relative refractoriness to treatment of
the late stages account for the fact that chronic simple
glaucoma is still a major cause of blindness in the USA.
Redeeming features of the disease are its responsiveness
to pressure-lowering treatment if instituted early and the
slow rate of progression. The permanent visual damage
that occurs during the first two years of the unrecognized
and therefore untreated disease is usually slight and rarely
causes serious disability.
Detection of chronic simple glaucoma during these
first two years, therefore, has become the goal of case-
finding campaigns conducted by private and governmental
agencies. Such campaigns, of necessity, must utilize
screening technique which have a number of disad-
vantages, the most annoying of which is the very con-
siderable number of false negatives and false positives.
It is most important to realize, as a spokesman of the
Public Health Service has very clearly stated, that
screening is not diagnosing, but only a means of reducing
the otherwise unmanageable number of potential suspects,
to a group that can feasibly be given the thorough
ophthalmological examination which is necessary for
diagnosis.
Aside from these and other methods of case-finding,
the glaucoma problem may be expected to be brought
closer to a solution by continuation of current studies
on the function of the aqueous outflow channels and on
the aqueous chemistry in early cases. Carbonic anhydrase
inhibitors have become a very valuable form of treatment
as well as a most revealing investigative tool.
3:00 INTERMISSION TO VIEW EXHIBITS
4:00 “EARLY DIAGNOSIS OF DISEASE AT
PLACE OF WORK”
Kieffer D. Davis, M.D., Bartlesville, Oklahoma
uly, 1957
4:30 “SELECTION OF THE TREATMENT FOR
THE LIMB WITH FAILING CIRCULA-
TION DUE TO ARTERIOSCLEROSIS”
Ormand C. Julian, M.D., Chicago, Illinois
Associate Professor of Surgery, University of Illinois
College of Medicine; Attending Surgeon, St. Luke* s Hos-
pital, Chicago; Consultant in Cardiovascular Surgery,
Veterans Administration Hospitals, Hines, Illinois, and
West Side Chicago
The treatment available for a limb with failing circu-
lation is selected on the basis of the anatomical distribu-
tion of the obstructing lesions rather than oer primam
on the basis of the patient’s age or the presence or ab-
sence of diabetes. It is always the aim oi surgical treat-
ment to restore the circulation wherever this is possible.
Definitive surgery of the type which brings about this
result can be applied to those patients having regional
or segmental forms of arteriosclerosis in the lower aorta
or in the arteries of the extremities. Selection of patients
for restorative surgery depends on the clinical appearance
of the extremity and the results of examination primarily.
Secondarily, final accurate selection is done on the basis
of visualization of the arterial system by x-ray.
Patients in need of improved circulation either be-
cause of symptoms or impending ischemic changes in the
extremity who are not suitable for a restorative operative
procedure are considered for sympathectomy, a procedure
which produces definite improvement in well selected
cases although less so than reconstructive operations. Ac-
curate selection of patients for sympathectomy has proven
very difficult and at the present time the decision to do
a sympathectomy depends more on the physical findings
than it does on temporary sympathectomy through the use
of novocaine.
Two additional groups of patients remain. These are
patients with insufficient change due to ischemia to justify
or require the use of either the two surgical measures
mentioned above, and a group of patients whose ischemic
changes have gone to the point at which neither opera-
tion can be expected to do any good. Supportive medi-
cal management is indicated in these patients. Those
with mild symptoms may respond well to the cessation
of smoking and the use of vasodilators. The patients with
advanced changes must be managed for the diminution
of pain and finally must be observed for the optimum time
for amputation when this is required.
5:00 END OF FOURTH ASSEMBLY
A “REFRESHER COURSE” OF GREAT
VALUE TO PRACTITIONERS— THAT’S
THE MSMS ANNUAL SESSION!
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THE EXHIBITS— JOIN THEM!
901
PROGRAM OF ASSEMBLIES AND SECTIONS
Program of Sections
THURSDAY AFTERNOON
September 26, 1957
SECTION ON GASTROENTEROLOGY AND
PROCTOLOGY
Meeting — 5:00 to 6:00 p.m. — Rooms D and E, Civic
Auditorium
Chairman: N. D. Nigro, M.D., Detroit
Secretary: E. J. Tallant, M.D., Detroit
Panel Discussion: “TREATMENT OF POLYPS
OF THE RECTUM AND COLON”
Leo S. Figiel, M.D., Detroit, Michigan
Clinical Instructor of Radiology, Wayne State Univer-
sity College of Medicine; Vice Chairman, Division of
Radiology, Grace Hospital
Raymond J. Jackman, M.D., Rochester, Min-
nesota
Don W. McLean, M.D., Detroit, Michigan
Associate Clinical Professor of Surgery , Receiving Hos-
pital; Chief, Rectal Division , Grace Hospital
For a number of years, it has been a generally ac-
cepted axiom that once a polyp is discovered in the
rectum or colon, it should be removed. These polyps
were seldom found until they had reached a size of
about 1 cm., and their predisposition to malignant
degeneration was recognized.
With modern improvements in the technique of
radiologic examination of the colon, we find ourselves
facing a somewhat different problem. The radiologist is
now finding 2 and 3 mm. polyps in the colon, and com-
monly finding polyps of less than one half cm.
Our problem now is this — do these tiny polyps now
carry the same malignant potential as the larger polyps,
and does the presence of a small polyp in the colon
justify its surgical removal?
We have studied 647 polyps treated in our practice,
and found that 82 per cent of these were less than 1 cm.
in diameter, and that in this group, malignant degenera-
tion occurred in 0.4 per cent. Polyps from 1 to 2 cms.
in diameter comprised 9 per cent of the cases, and the
incidence of malignancy was 3.3 per cent. In those
polyps over 2 cms. in diameter, the incidence of invasive
carcinoma was 22 per cent.
Thus, it is apparent that the malignant potential of
a polyp is dependent upon the size of the lesion. The
removal of polyps of the colon is a major procedure, and
carries a definite hazard for the patient. Where the
mortality and morbidity incident to this surgery is greater
than the malignant potential of the polyp, the removal
of such lesions is not indicated.
C. Allen Payne, M.D., Grand Rapids, Michi-
gan
Consultant in Pathology to United Memorial Hospital,
Greenville; Sunshine Hospital and Mary Free Bed Hospi-
tal, Grand Rapids; Director of Laboratories and Pathol-
ogist, Ferguson Hospital, Grand Rapids
Gerald A. Wilson, M.D., Detroit, Michigan
Assistant Professor of Clinical Surgery, Wayne State
University College of Medicine; Medical Director, Yates
Memorial Clinic, Detroit; Chairman, Tumor Board,
Dearborn Veterans Administration Hospital
SECTION ON GENERAL PRACTICE
Meeting — 5:00 to 6:00 p.m.
' Cocktails — 6:30 p.m.
Dinner — 7:30 p.m.
Continental Room, Pantlind Hotel
Chairman: F. P. Rhoades, M.D., Detroit
Secretary: F. C. Brace, M.D., Grand Rapids
902
“GENERAL PRACTICE AND PSYCHIATRY”
Benjamin Jeffries, M.D., Detroit, Michigan
Member of Boards of Trustees and of Directors of
Michigan Association for Epilepsy; President, Michigan
Society of Neurology and Psychiatry
The national societies for General Practice and
Psychiatry have established liaison. It is necessary that i
we review our needs and establish a program at the
“grass roots” level.
SECTION ON OPHTHALMOLOGY
Meeting — 5:00 to 6:00 p.m. — Room G, Civic Auditorium
Reception and Dinner — Peninsular Club
Chairman: B. C. Wildgen, M.D., Muskegon
Secretary: H. A. Dunlap, M.D., Detroit
“PRESENT TRENDS IN OPHTHALMOL-
OGY”
Peter C. Kronfeld, M.D., Chicago, Illinois
At this time, as well as during most periods in the
past, definite trends can be recognized in ophthalmology.
The faith in chemical agents controlling normal and
abnormal functions has been given a big boost. Of
the greatest practical value has been the discovery of
new agents that inhibit the rate of aqueous formation.
Such inhibitors may now be divided into different groups
with different modes and, probably, different sites of
actions. Very much in the foreground are the inhibitors
of carbonic anhydrase of which diamox has had extensive
clinical trial. Its indications and limitations have been
recognized and have given impetus to a good deal of
experimental and clinical work with various, proven or
potential, carbonic anhydrase inhibitors.
Somewhat related to the interest in diamox has been
the recent trend toward sharper distinction between true
angle-closure, on the one hand, and true open-angle
glaucoma, on the other.
The investigation of chemical allies, that is thera-
peutic agents, has gone hand in hand with the recognition
of new or relatively new specific poisons, such as certain
phenergan derivatives and oxygen in high concentrations.
Ophthalmology has been participating in the present
wave of concentration on atherosclerosis and its pre-
vention. Rome’s observations of significant therapeutic
results with anticoagulants in diseases such as Kuhnt-
Junius disciform macular degeneration have been con-
firmed by other ophthalmologists.
Another definite trend is the concentration on the
morphology, physiology and pathology of the outflow
channels. The term ocular rigidity is acquiring a real,
practical meaning.
In the field of retinal detachment surgery a very grati-
fying trend toward unifications of therapeutic principles
can be recognized.
SECTION ON OTOLARYNGOLOGY
Meeting— 5:00 to 6:00 p.m. — Reception and Dinner,
Rooms 322 and 324, Pantlind Hotel
Chairman: W. K. Locklin, M.D., Kalamazoo
Secretary: H. L. LeVett, M.D., Lansing
“PROBLEMS IN OTOLARYNGOLOGIC
PLASTIC SURGERY”
Oscar J. Becker, M.D., Chicago, Illinois
A discussion of plastic surgical procedures which apply
to otolaryngology will be discussed. Rhinoplasty, Oto-
plasty and Skin Grafts will be the main topics covered.
Diagrams and illustrations will be used to present the
subject.
SECTION ON PUBLIC HEALTH AND
PREVENTIVE MEDICINE
Meeting — 5:00 to 6:00 p.m. — Room 222, Pantlind Hotel
Reception and Dinner — 6:30 p.m. — Room 222,
Pantlind Hotel
Chairman: J. D. Monroe, M.D., Pontiac
Secretary: J. K. Altland, M.D., Lansing
“THE REVIVAL OF LEARNING IN PUB-
LIC HEALTH”
John D. Porterfield, M.D., Washington, D. C.
JMSMS
PROGRAM OF ASSEMBLIES AND SECTIONS
SECTION ON SURGERY
leeting — 5:00 to 6:00 p.m. — Red Room, Civic Audi-
torium
Chairman: E. T. Thieme, M.D., Ann Arbor
Secretary: H. M. Bishop, M.D., Saginaw
“TREATMENT OF THE BREAST TUMOR
DEVELOPING DURING PREGNANCY”
O. Theron Claggett, M.D., Rochester, Min-
nesota
The development of a breast tumor during pregnancy
offers many problems not associated with the development
of a breast tumor under other circumstances. While
carcinoma of the breast does not occur commonly dur-
ing pregnancy, it is well recognized that it is a par-
ticularly serious condition when it does occur, and its
appropriate treatment offers difficult decisions. Any sur-
gical intervention offers some hazard of interrupting
pregnancy in the pregnant woman. This hazard varies in
the different stages of pregnancy and must be evaluated
carefully. The special problems resulting from breast
tumors developing during pregnancy and the management
of these problems will be reviewed.
“VASCULAR COMPLICATIONS OF THE
LOWER LIMBS DURING PREGNANCY
Ormand C. Julian, M.D., Chicago, Illinois
The major vascular complications of the lower extremi-
ties which occur during pregnancy relate to the venous
system. Varicose veins of the legs are a very disturbing
and frequent complication of pregnancy. The etiology
of varicose veins during pregnancy is not entirely clear.
There seems to be two elements. (1) A hormonal dis-
turbance which produces relaxation of the vein walls;
and (2) The mechanical element which is the result of
intrapelvic obstruction to the venous drainage of the
legs. Opinions as to the application of ordinary vein
ligation and stripping of veins during pregnancy is very
much divided and the reasons for ana against surgery are
very clear and worthy of analysis.
The tendency toward deep thrombophlebitis of the
ilio-femoral systems during and immediately after preg-
nancy provides the second common vascular complication.
Stasis appears to be a major factor as does the rather
marked overdevelopment of the venous system in the
pelvis which at a post partum period has become use-
less and must atrophy. The treatment of this thrombo-
phlebitis differs in several ways from the usual manage-
ment of deep thrombophlebitis in the non-pregnant patient.
’’TREATMENT OF HYPERTHYROIDISM
COMPLICATING PREGNANCY’’
Theodore O. Wins hip, M.D., Washineton,
D. C.
THURSDAY EVENING
September 26, 1957
State Society Night
Ballroom, Pantlind Hotel
M.
1:30 An evening of entertainment for all registrants,
ladies and guests
Cabaret-style Dance and Floor Show
Host: Michigan State Medical Society
jly, 1957
FRIDAY MORNING
September 27, 1957
Fifth Assembly
Black and Silver Ballroom, Civic Auditorium
Chairman: W. K. Locklin, M.D., Kalamazoo
Secretary: W. R. Slenger, M.D., Ann Arbor
A.M.
9:00 “PEDIATRICS FOR THE GENERALIST”
E. Keith Hammond, M.D., Paoli, Indiana
Councilor , Third District , Indiana Medical Association ;
Councilor, Third District, Indiana Academy of General
Practice; Co-chairman Education Committee , Indiana
Academy of General Practice
An analysis of records kept in a general practice in-
dicates that children are brought to the doctor for
relatively few different reasons. The vast majority of
the clinical conditions encountered are relatively simple
and inocuous. This fact seems pleasant indeed, but it
is a trap which tends to lull the harried doctor into a
false sense of security and make serious conditions easier
to overlook. Many of these young patients are not even
sick. Consequently the physician who is bent upon
rendering the most service to his pediatric patients must
maintain two states of mind. He must first be “pre-
ventive medicine minded/’ At the same time he must
maintain a constant wariness in the presence of every
sick child, regardless of how benign the illness might
appear at first glance. These attitudes are of value
in all medicine, but they are particularly valuable when
dealing with children. Thoughts along these lines serve
as a starting point for considerable discussion concern-
ing the whole subject of pediatrics in the generalist’s
practice.
9:30 “BONE TUMOR PROBLEMS”
David C. Dahlin, M.D., Rochester, Minnesota
Consultant in Surgical Pathology, Mayo Clinic
Primary neoplasms of bone provide clinicians, surgeons,
radiologists and pathologists with some of their most
vexing diagnostic problems, partly because of their rel-
ative rarity.
Team work, applied to their diagnosis and manage-
ment, has produced recent great advances in our knowl-
edge of bone tumors. Some of the available informa-
tion has not yet been widely disseminated. Awareness by
the clinician of the signs and symptoms of bone tumors
promotes earlier recognition of osseous pathology, and
certain of these clinical features may give important
clues as to the pathologic diagnosis. The roentgenologist
who interprets the shadows produced by the lesional area
supplies invaluable aid and sometimes an exact diagnosis.
The pathologist responsible for the definitive histologic
diagnosis must correlate his findings with those of the
clinician and roentgenologist.
A classification of bone tumors that is useful to all
members of the team comprises entities with clinical
significance, especially from the standpoints of treatment
and prognosis. Such a classification will be presented.
The biopsy specimen is of paramount importance. Its
adequacy, which is vital to proper diagnosis and man-
agement, can be best insured by reference to the roent-
genograms. Various methods of procuring tissue for
bioDsy are available and will be discussed.
The pathologist must determine whether the lesion is
benign or malignant. In the latter case, his specific his-
tologic diagnosis indicates whether the neoplasm is radio-
sensitive or must be treated by ablative surgical means.
In either case, treatment should be instituted without
undue delay.
Many physicians have the erroneous impression that
all malignant tumors of bone have a practically hope-
less prognosis. Data will be presented to show that a
substantial cure rate may be anticipated for many of
these sarcomas. This fajct further emphasizes the im-
portance of instituting prompt, appropriate therapy.
10:00 INTERMISSION TO VIEW EXHIBITS
903
PROGRAM OF ASSEMBLIES AND SECTIONS
11:00 “SOME REMARKS ON IMMUNOBIOLOGY
OF SOME TUMORS OF THE SKIN”
Leon Goldman, M.D., Cincinnati, Ohio
Professor of Dermatology, College of Medicine, Uni-
versity of Cincinnati; Director of Dermatology, Cincin-
nati General Hospital and Children' s Hospital
Recently, there has been renewed research interest in
the fascinating study of immunity of cancer in man.
There will be a brief review of some of the data regarding
possible antibody response to local tumor invasion. The
type of tumor selected, perhaps unwisely, for our study
in this field is the multiple basal cell malignancy of the
skin. These locally invasive lesions especially over the
face can be destructive and disfiguring even without
therapy. There is obviously a definite need for some
program of prophylaxis. To date, no such program is
possible. Our experiments with skin testing, injections
of serum, and injections of so-called tumor vaccine ex-
tracts will be presented. The purely investigative nature
of these unsuccessful experiments will be emphasized
strongly. Of clinical importance is the early recognition
and early therapy of such tumors and the continued
observation of such patients.
11:30 “WIRE BRUSH SURGERY”
James W. Burks, Jr., M.D., New Orleans
Louisiana
Associate Professor of Medicine , Dermatology, Tulane:
Head of Dermatology (Tulane Unit), Charity Hospital,
New Orleans
Wire brush surgery, dermabrasion or surgical planing
of the skin has received world-wide recognition as the
most effective treatment of acne scars and certain other
cosmetic defects of the skin.
The major portion of this presentation is a motion
picture in color of planing a patient with acne scars, step
by step, from the pre-operative through the three months
post-operative period, and covers not only the basic
principles, equipment and actual technique of planing,
but also periodic clinical and pathologic correlations.
Appraisal of this subject and evaluation of results I
have obtained during the past five years in over 1500
planings will be given.
12:00 END OF FIFTH ASSEMBLY
FRIDAY NOON
September 27, 1957
12:00 noon to 1:00 p.m.
Discussion Conference
Black and Silver Ballroom, Civic Auditorium
Leader: Perry C. Gittins, M.D., Detroit
Participants: Leo H. Bartemeier, M.D., Balti-
more, Maryland: Samuel Bellet, M.D., Phila-
delphia, Pennsylvania; Richard J. Bing, M.D.,
St. Louis, Missouri ; James W. Burks, Jr., M.D.,
New Orleans, Louisiana; David C. Dahlin,
M.D., Rochester, Minnesota; Leon Goldman,
M.D., Cincinnati, Ohio: E. Keith Hammond,
M.D., Paoli, Indiana; Hans H. Hecht, M.D.,
Salt Lake City, Utah; Adelaide M. Johnson,
M.D., Rochester, Minnesota; Robert L. Novy,
M.D., Detroit. Michigan; Walter L. Palmer,
M.D., Chicago, Illinois; Robert J. Schneck,
M.D., Detroit, Michigan.
FRIDAY AFTERNOON
September 27, 1957
Sixth Assembly
Black and Silver Ballroom, Civic Auditorium
Chairman: Coleman Mopper, M.D., Detroit
Secretary: W. T. Kruse, M.D., Grand Rapids
2:00 Panel on “THE PROBLEM OF THE
DESTRUCTIVE IMPULSE IN THE PRAC-
TICE OF MEDICINE”
Leo H. Bartemeier, M.D., Baltimore, Maryland
Medical Director of the Seton Psychiatric Institute;
Chairman of the Council on Mental Health of the
American Medical Association
Adelaide M. Johnson, M.D., Rochester, Min-
nesota
Clinical Professor of Psychiatry, University of Minnesota
This problem may also be described as the unintentional
struggle of patients against their physicians. The destruc-
tive impulse is an unconscious force working more or less
in opposition to their recovery. This situation has led
to the assumption that some patients enjoy their illness
or do not wish to get well. Despite correct diagnosis
and proper treatment some patients fail to improve.
Others improve for a brief period, only to suffer a recur-
rence of their original symptoms. Still others react to
prescribed treatment in an opposite way to what is
expected.
3:00 FINAL INTERMISSION TO VIEW EX-
HIBITS
3:30 “GASTROINTESTINAL HEMORRHAGE”
Walter L. Palmer, M.D., Chicago, Illinois
Richard T. Crane Professor of Medicine , University
of Chicago
In this paper, the causes of gastrointestinal hemorrhage
will be reviewed with a brief discussion of differential
diagnosis. The treatment of acute and chronic hemor-
rhage will be reviewed together with a consideration of
measures for the alleviation of the underlying basic
diseases.
4:00 Panel on “WHAT’S NEW IN HEART DIS-
EASE” (Followed by meeting of Section on
Medicine)
Moderator : Robert L. Novy, M.D., Detroit,
Michigan
Delegate, American Medical Association; AMA Council
on Medical Service: Commissioner, Detroit Board of
Health: Trustee, Michigan Hospital Service
Participants:
Samuel Bellet, M.D., Philadelphia, Pennsyl-
vania
Professor of Cliiiical Cardiology, Graduate School of
Medicine ; Director, Division of Cardiovascular Diseases,
Graduate Hospital, University of Pennsylvania: Director,
Division of Cardiology, Philadelphia General Hospital
Richard J. Bing, M.D., St. Louis, Missouri
Professor of Medicine, Washington University: Chief of
Washington University Service at Veterans Administra-
tion Hospital, St. Louis, Missouri
Hans H. Hecht, M.D., Salt Lake City, Utah
L. E. Viko Professor of Cardiology, Department of
Internal Medicine, University of Utah College of Medi-
cine
Robert J. Schneck, M.D.. Detroit, Michigan
Chief, Department of Medicine , Harper Hospital:
Clinical Professor of Medicine, Wayne State University
College of Medicine
904
JMSMS
PROGRAM OF ASSEMBLIES AND SECTIONS
Program of Sections
FRIDAY AFTERNOON
September 27, 1957
SECTION ON ANESTHESIOLOGY
Meeting — 3:00 p.m. — Sadler Lounge, Pantlind Hotel
Reception and Dinner — 6:30 p.m. — Peninsular Club
Chairman: R B. Sweet, M.D., Ann Arbor
“MICHIGAN MEDICAL SERVICE AND THE
ANESTHESIOLOGISTS OF MICHIGAN”
L. Fernald Foster, M.D., Detroit
President, Michigan Medical Service; Secretary, Michigan
State Medical Society
Jay C. Ketchum, Detroit
Executive Vice President, Michigan Medical Service
SECTION ON DERMATOLOGY AND
SYPHILOLOGY
Meeting — 5:00 to 6:00 p.m. — Room 222, Pantlind Hotel
Chairman : Wm. T. Kruse, M.D., Grand Rapids
Secretary: Coleman Mopper, M.D., Detroit
“WIRE BRUSH SURGERY— AN INVESTI-
GATIVE THERAPEUTIC MODALITY”
James W. Burks, Jr., M.D., New Orleans,
Louisiana
The early acceptance by the American dermatologist of
surgical planing as an effective tool in the treatment of
acne scars and certain other cosmetic defects has led
to a widespread re-awakening in cosmetic dermatology.
Although, as expected, planing has its therapeutic limi-
tations, experience in the use of this tool in various
diseases of the skin indicates a wide application in der-
matological research.
Planing provides an unlimited supply of wounds in
human subjects for clinical as well as laboratory study.
Experiences in the study of some of these subjects will
include: a new concept of wound healing, histopathology
of recurrent lupus erythematosus, use of pigment stimu-
lators and inhibitors, allergic reaction of planed skin,
growth of certain skin tumors, alteration of collagen,
sources of regenerative tissue, alteration in anatomy and
chemistry of epidermal and dermal cells, anatomy and
physiology of appendages, effects of freezing, active acne
vulgaris, pre-canceroses, aged skin and others.
Exemplary lantern slides will be presented.
iECTION ON NERVOUS AND MENTAL DISEASES
Meeting — 5:00 to 6:00 p.m. — Schubert Room, Pant-
lind Hotel
Reception and Dinner — 6:00 p.m. — Schubert Room,
Pantlind Hotel
Chairman: W. R. Slenger, M.D., Ann Arbor
Secretary: S. C. Mason, M.D., Ann Arbor
Iuly, 1957
Panel Discussion
“PATIENT-CENTERED MEDICAL CARE”
Participants: Leo H. Bartemeier, M.D., Balti-
more, Maryland; Adelaide M. Johnson, M.D.,
Rochester, Minnesota
SECTION ON PATHOLOGY AND
THE MICHIGAN PATHOLOGIC SOCIETY
Meeting — 3:00 p.m. — Continental Room, Pantlind Hotel
Reception and Dinner — 6:30 p.m. — Continental Room,
Pantlind Hotel
Chairman: E. R. Jennings, M.D., Detroit
“BONE TUMOR PROBLEMS”
David C. Dahlin, M.D., Rochester, Minnesota
SECTION ON MEDICINE
Meeting — 4:00 to 6:00 p.m. — Black and Silver Ballroom,
Civic Auditorium
Chairman : J. M. Kaufman, M.D., Detroit
Secretary: J. W. Hall, M.D., Traverse City
(See program above)
P.M.
6:00 End of Scientific Assembly and of the 1957
Annual Session
1958 SESSION MSMS
The next Annual Session of
MSMS will be held in Detroit
at the Sheraton-Cadillac Hotel
W ednesday-Thursday-F riday
October 1-2-3, 1958
905
Annual Reports
ANNUAL REPORT OF POSTGRADUATE
MEDICAL EDUCATION COMMITTEE— 1956-1957
The Postgraduate Medical Education Committee met
twice during the year, on January 17 and May 24. The
members of the Committee have faithfully attended
these meetings, and have shown great interest in the
planning for postgraduate medical education programs
for the membership of the state society.
During the year a review of present centers has been
made, and consideration is being given to the establish-
ment of new centers for extramural programs.
The Subcommittee on Audio-Visual Aids is continuing
the study of these educational methods. The Executive
Office is cooperating in the process of compiling avail-
able teaching films for lay as well as medical audiences.
The content of the teaching program for the past
year was reviewed and subjects for 1957-58 extramural
program were suggested. The Committee directed the
members of the Committee who reside in Ann Arbor to
develop the autumn 1957 program.
The Chairman reported on the extramural program
in the various teaching centers:
The subjects presented during the year were:
Fall Program
Acute abdominal trauma
Accident prevention in children
Adrenalin insufficiency in the medical and surgical
patient
Changing concepts in treatment of Cancer
Indications and contra-indications for hysterectomy
Management of acute head trauma
Maxillo-facial aspects of trauma
Neurosurgical aspects of trauma
Ophthalmological aspects of trauma
Plastic surgical care of head and neck
Symposium on industrial medicine
Traumatic injuries from the neurosurgical standpoint
Treatment of advanced carcinoma of breast
Spring Program
Accident prevention in children
Changing concepts in treatment of cancer
Chemotherapy of leukemia and lymphoblastoma
Hormonal therapy of malignant diseases
Neo-natal Care. Panel discussion
Neurosurgical traumatic injuries
Plastic surgical correction of congenital and acquired
deformities
Psychiatric techniques of use to all physicians
Tranquilizers
Attendance — Extramural Program
Fall Spring
Center 1956 1957 1956-57
Battle Creek
51
45
70
Bay City
23
21
36
. 23
23
Flint
86
30
96
Jackson
73
52
75
Lansing
44
50
82
Muskegon
70
62
82
Port Huron
51
65
88
Traverse City
36
36
Upper Peninsula
Escanaba
16
20
24
Hough ton -Cal u m et
12
13
17
16
14
18
Iron wood
16
15
19
Marquette
27
20
31
Menominee
26
28
32
Sault Ste. Marie
22
9
23
587
483
775
University of Michigan Medical School
Intramural Courses Attendance
Anatomy 30
Basic Sciences 25
Clinical Exercises for Practitioners 36
Clinical Internal Medicine . 37
Diagnostic Radiology 29
Diseases of Blood and Blood-forming Organs 5
Diseases of the Gastrointestinal Tract 8
Diseases of the Htart „ 20
Electrocardiographic Diagnosis 32
Foreign Physicians 9
Interns, Assistant Residents and Residents 367
Metabolism and Endocrinology 35
Obstetrics and Gynecology 40
Ophthalmology 127
Otolaryngology 24
Pediatrics 32
Pulmonary Diseases 17
Radio-active Isotopes, Clinical Use of 19
Recent Advances in Therapeutics 25
Surgical Pathology Slides and Miscellaneous 33
Rheumatology 9
959
The following named physicians participated in the
extramural postgraduate teaching program: Shirley
Austin, M.D.; Arnold Axelrod, M.D. ; Jere M. Bauer,
M.D.; Samuel T. Behrman. M.D.; Robert E. L. Berry,
M.D. ; Hardee Bethea, M.D.; H. Waldo Bird, M.D.;
Duncan A. Cameron, M.D.; Edward A. Carr, Jr., M.D.;
Reed O. Dingman, D.D.S., M.D.; Bruce D. Graham,
M.D.; John M. Henderson, M.D. ; Jack Hertzler, M.D. ;
Robert S. Knighton, M.D.; George H. Lowrey, M.D. ;
John H. Packer, M.D.; Herbert E. Pedersen, M.D.;
Richard C. Schneider, M.D.; Richard W. Stander, M.D. ;
Charles S. Stevenson, M.D.; David H. P. Streeten,
M.D. : Robert B. Sweet. M.D.; A. Burgess Vial, M.D.;
Paul V. Woolley, Jr., M.D.
Upon recommendation of the Committe on Postgradu-
ate Medical Education, the Michigan Foundation for
Medical and Health Education granted certificates of
Associate Fellowship in Postgraduate Medical Education
to twenty-one physicians and certificates of Fellowship
to fourteen physicians
The Michigan Clinical Institute was held in Detroit
on March 13, 14 and 15. The meeting was well attend-
ed, the total registration of physicians was 1,654.
Wayne State University College of Medicine
Enrollment in intramural postgraduate courses:
Name of course Attendance
First Quarter
Anesthesiology 3
Biochemistry * 2
Dermatology 3
Electrocardiography 1 3
Ophthalmology 8
Pathology (Gynecologic) 36
(Neuro-) 6
Radiology (Physics of) 1
(Diagnostic) 5
(X-Ray Film Conference) 1
(Radiation Therapy) 8
Surgery 1 1
(Pathological Conference) 3
Second Quarter
Dermatology 1
Electrocardiography 4
Microbiology 2
Pathology (Beginning Hematology) 7
(Derma to-) 6
(Neuro-) 6
Radiology (Diagnostic) 4
(X-Ray Film Conference) 2
(Radiation Therapy) 35
(Physics of) 2
Surgery (Seminar) .1. 13
906
TMSMS
ANNUAL REPORTS
Third Quarter
Anatomy (Thorax and Abdomen) 14
(Head and Neck) 5
(Extremities) 8
Dermatology (Mycology) 2
Medicine (Seminar) 16
Pathology (Forensic) 11
Physiological Chemistry 2
Radiology (Diagnostic) 7
(X-Ray Film Conference) 1
(Radiation Therapy) 37
(Physics of) 4
Surgery (Seminar) 6
The Committee wishes to express its appreciation for
the support given to this program by the State Depart-
ment of Health, and for the many helpful suggestions
of Dr. Goldie B. Corneliuson, Chief of the Maternal
and Child Health Section.
The excellent cooperation of Wayne State University
College of Medicine and the University of Michigan
Medical School and their faculties, together with the
work of the Councilors and chairmen in arranging for
local programs, has contributed immeasurably to the
functioning of the extramural program. The Committee
is deeply appreciative of all these efforts.
Respectfully submitted,
John M. Sheldon, M.D., Chairman
D. A. Cameron, M.D.
E. I. Carr, M.D.
B. R. Corbus, M.D.
M. A. Darling, M.D.
A. C. Furstenberg, M.D.
J. R. Heidenreich, M.D.
D. H. Kaump, M.D.
R. M. McKean, M.D.
D. W. McLean, M.D.
F. P. Rhoades, M.D.
J. M. Robb, M.D.
G. H. Scott, Ph.D.
E. F. Sladek, M.D.
H. A. Towsley, M.D.
E. G. Upjohn, M.D.
H. H. Cummings, M.D.. Advisor
ANNUAL REPORT OF RHEUMATIC FEVER
CONTROL COMMITTEE— 1956-1957
The Rheumatic Fever Control Committee has met five
times during year as follows: September 5, 1956, De-
cember 5, 1956, February 6, 1957, March 20, 1957, and
May 22, 1957.
During these sessions, the Committee has reviewed
the reports from the diagnostic centers, received the
reports of the Medical Coordinator and directed his
activities. Dr. Leon DeVel resigned as Medical Co-
ordinator of the Committee effective February 1, 1957.
The Committee is at present attempting to find a re-
placement.
Two old Desk Reference Cards for rheumatic fever
were revised and one new Desk Reference Card was
prepared by the Committe.
The old pamphlet “Nine Questions and Answers for
Parents” was extensively revised and reprinted as “Ten
Questions and Answers for Parents.”
The pamphlet “The Cardiac and/or Rheumatic Child
in School” has proved very popular with school teachers,
and a large reprinting (25,000 copies) was ordered
for additional circulation.
The most important part of the Rheumatic Fever
Programs remains the many Rheumatic Fever Diagnostic
and Consultation Centers. Because of varying local
conditions, there are many minor differences in the
operation of the various Centers. However, they all
follow the basic idea that patients are seen only on
referral from doctors of medicine who wish aid and
guidance in the diagnosis of some of their cases. Dur-
ing the calendar year 1956, there were 261 new re-
ferrals to the clinics, of which 143 were diagnosed
July, 1957
rheumatic fever. There were 243 re-examinations of
old cases, making a total of 504 patients seen. As in
the past, several physicians who have given their time
to various Rheumatic Fever Diagnostic Centers were
awarded postgraduate fellowships at St. Francis Sani-
torium at Roslyn, Long Island, New York, as follows:
Gordon Manson, M.D., Detroit; Walter F. Kujawski,
M.D., Detroit; Bernard H. Siebers, M.D., Grand Rapids;
H. Mark Hildebrandt, M.D., Ann Arbor; and Craig E.
Booher, M.D., Grand Rapids.
At the present time and for several years the work
of the Committee has been entirely supported by the
Michigan Heart Association. The membership of the
Committee wishes to express its deep appreciation of
this support and of the support and aid given to it by
The Council of the Michigan State Medical Society,
the Executive Committee of The Council, MSMS, and
the staff and officers of the executive office of the
MSMS.
The Chairman of the Committee also wishes to ex-
press his appreciation for the counsel and work of the
various members of the Committee, and particularly
to Leon DeVel, M.D.
Respectfully submitted,
S. T. Harris, M.D., Chairman
R. E. Fisher, M.D., Vice Chairman
E. W. Adams, M.D.
J. G. Bielawski, M.D.
R. P. Bolton, Jr., M.D.
B. M. Bullington, M.D.
Carleton Dean, M.D.
Leon DeVel, M.D.
T. B. Hill, M.D.
C. L. Hoogerland, M.D.
F. D. Johnson, M.D.
J. D. Littig, M.D.
N. L. Matthews, M.D.
R. J. McGillicuddy, M.D.
A. E. Price, M.D.
W. B. Prothro, M.D.
H. H. Riecker, M.D.
E. E. Schumacher, Jr., M.D.
D. S. Smith, M.D.
B. J. Sweeney, M.D.
R. D. Tupper, M.D.
Frank Van Schoick, M.D.
Mr. James Gerity, Jr., Advisor
Thomas Francis, Jr., M.D., Advisor
Mr. E. T. Guy, Advisor
L. Fernald Foster, M.D., Secretary
ANNUAL REPORT OF MATERNAL HEALTH
COMMITTEE— 1 956- 1 957
The State Maternal Health Committee has had two
meetings in 1956-1957, the first on November 14 at
the Sheraton-Cadillac Hotel in Detroit, and the second
on April 1 1 at Blodgett Hospital in Grand Rapids.
We are continuing our Maternal Health audit under
the able direction of Vice Chairman, Dr. Harold Ott.
The material on the first five-year study is ready for
publication. We hope that we may organize short
articles for the MSMS Journal. These will be ar-
ranged with the Editor.
This year, we have attempted to establish ground
work for the creation of activities which will supplement
our Maternal Mortality audit. Dr. Norman Miller has
served as Chairman of the Evaluation Committee and
has been an excellent counselor for our group; Dr. C. E.
Toshach is organizing a Perinatal Mortality study; Dr.
Viola Brekke is working toward the development of
a Maternal Tissue Registry which is now in operation;
Dr. E. Freeman Hersey is attempting to coordinate the
Maternal Health Committe with a general lay educa-
tional program throughout the state. Dr. C. M. Bell
is organizing a program for cooperation with the local
907
ANNUAL REPORTS
county medical societies and attempting to create better
understanding between the state committee and local
maternal health committees.
The group feels that tremendous strides have been
made by the physicians in the state in reducing mor-
tality. Our study of maternal deaths must, by all
means, be continued. However, we are impressed by
the need of improving maternal health in the
obstetrical and post-partum patients. We are planning
a study of such problems with a view to directing
better adult education and a more thorough under-
standing of the problem. We all feel that the need is
there but we are uncertain as to how to proceed. By
study groups and discussions, we hope to arrive at some
concrete suggestions.
We are happy that House Bill 347 has been passed.
The Committee feels that this makes our study more
secure.
A June meeting is planned for Lansing, provided our
subcommittee chairmen feel that there is anything to
be accomplished by this session.
Respectfully submitted,
F. A. Jones, Jr., M.D., Chairman
H. A. Ott, M.D.
F. W. Bald, M.D.
C. A. Behney, M.D.
C. M. Bell, M.D.
H. R. Brukardt, M.D.
G. B. Corn eliu son, M.D.
A. L. Foley, M.D.
W. F. Goins, M.D.
E. Freeman Hersey, M.D.
E. S. Hoffman, M.D.
W. C. Lambert, M.D.
H. W. Longyear, M.D.
A. G. McCuaig, M.D.
N. F. Miller, M.D.
H. W. Sill, M.D.
C. S. Stevenson, M.D.
D. W. Thorup, M.D.
C. E. Toshach, M.D.
P. E. Sutton, M.D.
Kathryn D. Weburg, M.D.
H. R. Williams, M.D.
Viola G. Brekke, M.D., Advisor
Mary Lou Byrd. M.D., Advisor
J. V. Fopeano, M.D., Advisor
ANNUAL REPORT OF TUBERCULOUS CONTROL
COMMITTEE— 1956-1957
The Tuberculosis Control Committee met on January
1 1, 1957, and again on April 3, 1957. The principal
items brought up for discussion were as follows:
Tuberculosis Control Legislation: — The Committee
recommended that the present law regarding tuber-
culosis control be strengthened by amendment to in-
clude: (1) adequate control of committed cases; (2)
adequate control of uncooperative suspects; (3) desig-
nation of facilities at Gaylord as the site for hospitaliza-
tion for recalcitrant patients: and (4) provision for a
Board of Review composed of three physicians to advise
probate courts on commitment proceedings and to re-
view committed cases on appeal.
Proposal for Closing of Tuberculosis Sanatoria : — Dr.
Isbister reported on the proposal that the State close
tuberculosis sanatoria as the reduction of tuberculosis
patients may allow, as suggested in the report on tuber-
culosis control made by the Public Administration Serv-
ice to the Senate Committee on Finance and Appropria-
tions. This Committee recommended that the State
should continue to make beds available, if needed, on
a reservoir basis. If any further action was to be taken
by the State in this regard, the Committee requested that
it be informed.
908
Budget proposals: — The proposed budget of the
Michigan Department of Health regarding tuberculosis
hospital care, follow-up and expanded tuberculosis con-
trol was reviewed in detail and its principles approved
in toto, except for the item pertaining to the Medical
Audit of Tuberculosis Patients. The Committee accepted
this budget more with regard to principles than to
actual amounts in dollars and cents.
Role of private physician: — The Committee reaffirmed
that the effectiveness of future case finding and treat-
ment of tuberculosis is dependent largely upon the
private practitioner in the State of Michigan.
Program of Thoracic Surgery: — There was a lengthy
discussion on the present program of thoracic surgery
in the various State and county sanatoria with consider-
ation of alternate plans which might benefit both the
state and the patient, particularly the program of the
Michigan Tuberculosis Sanatorium Commission for con-
solidation of thoracic surgery in state tuberculosis sana-
toria. It was finally recommended that changes at the
present time would be both economically and profession-
ally unsound.
Utilization of “Excess” Tuberculosis Beds: — The Tu-
berculosis Control Committee was advised that the 1956
MSMS House of Delegates had authorized the appoint-
ment of a committee to study the use of excess beds in
tuberculosis sanatoria. The Committee requested direc-
tion as to whether it should undertake the study of this
situation. In February the Chairman was advised that
the President of the MSMS had decided to appoint the
Tuberculosis Control Committee as the group to handle
the resolution. A special meeting was. therefore, called
for April 3, at which this matter was discussed. A very
lengthy discussion followed and there was great differ-
ence of opinion among the Committee members. It was
difficult to reach a uniform decision, but the following
conclusions were finally made.
The Committee recognized that there was a continual
decline in tuberculosis hospitalization requirements for
the State of Michigan. On the other hand, the Com-
mitte recognized that there were many persons with
active tuberculosis who were not hospitalized. It was
felt that as much influence as possible should be brought
to bear on the state legislature to enact an adequate
law for the management of recalcitrant oatients so that
many of these beds might be filled. Case finding, of
course, should continue at an accelerated pace in an
effort to reduce further the number of patients with
pulmonary tuberculosis.
The Committee endorsed the following recommenda-
tions to strengthen the economic position of the state
tuberculosis hospitals by:
( 1 ) requiring that state-at-large patients be hospitalized
at a state sanatorium whenever bed space is avail-
able ;
(2) directing that veterans who meet county residence
requirements should be treated as county charge
patients, rather than state-at-large patients; and
that veterans who have not established residences
continue to be provided hospitalization at state ex-
pense ;
(3) providing that selected tuberculosis patients in
mental hospitals may be transferred to State tuber-
culosis hospitals as state-at-large patients when in
the opinion of the medical directors of mental
and tuberculosis hospitals the transfer would be in
the best interest of the patient.
(4) providing that selected corrections department pris-
oners with tuberculosis may be transferred to the
State tuberculosis hospitals as State-at-large pa-
tients when in the opinion of the director of the
said department and the director of the State tuber-
JMSMS
ANNUAL REPORTS
culosis department hospital that transfer would be
in the best interest of the patient and the public;
5) establishing an effective security unit of the tuber-
culosis sanatorium in requiring that all patients
committed by court order be isolated and treated
in this unit or in a county tuberculosis sanatorium,
if practicable.
Action should be taken to provide for the adjustment
if tuberculosis care provisions to patient needs by: (1)
.uthorizing the State Health Commissioner, with con-
urrence of the State Council of Health, to declare a
anatorium or any portion of a sanatorium to be in
ixcess of reasonable tuberculosis hospitalization needs
if any area and that, on this basis, the Commissioner
nay withhold state subsidy from any sanatorium so
lesignated, or reduce the number of beds approved for
ubsidy, making a proportionate reduction in the allow-
ble per diem costs for any patients hospitalized at state
xpense; (2) stipulating that when state action results
rom the closing or reduced operations of the sanatorium,
unds be provided by the legislature to maintain diag-
lostic and out-patient services for tuberculosis in the
,rea concerned.
Authorization of counties and cities to utilize excess
anatorium beds for other purposes met with a variance
if opinion by members of the Committee. It was finally
ecommended that counties and cities be given the
uthority to use sanatorium beds or sanatoria for the
are of tuberculosis or other public health responsibili-
ies, such as mentally ill, indigent, alcoholic and tuber-
ulosis patients in state prisons.
Respectfully submitted,
R. L. Rapport, M.D., Chairman
Abraham Becker, M.D.
P. T. Chapman, M.D.
W. N. Davey, M.D.
J. L. Egle, M.D.
J. L. I sbister, M.D.
Louis Jaffe, M.D.
L. R. Nelson, M.D.
R. A. Rasmussen, M.D.
W. F. Stephenson, M.D.
A. F. Stiller, M.D.
C. J. Stringer, M.D.
S. A. Yannitelli, M.D.
G. T. McKean, M.D., Advisor
INNUAL report of committee on
CENTAL HEALTH— 1956-1957
During the year ending May, 1957, the Committee
in Mental Health held three general meetings. The
iubcommittee on Alcoholism was enlarged to include
larcotic addiction.
Members participated in the following meetings:
rhird Annual Conference on Mental Health, American
dedical Association at Chicago ; Preventive Medicine
Committee Meeting of Michigan State Medical Society;
,nd Meetings with Michigan Society of Neurology and
'sychiatry.
The Committee worked with The Council on Mental
lealth of the American Medical Association on a sur-
■ey of the use of tranquilizing drugs in the State of
Michigan.
The importance of the care of individuals having
onvulsive disorders was again re-emphasized, and the
lommittee offered to furnish speakers on this subject
o county medical societies.
A number of mental health bills, which had been
ntroduced in the state legislature, were studied by the
lommittee. Its conclusions on these bills were submitted
or the information of the Legislative Committee.
It noted that the program is lagging concerning county
nedical societies having Mental Health Committees,
ind offered assistance to county medical societies in de-
reloping programs in the field of mental health.
uly, 1957
We considered the “Resolution on Hospitalization ©f
Patients with Alcoholism” as adopted by The Council
of the American Medical Association and printed in the
October 20, 1956, issue of the Journal of the American
Medical Association. This resolution deals with the
problem of the hospitalization of patients with a diag-
nosis of alcoholism. Our Committee felt this resolution
should be publicized to a greater extent.
The Committee offered to help the Michigan Society
of Neurology and Psychiatry in its sponsoring of a di-
visional meeting of the American Psychiatric Associa-
tion in October, 1959.
At present the Committee is busy assembling material
on mental health for the October, 1957, issue of the
Journal of the Michigan State Medical Society.
The Chairman wishes to thank the members of the
Committee on Mental Health for their interest and
support, and it is our hope that the activities of the
Mental Health Committee have been of some assistance
to the Michigan State Medical Society.
Respectfully submitted,
I. A. LaCore, M.D., Chairman
Z. S. Bohn, M.D., Vice Chairman
H. W. Bird, M.D.
P. N. Brown, M.D.
W. E. Clark, M.D.
F. P. Currier, M.D.
J. M. Dorsey, M.D,
T. J. Heldt, M.D.
L. E. Himler, M.D.
M. H. Hoffmann, M.D.
R. F. Kernkamp, M.D.
M. H. Marks, M.D.
P. A. Martin, M.D.
F. O. Meister, M.D.
C. J. Mumby, M.D.
W. H. Obenauf, M.D.
R. W. Waggoner. M.D.
E. M. Williamson, M.D.
H. B. Zemmer, M.D.
ANNUAL REPORT OF IODIZED SALT
COMMITTEE— 1956-1957
Two meetings of the Iodized Salt Committee were
held during the year, one on December 14, 1956 and the
second on February 8, 1957.
The theme of these meetings was to promote good
will and cooperation between the Salt Producers As-
sociation and our Committee. At the meeting on De-
cember 14, our guests were: Frank J. Madden, General
Manager of the Salt Institute of Chicago; Lloyd Mc-
Bride, Attorney for the Salt Producers Association;
Charles B. Moore, President of the Morton Salt Com-
pany; J. H. Wright of the Salt Producers Association;
and Dr. J. K. Altland of the Michigan Department of
Health.
Dr. Towsley presented for the guests the history of
our Committee and its past accomplishments. Dr.
Towsley also summed up the work presently facing our
Committee. Dr. Moehlig reported on the experience
in Switzerland, Canada, and South American countries
in regard to iodine deficiencies and goiter.
Dr. Blodgett spoke of the changing incidence of
thyroid surgery and Dr. Altland reviewed the results
of our surveys of endemic goiter in Michigan school
children.
Dr. Brush spoke of the responsibility of the Medical
Society to keep goiter at a low level, and asked the
attitude of the salt producers toward making iodized
salt compulsory in Michigan.
Each of our guests was heard from, and a general
discussion of the problem followed. A subcommittee
was appointed consisting of Messrs. J. H. Wright and
William J. Burns to integrate and develop an educa-
tional program regarding the need for iodized salt.
909
ANNUAL REPORTS
We believe that during the past year we have made
strides in the right direction and expect that they will
bear fruit in the next few years.
Respectfully submitted,
B. E. Brush, M.D., Chairman
H. A. Towsley, M.D., Vice Chairman
L. A. Berg, M.D.
J. B. Blodgett, M.D.
J. R. Carney, M.D.
R. C. Moehlig, M.D.
R. L. Rapport, M.D.
R. L. Waggoner, M.D.
ANNUAL REPORT OF THE SCIENTIFIC
RADIO COMMITTEE— 1956-1957
During the year, forty programs for lay education
were tape-recorded and distributed over nine radio
stations throughout the state. The stations carrying the
programs were: WUOM, WFUM. WPAG, WAGN,
WBRN, WDET. WLDM, and WMDN. The topics and
their date of original distribution and the members of the
Michigan State Medical Society who presented the
topics are
as follows:
1956
10- 5
The Childless Couple
S. J. Behrman
10-12
The Importance of
Prenatal Care
Tommy Evans
10-19
Preparing the Family
for the New Baby
E. H. Watson
10-26
What is the Meaning of
Vomiting in the Baby?
Robt. Heavenrich
11- 2
What is the Meaning of
Diarrhea in the Baby?
Wm. Stewart, Jr.
11- 9
Why Does Your Baby
Need “Shots”?
George Lowrey
11-16
Muscular Dystrophy
Russell Dejong
11-23
The Menopause
D. Tamblyn
11-30
Health Investments for
Advancing Years
S. E. Miller
12- 7
Why You Need an An-
nual Health Examination
John Rodger
12-14
Rheumatism
Wm. Mikkelson
12-21
Advances in the Treat-
ment of Arthritis
Wm. Caster
12-28
Backache
Chas. Frantz
1957
1- 4
Research and the
March of Dimes
J. L. Wilson
1-11
What is being done for
the Polio Patient Today?
D. G. Dickinson
1-18
Body Functions and the
Endocrine Glands
D. H. Streeten
1-25
The Thyroid Gland
Wm. Beierwaltes
2- 1
Trends in the Treat-
ment of Diabetes
Stefan Fajans
2- 8
Coronary Heart Disease
Park Willis
2-15
Rheumatic Heart Disease
Aaron Stern
2-22
How to Live with Your
Heart Disease
F. D. Johnston
3- 1
High Blood Pressure
Sibley Hoobler
3- 8
What Can You Do for
the Victim of an Auto-
mobile Accident?
C. Thomas Flotte
3-15
What Can You Do for
the Burned Victim?
Robt. E. L. Berry
3-22
What Can You Do for
the Person Who Swal-
lows Poison?
Craig Booher
3-29
What Can You Do to
Prevent Accidents in
the Home?
Robert Trimby
4- 5
Early Warning Signs of
Cancer of the Female
Generative Organs
T. N. Evans
910
4-12
Breast Cancer
M. S. DeWeese
4-19
Cancer of the Blood
Frank Bethell
4-26
Cancer Research
H. B. Latourette
5- 3
What Is Cerebral Palsy?
Kenneth Magee
5-10
What Is Being Done for
the Cerebral Palsied?
Richard Allen
5-17
The Problem of Sex
Education
Stuart Finch
5-24
The Emotional Aspects
of Epilepsy
H. Waldo Bird
5-31
What Can Be Done for
the Hard of Hearing?
James Maxwell
6- 7
Recent Advances in the
Treatment of Appendi-
citis
Paul Hodgson
6-28
Hay Fever
Robert Lovell
7- 5
Summer Itch
Richard Harrell
The attempt was made again this year to place cer-
tain programs on the air to coincide with the activities
of national or state agencies; i.e., cancer month, heart
month, and so forth.
This Committee would like to call to your attention
that all of these broadcasts are recorded and are avail-
able to any county society or any member of the state
society who would like to use them for rebroadcasts,
their local radio stations, or as source material in talks
that might be given to local lay groups, including
parent-teacher associations, the local Grange, or other
lay organizations.
This Committee would like to call your attention to
the fact that we would like to broaden the number of
stations over which these programs are distributed. To
do this, we urge the members of the county societies
to consult with their local radio stations and make an
effort to obtain the service of the station for broadcasting
these programs. Further information of the procure-
ment of these tape recordings can be obtained by writ-
ing to the Office of Public Relations of the Michigan
State Medical Society or to Station WUOM at the
University of Michigan Broadcasting Service, Ann Arbor.
This Committee has not had an annual meeting dur-
ing the year. However, one is scheduled for July, 1957,
to compile the program for the year of 1957-58.
Respectfully submitted,
Harry A. Towsley, M.D., Chairman
Carl B. Beeman, M.D.
John H. Buell, M.D.
William L. Foster, M.D.
C. E. Lemen, M.D.
Gordon H. Scott, Ph.D.
John M. Sheldon, M.D.
R. Wallace Teed, M.D.
Kenneth W. Toothaker, M.D.
ANNUAL REPORT OF PREVENTIVE MEDICINE
COMMITTEE— 1956-1957
As co-ordinator for its numerous advisory committees,
the Preventive Medicine Committee has noted the initia-
tion of important projects and continued development of
those now in progress. The keen and devoted interest
displayed has been highly gratifying since it promises
significant accomplishment towards the solution of many
difficult problems.
A brief review of what is being done and planned
follows:
The Geriatics Committee is concerned with establish-
ing rules for licensure of nursing homes; with an insur-
ance program for older people; with the setting up of
community health forums; and with a driver-training
program for older people. A Geriatrics Issue of the state
Journal was prepared and published in May, 1957.
The Iodized Salt Committee has been integrating the
activities of several interested groups for more and
JMSMS
ANNUAL REPORTS
lodern education of the public towards increased use
f iodized table salt.
The Maternal Health Committee has apportioned its
fork among several cities of the state and has published
guide for Maternal Mortality Studies; established a
laternal tissue register; initiated a study of rubella;
onsidered the formulation of minimum standards for
bstetrical care; proposed a Medical Liaison Committee
dvisory to county societies; started a program of lay
ducation in the form of a brochure “Expectant Parent
londitioning” ; sponsored and participated in an exhibit,
Care of Mothers and Children” by the Michigan De-
artment of Health; and proposed the preparation of a
;ries of single pages for the state Journal giving
lformative material.
The Rheumatic Fever Control Committee plans to
take a study of the incidence of rheumatic fever in
Michigan; is continuing with the operation of the
sveral Rheumatic Fever Centers in the state; is con-
tantly revising informative material that is made avail-
ble to every member of the Society; and, in co-opera-
ion with the Michigan Heart Association, has again
warded six postgraduate fellowships to local physicians
/ho will study at St. Francis Sanitarium in Long
sland, N. Y.
The Tuberculosis Control Committee has been con-
erned with the problems of proper utilization of excess
ieds in tuberculosis sanatoria: control of recalcitrant
latients; and the role of private physicians in the find-
rig, care and treatment of tuberculosis.
The Mental Health Committee is arranging a speak-
r’s program on convulsive disorders ; had sponsored a
Milestones for Marriage” project to be administered by
he Woman’s Auxiliary; and is concerned with the im-
lortant problems of medical testimony, alcoholism, cer-
ification of psychologists and narcotic rehabilitation.
The Child Welfare Committee sponsored the March,
957, issue of The Journal, MSMS; promoted educa-
ion of law and medical students on the problem of adop-
ion; considered the problem of prophylaxis for neonatal
phthalmia; technique of examining children’s eyes; visual
.cuity testing equipment; continued screening clinics for
tearing defects; worked on school health problems and
tandardized forms; initiated action toward poison con-
rol centers and accident prevention ; and proposed a
oint meeting of committee members and representatives
if each county society to promote child welfare activities
ocally.
This brief review describes only a few of the actions
aken by several of the committees. For more complete
nformation, the reader is referred to the individual
eports of the advisory committees appearing in this
landbook.
As in the past, our State Health Commissioner, Dr.
L E. Heustis, has participated actively and helpfully
n our deliberations and we are grateful for his contribu-
ions.
Respectfully submitted,
W. S. Reveno, Chairman
I. A. LaCore, M.D.
B. E. Brush, M.D.
S. T. Harris, M.D.
R. M. Heavenrich, M.D.
A. E. Heustis, M.D.
W. A. Hyland, M.D.
O. J. Johnson, M.D.
F. A. Jones, Jr., M.D.
A. H. Price, M.D.
R. L. Rapport, M.D.
J. M. Sheldon, M.D.
Frank Stiles, Jr., M.D.
H. A. Towsley, M.D.
ANNUAL REPORT OF MEDIATION
COMMITTEE— 1956-1957
During this time there have been no complaints sub-
mitted to the Mediation Committee, and no meetings
have been held.
Respectfully submitted,
Luther R. Leader, M.D., Chairman
D. R. Boyd, M.D.
A. E. Gamon, M.D.
E. B. Johnson, M.D.
W. Z. Rundles, Sr., M.D.
R. W. Teed, M.D.
Charles TenHouten, M.D.
ANNUAL REPORT OF COMMITTEE ON STUDY
OF PREVENTION OF HIGHWAY ACCIDENTS—
1956-1957
One meeting of the Committee on Study of Preven-
tion of Highway Accidents was held in December. Gor-
don Sheehe, Director of the Highway Traffic Safety
Center of Michigan State University, gave a report on
the work of the Center. The resolution which had been
referred to the Committee by the 1956 House of Dele-
gates relating to ambulances disregarding traffic regula-
tions was considered and approved. The Committee
stated that in its opinion no medical emergency could
exist that would be more important than public safety,
and that ambulance drivers should at all times comply
with the letter of the motor vehicle laws and not hurry
at the expense of safety. It was moved that appropriate
publicity be given to this action.
The Committee, recognizing the value of seat belts,
and feeling that all students learning to drive should be
impressed with their value and use, moved
“That the Michigan State Medical Society suggest
to the Department of Public Instruction that it con-
sider recommending to all public school systems giving
driver training that seat belts be installed in all driver
training vehicles.”
The Committee moved that members of the Com-
mittee prepare material on traffic first aid “don’ts” to
be submitted to the MSMS Public Relations Counsel for
possible release to state newspapers. It also was moved
that the Committee suggest to the Postgraduate Medical
Education Committee that it seriously consider a continu-
ation of the excellent automobile trauma program used
this year in some of the extra-mural postgraduate centers.
Plans were considered as to topics and authors for the
requested Traffic Safety Number of the MSMS Journal
for September, 1957.
The AMA Committee on Medical Aspects of Automo-
bile Injuries and Deaths is currently preparing a manual
entitled “Medical Guide for the Operation of Motor
Vehicles.” When completed this will be a valuable
source of information which can be tailored to state
needs, and for this reason some work which might have
been considered by the MSMS Committee this year
has been postponed until next year when it is hoped
this manual will be ready.
In the name of the Committee, the Chairman made
the following contacts during the year:
1 . Spoke at Portland, Oregon, in November at a meet-
ing of the Oregon Lifesavers, on Michigan’s Student
Driver Training law. This meeting was arranged by the
Oregon State Medical Society. This winter the Oregon
legislature passed a student driver training law which
in general is patterned after the Michigan law;
2. Had a one-day conference with a representative of
General Motors on matters of mutual interest to the
medical profession and the motor car industry;
fuLY, 1957
911
ANNUAL REPORTS
3. Represented MSMS in Washington in March at
hearings of the House Subcommitte on Traffic Safety,
giving testimony in relation to three areas:
(a) Reasons for the resolution calling for Federal
supervision of safety standards of motor car design
and construction, which resolution was introduced
by the Michigan Delegation at the November,
1955, session of the AMA House of Delegates
and which was unanimously adopted by that
body;
(b) Michigan's student driver training program as a
pattern for other states;
(c) The problem of the sleepy driver.
The above testimony was offered as supplementary to
that which will be given later this year by the AMA.
4. Appeared in Lansing before a Senate committee
in support of SB 1423, a bill requiring the answering
of certain questions regarding health on driver applica-
tions and the furnishing of physicians’ certifications where
questions of driver fitness arise. This bill, which was
recommended by the MSMS Traffic Committee last
year, was not reported out of the Senate committee
this year;
5. Took part in a panel discussion on Traffic Safety
at the meeting of the AMA Auxiliary in June, emphasiz-
ing the opportunities for state auxiliaries to initiate
student driver training legislation similar to Michigan’s;
6. Spoke on the Medical Aspects of Driver Safety
before the annual meeting of Michigan Chiefs of Police
in June.
Respectfully submitted,
John R. Rodger. M.D., Chairman
G. H. Agate, M.D.
H. E. DePree, M.D.
J. M. Dorsey, M.D.
H. F. Falls, M.D.
A. Z. Howard, M.D.
H. T. Johnson, M.D.
R. F. Powers, M.D.
C. L. Straith, M.D.
H. J. Meier, M.D.
ANNUAL REPORT OF ADVISORY COMMITTEE
TO WOMAN’S AUXILIARY— 1956-1957
This Committee did not have an official meeting
during the year, although matters relating to the activi-
ties of the Auxiliary were discussed between the Presi-
dent of the Auxiliary and the Chairman and some mem-
bers of the Committee.
The Committee has studied the National Science Fair
idea with the Auxiliary’s First Vice-President and reports
much interest in support of this project.
The members of the Committee take this opportunity
to commend the officers of the Auxiliary for the excellent
way in which they have executed their duties this year.
Respectfully submitted,
John E. Hauser, M.D., Chairman
A. B. Aldrich, M.D.
W. J. Butler, M.D.
W. L. Sherman, M.D.
ANNUAL REPORT OF ADVISORY COMMITTEE
TO MICHIGAN STATE MEDICAL ASSISTANTS
SOCIETY— 1956-1957
There were no formal meetings of this Committee, the
membership voting by mail on an insurance problem and
on a method of approving advertising in the new Bulle-
tin of the Michigan State Medical Assistants Society.
The MSMAS was represented in Milwaukee, Wis-
consin, in October, 1956, at the first annual meeting of
the American Association of Medical Assistants. Miss
Hallie Cummins of Caro, Michigan’s delegate to the
National Board of Directors, was elected Chairman of
the Executive Committee. Many Michigan members are
serving on and heading committees in the national or-
ganization. Ralph W. Shook, M.D., of the Advisory
Committee was among the physicians attending. The
Advisory Committee helped with the many problems
concerning the adoption of the first constitution and by-
laws. The second annual meeting will be held in San
Francisco, October 4, 5, and 6, 1957.
Two Presidents’ Conferences were held this year as
training programs for officers and standing committee
chairmen of component Medical Assistants Societies in
Michigan. The fall conference was held November 4,
1956. in Saginaw with an attendance of sixty members.
The theme was an organization workshop with presenta-
tion of job manuals for officers and standing committee
chairmen. The spring conference was held in Muskegon
on April 17, 1957, with thirteen counties represented.
The theme was public speaking.
A revision of the voting procedure has been under
consideration. A detailed method of voting by mail
will be submitted to the MSMAS membership at the
annual meeting in September.
The news organ, mimeographed in January, assumed
a “new look” in May, when the “Bulletin” of the
MSMAS was printed for the first time and sent to each
member. This is an excellent publication and all con-
cerned are to be congratulated. The Bulletin, which
carries approved advertising, is to be issued quarterly
and will include important conference and convention
speeches and reports.
A standing committee on education was initiated this
year to study, encourage and promote a well-rounded
educational program for medical assistants throughout the
state. Through the efforts of this MSMAS committee
members are being encouraged to start evening school
programs in all counties. Brochures from the one-year
training program for medical assistants in Highland Park
Junior College and from the two-year training program
from Ferris Institute in Big Rapids have been distri-
buted to high schools throughout the state. Many mem-
bers have spoken to high school groups concerning the
benefits of becoming trained medical assistants. The
one-year scholarship to Highland Park for a medical
assistant has been continued. A method of accrediting
medical assistants for the knowledge and training they
acquire is another committee activity.
The membership as of May 30, 1957, is over 900,
and two new component societies in Branch and Eaton
counties have been organized. Contacts have been made
with twenty-two unorganized counties, and the medical
assistants feel sure that within the next few years the
coverage will be complete in Michigan. Thanks are due
to county medical societies, Michigan Medical Service
representatives, and drug detail men who have assisted
greatly in the efforts to organize new county societies
of medical assistants.
The Upper Peninsula Society has made great strides
since its organization in June, 1956. Extensive plans
have been made for the first convention in Houghton
in June, 1957, and many district groups have formally
organized.
The MSMAS was contacted by the Ontario Medical
Association for suggestions and advice on the proposed
Ontario Medical Secretaries Association. This meeting
was held in Lansing.
We, as physicians, are pleased and proud of the
calibre, aims, and accomplishments of the members of
the MSMAS.
Respectfully submitted,
David Kahn, M.D., Chairman
Ralph W. Shook, M.D.
E. R. Sherrin, M.D.
T. J. Trapasso, M.D.
Otto VanderVelde, M.D.
J. E. Webber, M.D.
912
TMSMS
BROAD ANTICHOLINERGIC BLOCKADE
Pro-Banthine® Relieves Pain,
Accelerates Peptic Ulcer Healing
The efficiency of Pro-BanthTne (brand of
propantheline bromide) in inhibiting the
chemical substance which mediates para-
sympathetic gastric activity explains the
success of the drug in ulcer therapy. Pro-
BanthTne blocks acetylcholine at both the
ganglia and parasympathetic effector
sites. This dual action controls excess
neural stimulation of both gastric secre-
tion and motility.
The therapeutic benefits of this anti-
cholinergic blockade consist, as many
clinical investigators have noted, in
prompt relief of ulcer pain and pro-
nounced acceleration of ulcer healing.
The suggested initial dosage is one 1 5-
mg. tablet with meals and two tablets at
bedtime. Two or more tablets four times
a day may be indicated in severe manifes-
tations. G. D. Searle & Co., Chicago 80,
Illinois. Research in the Service of
Medicine.
July, 1957
Say you saw it in the Journal of the Michigan State Medical Society
913
Michigan’s Department of Health
Albert E. Heustis, M.D., Commissioner
PUBLIC HEALTH LEGISLATION
A bill which will be of interest to all physicians was
passed by this session of the Legislature. It provides for
protection of the confidential nature of information
shared with the State Health Commissioner, in the con-
duct of studies which the State Health Commissioner
designates in advance to be medical research.
A bill of special concern to local health departments
empowers them to employ personnel in addition to the
presently authorized physicians and nurses. Up to this
time, local health departments were not authorized to
hire sanitarians though they have long been accepted
as indispensable members of the basic staff of an effec-
tive health department. Passage of the bill makes possi-
ble the legal employment of any qualified persons needed
to perform the tasks of providing community health
services.
Two other bills passed at this session, of particular
interest in connection with tuberculosis control will per-
mit county and joint county tuberculosis sanatoria to
hospitalize patients for treatment of diseases other than
tuberculosis.
Another change in tuberculosis statutes provides for
a specialized care facility at Northern Michigan Tuber-
culosis Sanatorium or at any approved hospital main-
tained for the care and treatment of patients with tuber-
culosis, in which committed or so-called recalcitrant
patients would be hospitalized. This legislation provides
only the legal basis for the special care facility. No
funds have been appropriated for construction, equipping
or staffing such a unit.
A proposal which did not pass the Legislature was a
bill regarding air pollution control. The objective of
this bill was to grant specific authority to the State
Health Commissioner to control air pollution sources.
The bill passed the House but was not reported out of
committee in the Senate.
Another bill providing for reorganization of state
health agencies failed enactment.
INTER-PERSONAL RELATIONS
Physicians who are board of education members or
those whose advice may be asked on setting up family
living courses in their schools will find helpful an article
in the January issue of Michigan’s Health, a monthly
publication of the Michigan Department of Health.
Title of the article is “Inter-Personal Relations” and it
is by Henry Eddy, Principal of Northeastern High
School, Detroit. Mr. Eddy describes the steps taken in
building community understanding and support of a
highly successful course at the ninth grade level in that
school. The course begins with discussion of family
relations, considers boy and girl relations, maturity and
reproduction, and closes with a summary of attitudes
and values in personal and community living.
REPORTING RESULTS OF SEROLOGIC
REACTION FOR SYPHILIS
A new terminology for reporting the results of sero-
logic tests for syphilis has been recommended by the
National Serology Advisory Council to the Surgeon |
General of the United States Public Health Service. In
accordance with this recommendation, and with the i
approval of the Venereal Disease Control Committee of
the Michigan State Medical Society, the Division of
Laboratories of the Michigan Department of Health will
now report the laboratory results of the serologic tests I
for syphilis as Nonreactive, Weakly Reactive, and Re- 1
active. These terms for listing results are used as i
follows:
New Terms
Nonreactive
Weakly Reactive
Reactive
Terms Previously Used
Negative
Doubtful
Positive
There will be no change in the quantitative testing
of bloods found to be Reactive (Positive) on routine
test.
NEW FLUORIDATION FILM AVAILABLE
“The Truth about Fluoridation,” a new sound film, in
color, with a running time of twelve minutes, is now
available from the film loan library of the Michigan
Department of Health. The film describes the mechanics
of fluoridation, points out the actual reduction of dental
caries from use of fluoridated water in Grand Rapids
and emphasizes that the fluoride added to water is the
same as that occurring naturally in water in many
areas. Assurance is given that ingested fluorides present
no hazard to health and that fluoridation is an eco-
nomical way to reduce dental decay for communities
with a public water supply.
SUMMER COURSES FOR HEARING AND
VISION TECHNICIANS
A preliminary hearing technicians training program
was held at Eastern Michigan College from June 23 to
28. Purpose was the preparation of technicians to work
in community hearing conservation programs.
Classes for training vision technicians are scheduled
at two centers during the summer, at Central Michigan
College, July 8 through 12, and at Eastern Michigan
College, July 15 through 19. Technicians trained are
employed by communities throughout the state to work
in vision programs in schools.
Tumors of the kidney are almost invariably malignant.
Diagnosis must be early if cure is to be effected.
Nephrectomy is the only procedure which will eradicate
the growth. Hematuria is the most important symptom.
Pain in the flank is the second most important symptom.
914
JMSMS
Ifl&uJ
“PREMARIN”c MEPROBAMATE
Conjugated Estrogens (equine) with Meprobamate
It was inevitable that these two therapeutic agents— the
leading natural oral estrogen and the foremost, clinically
proven tranquilizer— should be combined for control of
the menopausal syndrome when unusual emotional stress
complicates the picture.
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July, 1957
Say you saw it in the Journal of the Michigan State Medical Society
915
In Memoriam
Jerome W. Ankley, M.D., sixty, of Grosse Pointe Park,
was a Detroit physician for thirty-five years. He was
a member of St. Ambrose Roman Catholic Church, and
a retired member of the Michigan State Medical Society.
He died April 27, 1957.
* * *
Claude W. Behn, M.D., sixty-two, Detroit derma-
tologist for thirty years, died May 12, 1957, after a
long illness.
* * *
Karl B. Brucker, M.D., seventy-two, Lansing procto-
logist, was born at South Lyons, July 27, 1884. He was
a graduate of the University of Michigan. Devoting
much time to civic affairs, he was a charter member
and past president of the Lions Club and helped with
its work with blind children. His interest in amateur
theatricals was directed toward the Civic Player organi-
zation, with which he was associated for a quarter of
a century. His acting talents earned him many lead
and top supporting roles in its productions. He was a
life member of Capital Lodge No. 66 A. & F. M.;
B.P.O.E. No. 196 and the Central Methodist Church.
Doctor Brucker was a retired member of the Michigan
State Medical Society. He died May 20, 1957, of a
heart attack.
* * *
Murray M. DeWar, M.D., sixty. Grand Rapids
ophthalmologist, was a 1919 graduate of Wayne Uni-
versity and took postgraduate work at hospitals in
New York, Vienna and London. He died March 30,
1957.
* * *
Joseph M. Foley, M.D., fifty-eight, Detroit radiologist,
was born in Chicago but had lived and practiced in
Detroit since 1944. A graduate of the medical school
at St. Louis University in 1926, Doctor Foley was a
member of the American Roentgen Society and the
Huron River Hunting and Fishing Club. He died
April 29, 1957.
* * *
Mr. Homer C. Fritsch, Executive Vice President of
Parke-Davis Company, died suddenly April 8, 1957, in
Montreal, where he had gone on company business.
His loss will be deeply felt, for he was a man of
diverse talent and warm, friendly personality. Few
persons in the history of Parke-Davis have left their
imprint for good on as many people as did Mr. Fritsch.
During more than forty years, he served his company,
community, and nation well.
The medical profession will remember Mr. Fritsch for
his support of various medical programs and projects.
Perhaps he will be longest remembered for his aid in
bringing about the fulfillment of the Beaumont Memo-
rial dream.
* * *
N. Arthur Gleason, M.D., fifty-nine, a Flint derma-
tologist for twenty-eight years, was a graduate of the
Wayne University College of Medicine. Dr. Gleason i
served as deputy district governor of the Lions Club in
1944, and was a member of the Elks, Masonic Lodge,
the Commandery and Knights Templar. He died April
4, 1957.
* * *
William H. Gordon, M.D., sixty-six, Detroit, long-
time chairman of the MSMS Committee on National
Defense, was a member of the staff at Harper Hospital.
A native of Findlay, Ohio, Doctor Gordon was a 1916
graduate of the Llniversity of Michigan Medical School.
He was a veteran of both World Wars. During World ;
War I, he was awarded the Purple Heart and was taken
a prisoner by the Germans. During World War II, he
commanded the 94th General Hospital in England. He
died May 5, 1957, of a heart attack.
* * *
John N. Kemp, M.D., eighty-six, prominent Saginaw
physician, served almost forty-five years as Chief of
Staff of the Saginaw County Infirmary Hospital before
retiring from that position in 1947. He also served on
the staffs of St. Mary and Saginaw General Hospitals.
He helped organize the Saginaw Valley Medical College
and was a demonstrator of anatomy and professor of
minor surgery on its staff. Doctor Kemp was a life
member of the Michigan State Medical Society, a mem-
ber of the Saginaw School Board for six years, and of
Masonic Lodge No. 155 and the Elf Khurafeh Shrine.
Death occurred April 20, 1957.
* * *
William T. King, M.D., eighty-two, Houghton Coun-
ty, was born in Calumet, December 5, 1874, and gradu-
ated from the University of Michigan in 1901. Doctor
King was a physician-surgeon for the Old Dominion
Mining Company of Globe, Arizona, from 1903-04.
Returning to the copper country, Doctor King was
physician-surgeon for the Allouez-Ahmeek Mining Com-
pany and later for Calumet and Hecla, Inc., from 1904
until his retirement in 1953. He was a member of Calu-
met Lodge No. 271, F. & A. M.; Calumet Chapter No.
135; Royal Arch Masons; Montrose Commandery, No.
38; Knights Templar: Ahmed Temple, Shrine of Mar-
quette, and the Calumet Lions Club. Doctor King was
also a director of the Keweenaw Savings Bank. He was
an emeritus member of the Michigan State Medical
Society. He died May 1, 1957.
* * *
John C. Koch, M.D., seventy-five, retired Detroit
physician, died March 16, 1957.
* * *
Rudolph Leiser, M.D., fifty-five, Detroit psychiatrist
and one-time clinical director of Wayne County General
Hospital, was born at Breslaw, Germany, where he
became a professor at the University of Breslaw Medical
School. Doctor Leiser came to this country in 1933 and
was in private practice at the time of his death April
22, 1957.
916
TMSMS
IN MEMORIAM
John Norup, M.D., fifty-nine, a practicing physician
of Berkley for twenty-seven years, was on the staffs of
Beaumont and Mt. Carmel Mercy Hospitals. A native
of Denmark, Doctor Norup graduated from the Uni-
versity of Copenhagen and in 1925 came to this coun-
try, where he studied further at the University of
Illinois. He died April 16, 1957.
* * #
A. J. O’Brien, M.D., seventy-four, prominent physi-
cian and surgeon of Wakefield for nearly fifty years,
was born in Michigamme, Marquette County, August
18, 1882. He attended the University of Michigan and
received a degree as a pharmacist, following which he
worked in drug stores in Pontiac, Detroit, and Bessemer.
In 1904, he returned to the University of Michigan
and received his degree in medicine in 1908. A life-
long member of the Knights of Columbus, Dr. O’Brien
was also an Elk and Rotarian. He was a life member
of the Michigan State Medical Society. He died April
23, 1957.
* ■» ■»
Burton Parker, M.D., eighty, practiced in Detroit for
sixty years following graduation from the Michigan
College of Medicine. Doctor Parker had been on the
staff of Grace Hospital for fifty-three years at the time
of his retirement ten years ago. A member of the crew
of the U.S.S. Y os, emit e in the Spanish American War,
he served as a captain in the medical corps of the U. S.
Army during World War I. He died March 27, 1957.
* * *
P. Wilfred Patterson, M.D., fifty-nine, Grand Rapids,
received his medical degree from the University of
Western Ontario and served his internship in London,
England. He died April 8, 1957.
* * *
George L. Riley, M.D., sixty-seven, Grand Rapids,
served on the senior staff of Butterworth Hospital
nearly forty years, and was Grand Trunk Railroad
surgeon for twenty years. A native of Broken Bow,
Nebraska, and a graduate of St. Louis University School
of Medicine in 1917, Doctor Riley served in France
as a lieutenant in the Army Medical Corps in World
War I. He died March 27, 1957.
* * *
Michael D. Ryan, M.D., eighty-nine, of Saginaw, was
one of the last of the doughty “horse-and-buggy” doc-
tors of early Michigan medicine. His active practice
dates back to the lumberjack days when Saginaw was
milltown mecca of the world. Born December 16, 1867
in Kingston, Ontario, and a graduate of Queens Uni-
versity in Kingston, he first came to Saginaw in 1891.
In community service. Doctor Ryan had functioned as
Saginaw City Health Officer, Police Commissioner and
a member of the Board of Estimates. He was a member
of the Knights of Columbus, and an emeritus member
of the Michigan State Medical Society. He died April
18, 1957.
* * *
William H. Stokes, M.D., sixty-two, Lake City eye
surgeon, was a native of the British East Indies before
coming to the United States in 1913, Doctor Stokes
attended schools in Germany before graduating from the
July, 1957
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Say you saw it in the Journal of the Michigan State Medical Society
917
IN MEMORIAM
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University of Michigan in 1922. In 1925, he became
the ophthalmologist for the Dallas Medical and Sur-
gical Clinic in Dallas, Texas. Doctor Stokes was a
professor at the University of Nebraska Medical Col-
lege until 1943 when he was forced by illness to retire.
Since retirement, he had conducted a limited practice
in Lake City. He died suddenly of a heart attack,
April 8, 1957.
O. H. Stuck, M.D., seventy-four, of Otsego, was
born December 26, 1882, in Plainwell, Michigan. He
graduated from the Chicago School of Medicine and
Surgery and had practiced in Otsego during the past
forty-five years. Doctor Stuck was a member of the
DeWitt Clinton Consistory, Ambassador of the Saladin
Shrine of Grand Rapids, Past Master of the Otsego
Lodge No. 78 F. & A.M. and a member of B.P.O.E.
No. 1711. He died suddenly May 2, 1957, of a heart
attack.
# ■* ■*
Henry A. Tressel, sixty-nine, Wakefield physician,
was born in Clay County, Indiana, July 19, 1887. He
received his doctor of medicine degree at Northwestern
University and began practice in Wakefield forty-four
years ago. A member of the Odd Fellows, Masonic
Lodges and Rotary, Doctor Tressel was honored in
1946 at a public testimonial dinner for his community
service. He died April 23, 1957, of a heart attack.
* * *
John J. Watts, M.D., sixty-four, of Detroit, was a
native of Tecumseh, Ontario, before coming to Detroit
in 1911. He graduated from the Detroit College of
Medicine in 1916 and served as an Army Captain in
World War I. Doctor Watts was a member of Provi-
dence Hospital staff. He died May 3, 1957.
LENTE INSULIN
(Continued from Page 883 )
evidence that the latter are harmful in daily use.
However, allergies do occur and in these cases
Lente would be of distinct advantage.
Summary
1. Lente is an intermediate insulin.
2. Variations seen in response to a single dose
are noted.
3. These fall into two main types — with lowest
blood levels at 4 P.M. and at noon.
4. Certain potential advantages are discussed,
indicating that there is a place for Lente in our
armamentarium.
Reference
1. Hallas-Moller, K: The Lente Insulins. Diabetes,
5:7-14 (Jan. -Feb.) 1956.
918
Say you saw it in the Journal of the Michigan State Medical Society
JMSMS
CORRESPONDENCE
Correspondence
William J. Burns, LL.B.
Executive Director
Michigan State Medical Society
Lansing, Michigan
Dear Bill:
I have read with rapt interest the April issue of
The Journal of the Michigan State Medical Society
and believe it has reached an all-time high for pro-
fessional journals in presenting the problem of cancer
control.
Congratulations to all concerned, and may your con-
tinued efforts meet with the success which they so richly
deserve.
With warmest personal regards, I am.
Sincerely yours,
W. Kenneth Clark, M.D.
Acting Medical and Scientific Director
American Cancer Society, Inc.
New York, N. Y.
May 28, 1957
* * *
Dear Doctor Clark:
To say the least, your May 27 words are highly ap-
preciated— they just stimulate us to greater effort in
behalf of a better Journal of the Michigan State Medi-
cal Society.
May I have your permission to quote your letter in
JMSMS — the Correspondence section?
Respectfully yours,
William J. Burns
Business Manager
Lansing, Michigan
June 7, 1957
Dear Doctor Haughey :
During the past ten years or so, an annual “Summer
Round-up” for pre-school children has been conducted
under the supervision of the St. Clair County Health
Department with the co-operation of the various local
PTA’s and members of the Medical Society.
A committee of the Medical Society and the Health
Director have had this matter under study during the
past year and upon their advice and with the acceptance
of the Port Huron and St. Clair Councils of PTA, the
program has been changed in order to insure a better
health program for the child by placing the matter back
in the hands of the child’s physician where we feel that
it belongs.
This year, parents are being directed by letters re-
leased from the various schools to take their children
to their physicians and dentists for health examinations.
Forms are distributed to be completed by the examiners.
Unfortunately, some parents were prematurely advised
to accomplish this during April and May. We are
informed that this early deadline is not necessary and
examination any time before the beginning of the new
school year in September will suffice.
If you normally include children in your practice, we
urge you to co-operate fully in the program to insure
its success. The PTA and school authorities plan to
make a survey in the fall to determine the amount of
participation by parents. By our continuing interest, the
program will be improved from year to year. Very
likely some form of mass examinations for the relatively
few indigent and irresponsible families may be needed ;
if so. any need for your participation will be announced
through the Medical Society.
Port Huron, Michigan
May 20, 1957
Charles N. Hoyt, M.D.
President, St. Clair Medical Society
GINGER ALE
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July, 1957
Say you saw it in the Journal of the Michigan S'tate Medical Society
91*9
NEWS MEDICAL
MICHIGAN AUTHORS
John W. Smillie, M.D., Ann Arbor, is the author of
an article entitled “External Ankyloblepharon with
Pseudo-Exotropia” published in the American Journal
of O phthalmology, March, 1957.
Carey P. McCord, M.D., Ann Arbor, is the author
of an article entitled “Seven Thousand New Mouths to
be Fed Every Morning,” published in Industrial Medi-
cine and Surgery, May, 1957.
John G. Batsakis, M.D., Ann Arbor, is the author of
an article entitled “Brain Damage Following Urokon
Injection in the Brachial Artery: Report of a Case,”
published in University of Michigan Medical Bulletin ,
February, 1957.
Gail H. Williams, M.D., and Edward J. Klop, Jr.,
M.D., Ann Arbor, are the authors of an article en-
titled "Intermesenteric Arterial Communications” pub-
lished in the University of Michigan Medical Bulletin,
February, 1957.
Floyd J. Lemmen, M.D., Pittsburgh. Arthur L. Drew,
M.D., Indianapolis, Janice G. Glimn, and James E.
Higgins, Ann Arbor, are the authors of an article en-
titled, “Study of Cerebrospinal Fluid Proteins with
Paper Electrophoresis II. Techniques for Quantitation
of Serum and Cerebrospinal Fluid,” published in the
University of Michigan Medical Bulletin, February,
1957.
Robert C. Hendrix, M.D., Ann Arbor, is the author
of an article entitled “Experience in Forensic Pathology
in a General University Hospital and Department of
Pathology,” published in the University of Michigan
Medical Bulletin, February, 1957.
C. Howard Ross, M.D., Ann Arbor, is the author of
an article entitled “Philosophy’s Dance About the Fee,”
published in The New Physician, May, 1957.
Sidney Adelson, M.D., and David C. Laderach, M.D.,
Detroit, are the authors of an article entitled “Reserpine
in the Elderly Hypertensive Patient,” published in
Harper Hospital Bulletin, March-April, 1957.
John R. Simpson, M.D., Detroit, is the author of an
article entitled “Steroid Diabetes — Case Report,” pub-
lished in Harper Hospital Bulletin, March-April, 1957.
John C. Mayne, M.D., Detroit, is the author of an
article entitled, “Reconstructive Surgery on the Fallopian
Tubes,” published in Harper Hospital Bulletin, March-
April, 1957.
H. Saul Sugar, M.D., Detroit, Ahmed Riazi, M.D.,
Shiraz, Iran, and Rome Schaffner, M.D., Detroit, are
the authors of an article entitled “The Bulbar Con-
junctival Lymphatics and Their Clinical Significance,”
presented at the Sixty-first Session of the American
Academy of Ophthalmology and Otolaryngology, Octo-
ber, 1956, Chicago, and published in Transactions,
American Academy of O phthalmology and Otolaryngol-
ogy, March-April, 1957.
Lynn A. Ferguson, M.D., Grand Rapids, is the author
of an article entitled “Medical and Surgical Aspects of
Chronic Ulcerative Colitis: An Appraisal,” read at the
Mid- Atlantic Division Regional Meeting of the United
States and Canadian Sections, International College of
Surgeons, White Sulphur Springs, Virginia, February,
1957, and published in the Journal of the International
College of Surgeons, April, 1957.
Vergil N. Slee, M.D., Ann Arbor, is the author of an
article entitled “Medical Practice and Statistics” pre-
sented at the Washington University Medical Alumni
Association Annual Clinics Session, St. Louis, Missouri,
June, 1956, and published in Arizona Medicine, April,
1957.
Frank W. Hartman, M.D., and Gerald A. Logrippo,
M.D., Detroit, are the authors of an article entitled
“Beta-Propiolactone in Sterilization of Vaccines, Tissue
Grafts, and Plasma,” read before the Section on Pathol-
ogy and Physiology at the 105th Annual Meeting of the
American Medical Association, Chicago, June, 1956, and
published in the Journal of the American Medical As-
sociation, May, 18, 1957.
Charles G. Johnstop, M.D., Detroit, is the author of
an article entitled “Of One Medicine, Nine Surgeries,”
the presidential address read at the 64th Annual Meet-
ing of the Western Surgical Association, Cincinnati, No-
vember, 1956, and published in AM A Archives of
Surgery, May, 1957.
H. Mason Morfit, M.D., Denver, Calvin T. Klopp,
M.D., Washington, D. C., and Adrian J. Neerken, M.D.,
Kalamazoo, Michigan, are the authors of an article
entitled “Bridging of Laryngopharyngeal and Upper
Cervical Esophageal Defects.” read at the 64th Annual
Meeting of the Western Surgical Association, Cincin-
nati, November, 1956, and published in AMA Archives
of Surgery, May, 1957.
Brock E. Brush, M.D., Melvin A. Block, M.D.,
Thomas Geoghegan, M.D., Dwight C. Ensign, M.D..
and John W. Sigler, M.D., Detroit, are the authors ol
an article entitled “The Steroid-Induced Peptic Ulcer,”
read at the 64th Annual Meeting of the Western Surgical
Association, Cincinnati, November, 1956, and publishec
in AMA Archives of Surgery, May, 1957.
Nicholas S. Gimbel, M.D., Donald I. Kapetansky
M.D., Frederick Weissman, M.D., and Hermann K. B
Pinkus, M.D., Detroit, are the authors of an artick
entitled “A Study of Epithelization in Blistered Burns,’
(Continued on Page 922)
920
jmsm;
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Cobalt— 0.1 mg.
Copper 0.2 mg.
Vitamin A 5,000 I.U.
Vitamin D 400 I.U.
Vitamin E 1 I.U.
Cal. Pantothenate 3 mg.
Thiamine Hcl 2 mg
Riboflavin 2 mg
Pyridoxine Hcl. 0.3 mg
Niacinamide 20mg
Manganese ... I mg
Magnesium 5 mg
Iodine 0.15 mg
Potassium 2 mg
Zinc 1 mg
Choline Bitartrate 40 mg
Methionine 20 mg
Inositol 20 mg
Write for Latest Technical Bulletins.
'REFERENCE: J.A.M.A. 163: 359, 1957 (February 2)
DETROIT
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FOR ALCOHOLISM
A facility designed to rehabilitate or to aid
the addict in arresting his addiction.
Walter E. Green, M.D., Superintendent and Medical Director.
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July, 1957
921
Say you saw it in the Journal of the Michigan State Medical Society
NEWS MEDICAL
(Continued from Page 920)
read at the 64th Annual Meeting of the Western Sur-
gical Association, Cincinnati, November, 1956, and
published in AMA Archives of Surgery , May, 1957.
Harry A. Towsley, M.D., Ann Arbor, is the author
of an article entitled “University of Michigan Plan for
Postgraduate Medical Education : An Example of the
Potentialities of Regional Hospital-Medical School Af-
filiation,” published in the Journal of the American
Medical Association, May 25, 1957. This paper was
read before the 53rd Annual Congress on Medical Edu-
cation and licensure, Chicago, February 11, 1957.
* * *
M. K. Newman, M.D., Detroit, presented a talk en-
titled “Clinical Applications of Electromyography” to
the Eastern Michigan Section of the American Physical
Therapy Association at Sinai Hospital. April 16, 1957.
On May 15, 1957, before the Livingston County Chapter
of the Muscular Dystrophy Associations of America, Dr.
Newman presented a paper entitled “Development of
a Muscular Dystrophy Clinic and Its Value in Man-
agement of Both Childhood and Adult Types of Myo-
genic Disease.”
* * *
John M. Sheldon, M.D., A nn Arbor, was a speaker
at the Eighty-ninth Annual Session of the Nebraska
State Medical Association, held at Omaha, May 13-16.
1957. The title of his talk was “Office Management of
Allergy Problems” and covered means and methods by
which the general practitioner can diagnose and treat
allergy problems in his own office.
* * *
Dr. Alexander W. Blain, Sr., president of the De-
troit Museum of Science Society, has established a
Museum of Natural History and Health on the second
floor of the old City Hall Building, Woodward Avenue,
Detroit, Michigan.
The Detroit Museum has exhibits of birds and bird
eggs, American and African animals, fish, astronomy,
horticulture, and Indian display and a prehistoric ani-
mal exhibit including a skeleton of a mastodon un-
earthed in Michigan.
Detroit, up to this time, has been unique in being
the only city in the world of any size without a Museum
of Science.
Dr. Robert Hatt, Director of the Cranbrook Insti-
tute of Science, has recently returned from a trip to
Iran and Indonesia where he established a Museum of
Science for their respective governments.
* * *
Additional Polio Innoculations — Children who re-
ceived the recommended series of three Salk vaccine
shots a year or more ago should now receive a fourth
“ booster ” innoculation, Thomas Francis, Jr., M.D.,
of the University of Michigan recommends.
Chairman of the Department of Epidemiology in the
U-M School of Public Health, Dr. Francis evaluated the
922
Say you saw it in the Journal of the Michigan State Medical Society
jmsm:
NEWS MEDICAL
954 field trials of the Salk vaccine. He advises the
aoster as a safety measure “until we have a much
rmer picture of the lasting potency of the vaccine.”
[e suggests children and teen-agers should get the
ooster to help “make sure the vaccine has an oppor-
tnity to exert its full effect.”
The U-M expert does not recommend that the Salk
ooster shots become an annual affair, however. Citing
le fact that this is only the third year the vaccine has
een used on a national basis, Dr. Francis says boosters
’ill probably be needed less frequently as improvements
r the potency and consistency of the vaccine are made.
Should a shortage of vaccine occur, Dr. Francis be-
eves the under-20 age group should receive first priority
1 getting their initial series of three shots. Children who
ad the series a year or more ago should receive second
riority for vaccine, he maintains.
Dr. Francis discounts giving the vaccine credit for
re low incidence of polio in 1956, which was the lowest
olio year since 1947, but adds, “There is clear evidence
lat the severity of polio is less in vaccinated cases.”
He states that known fluctuations indicate the decline
l polio last year may be the result of natural variation
l the incidence of the disease. However, he does credit
le vaccine for the sharp drop in the number of paralytic
ises in the highly susceptible five- to nine-year-old age
roup.
* * *
Lampreys are being fatted in a huge fish bowl at the
iboratories of the University of Michigan School of
ledicine in the Kresge Medical Research Building, De-
oit for research in diseases of the inner ear. A report
om Merle Lawrence, M.D., Medical Acoustics, states:
“There are certain diseases of the inner ear, involving
:oustic trauma, about which we know very little. In
rder to obtain the type of information we are seeking,
e have to dissect the inner ear of a living creature.
7e then observe and make electrical response readings
> gather data.”
Dr. Lawrence and his colleagues are interested in
le reactions of the inner ear’s sensory organs to various
imuli and in the nature of environmental factors in
le ear fluid. They are also interested in the effect of
le lamprey’s inner ear fluid on the behavior of inner
ir cells.
The lamprey was chosen for this research because
F the accessibility of his inner ear to the scientist.
The sensory cells of the lamprey’s inner ear will be
:sted in a number of ways to find out what kind of
ixic conditions in that part of the auditory structure
Feet hearing — noise, vibration, shock, or other factors.
* * *
Award of fifty-five unclassified life science research
mtracts in the fields of medicine, biology, biophysics,
idiation instrumentation and in special training was
inounced by the U. S. Atomic Energy Commission,
he contracts were awarded to universities and private
istitutions as part of AEC’s continuing policy of as-
sting and fostering research and development in fields
dated to atomic energy as specified in the Atomic
nergy Act of 1954, and as amended in 1956.
Three of these awards were made to Michigan in-
EVERY WOMAN
WHO SUFFERS
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DESERVES
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jly. 1957
Say you saw it in the Journal »f the Michigan State Medical Society
923
NEWS MEDICAL
for modern
control of
salt retention
edema
CUMERTIUN*
(Brand of Mercumatilin, Endo)
Tablets
• effective oral diuretic with no sig-
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• Suitable for long-term mainte-
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• eliminates need for injections ir
certain cases, lengthens interval
between injections in others
• basically different in chemical
structure, extending the therapeu-
tic choice in organic mercurials
DOSAGE: 1 to 3 tablets daily as required.
SUPPLIED: As orange tablets, in bottles
of 100 and 1000. Also available —
CUMERTILIN Sodium Injection, 1- and 2-cc.
ampuls, in boxes of 12, 25, and 100; and
10-cc. vials, individually and in boxes
of 10 and 100.
1. Pollock, B. E., and Pruitt, F. W.: Am. J. M.
Sc., 226:172, 1953.
THE G. A. INGRAM COMPANY
4444 Woodward Avenue, Detroit 1. Mich.
stitutions: (1) to Wayne State University — An Evalu-
ation of Radioactive Isotope Gamma Ray Source for
Medical Teletherapy, the investigator being J. E. Lof-
strom; (2) to the University of Michigan — Develop-
ment of Information concerning (a) Human Mutation
Rates, (b) The Accumulation of Deleterious Recessive
Genes in Human Populations, and (c) The Manner
of Action of Selective Factors on Both Contemporary
and Primitive Human Populations, the investigator being
J. V. Neel; and (3) to Michigan State University — I.
The Absorption and Utilization of Radioactive Minerals
Applied to the Leaves of Plants; II. The Absorption
and Utilization of Ruthenium by Plants; III. The
Leaching of Nutrients from Leaves of Plants, the in-
vestigator being H. B. Tukey.
* * *
New techniques of surgery for tuber-
culosis and lung cancer are shown in
“Some Surgical Techniques in a Chest
Hospital,” a film just released by the
Michigan Tuberculosis Association. It
is designed for physicians and other
medical personnel.
The color film may be obtained by
writing to the Michigan Tuberculosis
Association. 403 Seymour Avenue,
Lansing 14, Michigan. It is available
for use by medical societies, nurses training schools, and
other professional groups in the medical sciences.
Michigan Tuberculosis Association
* * *
A two-month course in occupational medicine is
offered to physicians by the New York University Post-
graduate Medical School, September 16-November 8,
1957. Tuition is $350.00. For further information,
write the Office of the Associate Dean, New York Uni-
versity Postgraduate Medical School, 550 First Avenue,
New York 16, N. Y.
* * *
Los Angeles will be the host city for the 1957 Inter-
national Conference of Ultrasonics in Medicine on Sep-
tember 6-7. Additional details may be obtained from
John H. Aides, M.D., Secretary, 4833 Fountain Avenue,
Los Angeles 29, California.
* * *
Frederick A. Coller, M.D., Ann Arbor, received two
honors from Washington University at the commence-
ment exercises, June 10-12. He received an honorary
degree of Doctor of Science and the Doctor Evarts
Graham Medal for 1957. Congratulations, Dr. Coller!
* * *
Following the showing of Upjohn’s fourth and fifth
Grand Rounds at the June AMA Convention in New
York, all five of the filmed series will be available with-
out charge for showing before any group in the medical
profession, including students. Arrangements for show-
ing can be made through the local Upjohn representa-
tive.
* * *
The American Urological Association offers an annual
award of $1,000 for essays on the result of some clinical
or laboratory research in urology. Competition is limited
924
Say you saw it in the Journal of the Michigan State Medical Society
JMSMS
NEWS MEDICAL
urologists who have been graduated not more than
I years and to hospital interns and residents doing
iearch work in urology.
Essays shall be submitted before December 1, 1957,
William P. Didusch. Executive Secretary, 1120 North
larles Street, Baltimore, Maryland.
•* * *
The Provident Life and Accident Insurance Com-
ny reports that its group accident and sickness in-
■ance, available through the Michigan State Medical
ciety, had paid over 500 claims to doctor-members,
e amount paid varied up to $7,500 per claim. The
gest claims to date have been paid for disabilities
mlving the heart and tuberculosis. Four accidental
ith claims have been paid with three deaths due to
tomobile accidents and one drowning. The Michigan
>resentative, Mr. Richard McDermott, has been as-
ned on a full-time basis to assist MSMS members.
* * *
The Institute of Industrial Health of the University
Cincinnati announces that the third biennial course
instruction in occupational skin problems will be
ren during the week of October 28-November 1, 1957.
ysicians interested in attending the course should
ite to Secretary, Institute of Industrial Health, Eden
d Bethesda Avenues, Cincinnati 19, Ohio. Attendance
II be limited.
* * *
Jerome W. Conn, M.D., Ann Arbor, has been award-
the Claude Bernard Medal from the University of
antreal’s Institute of Experimental Medicine and
rgery. The honor is in recognition of work which
1 to the description two years ago of a new disease
ociated with high blood pressure, now called Conn
ndrome.
* * *
A clever and informative Northern Michigan Medi-
I Society Newsletter was first published in March,
cretary E. F. Crippen, M.D., is serving as Editor
d plans the publication as a monthly service to
imbers, featuring items of general interest to the
:al profession.
* * *
The Proceedings of the Third National Cancer Con-
ence, held last June in Detroit, have just been pub-
ted. The 961 -page illustrated volume is available at
.00 per copy from J. B. Lippincott Company, Phila-
Iphia, Pennsylvania.
* * *
Britain’s Health Service of no Value to Eden. — While
itain’s National Health Service is in the throes of a
sis, Anthony Eden made a hurried 11,000-mile trip
>m New Zealand to the Lahey Clinic in Boston for
urgency medical care.
Apparently, the former British prime minister wanted
part of his country’s medicine, which was socialized
decade ago.
It’s the second time he has sought medical attention
the Lahey Clinic. He underwent surgery there in
53 to correct a bile duct obstruction. Mr. Eden is
w suffering from a liver ailment.
Just a few weeks before his arrival here, Britain’s
CAMBRIDGE
AUDIO-VISUAL "SIMPLI-SCRIBE”
HEART SOUND DIRECT WRITING
RECORDER ELECTROCARDIOGRAPH
■71
A Logical Combination
The Cambridge Audio-Visual Heart Sound Recorder
is a radically new portable instrument which enables
the Doctor to HEAR, SEE and permanently RECORD
heart sounds — simultaneously.
Heart sounds, picked up by the microphone, are
amplified to any desired degree for auscultation. The
Physician hears the heart tones faithfully reproduced
through an electrical stethophone fitted with bin-
aural ear pieces similar to those he is accustomed
to using. The heart sounds being heard are simul-
taneously visible upon the long persistence screen of a
three inch cathode ray tube.
Any portion of the heart sounds may be permanently
recorded upon paper-thin magnetic discs that may be
filed with the patient's history or mailed to a consultant.
They may be “played-back” (both heard and viewed)
at any time for review, study or consultation.
The Cambridge “Simpli-Scribe” Model is a direct
writing, portable electrocardiograph. When used in
combination with the Audio-Visual Recorder, the
electrocardiogram from the “Simpli-Scribe” may be
viewed upon the cathode ray screen of the Recorder
while listening to the heart sounds, or the electro-
cardiogram may be superimposed upon the heart sound
trace for timing complex cases.
Now the Physician, Hospital or Clinic has available a
pair of complementary instruments making possible
more rapid, accurate and complete diagnosis of heart
disease.
Send for Bulletin 18S
CAMBRIDGE INSTRUMENT CO., Inc.
3732 Grand Central Terminal, New York 17, N. Y.
Oak Park, III., 6603 West North Avenue
Philadelphia 4, 135 South 36th Street
Cleveland 15, 1720 Euclid Avenue
Detroit 2, 7410 Woodward Avenue
Silver Spring, Md., 933 61st Avenue
ly, 1957
Say you saw it in the Journal of the Michigan State Medical Societ
925
NEWS MEDICAL
Protection against loss of income from
accident and sickness as well as hospital
expense benefits for you and all your
eligible dependents.
PHYSICIANS CASUALTY & HEALTH
ASSOCIATIONS
OMAHA 2. NEBRASKA
Since 1902
Flint Medical Laboratory
633 Mott Foundation Building
Flint
Phone CE. 4-9312
E. G. Murphy, M.D.
W. T. Hill, M.D.
W. L. Eaton, M.D.
C. J. Flanagan, M.D.
J. D. Wheeler, M.D.
W. Caraway, Ph.D., Biochemist
M. Dumoff, Ph.D., Microbiologist
COMPLETE SERVICES IN LABORATORY
MEDICINE
Tissue diagnosis
Serology
Chemistry
Bacteriology
Protein bound iodine
Exfoliative cytology
Basal Metabolism
Electrocardiograms
Pregnancy tests
Hematology
Urinalysis
Autopsies
40,000 socialized medicine doctors threatened to stril
unless the government quits stalling on their demand fi
a 24 per cent increase in pay. The matter now res
with a royal commission which is to make a stuc
report in October.
“Why did the once prominent prime minister choo
an American hospital instead of one in his homeland :
Mrs. Stephen C. Bacheller asked in one of her rece:
letters to me. She is area legislative chairman of tl
Woman’s Auxiliary to the AMA in Enderlin, Nor
Dakota.
“Of course,” she then added, “Mr. Eden isn’t the fii
foreign notable to take advantage of the excelle:
medical care available in the United States.”
The truth of the matter is that British doctors ha'
been on a demoralizing treadmill for a long time, wi
the result that they have been progressively losing the
freedom and status as a learned profession.
Good medicine simply can’t flourish in such a climal
Possibly Mr. Eden is well aware of this; hence I
hurried air trip to the Lahey Clinic. — AMA Secretar
Letter, April 17, 1957.
* * *
The Seventh Congress of the Pan-Pacific Surgic
Association will be held in Honolulu, Hawaii, Novel
ber 14-22, 1957. Information and brochures may
obtained by writing F. J. Pinkerton, M.D., Directc
General of the Pan-Pacific Surgical Association, You?
Building, Honolulu, Hawaii.
* * *
The Sixth Conference on Physicians and Scho
has been scheduled by the AMA for October f
November 2.
* * *
The Genesee County Medical Society announces
will present its Thirteenth Annual Cancer Day P
gram on Wednesday, April 9, 1958.
* * *
A postgraduate course in pediatric allergy will
presented in New York in weekly one-day sessions et1
Wednesday between the dates of November 6, 19
and May 28, 1958. The fee for the thirty sessions
$300.00 and applicants must be certified in pediati
or have the requirements for certification. Apply to
Office of the Dean, New York Medical College, Fi
Avenue at 106 Street, New York 29, N. Y.
* * *
A one-week course in radiation for industrial ph
cians and lawyers will be offered by the Institute
Industrial Health and the College of Law of the I
versity of Cincinnati during the week of Septembei
The course is the first of its kind and enrollment
be limited. Tuition is $100.00 per person. For furl i
information and application, write Secretary, Insti <
of Industrial Health, College of Medicine, Universit' i
Cincinnati, Cincinnati 19, Ohio.
* * *
The LIniversity of Illinois College of Medicine 1
nounces its Annual Assembly in Otolaryngology J
tember 30-October 6, 1957. Interested physicians shi I
write direct to the Department of Otolaryngology 1
W. Polk Street, Chicago 12, Illinois.
926
Say you saw it in the Journal of the Michigan State Medical Society
1M I
NEWS MEDICAL
rhe Ninth Postgraduate Assembly in Endocrinology
d Metabolism is scheduled in Augusta, Georgia, Oc-
>er 21-25, 1957. For further information on the
jgram and registration, write to Robert B. Green-
itt, Department of Endocrinology, Medical College
Georgia, Augusta, Ga. Registration is limited to 100;
tion fee is $100.00.
* * *
rhomas Francis, Jr., M.D., and Rueben L. Kahn,
D., of Ann Arbor, have been named as Charter
Hows in the newly established American Academy of
crobiologists.
■*■ * *
Dr. Penberthy honored — A $50,000 gift to the Surgery
partment of Wayne State University College of
:dicine was announced recently as a major bequest
m the estate of William A. Spitzley, M.D., prominent
troit physician. According to the will, the money
in honor of Grover C. Penberthy, M.D., Clinical
>fessor of Medicine at Wayne since 1913. The be-
;st was that the money be used for research as de-
mined by the Chairman of the Department of Sur-
y, Charles Johnston, M.D.
* * *
lames M. Robb, M.D., Detroit, received an alumni
ard for significant achievement in the field of medi-
e at the 89th Annual Reunion of Wayne State
iversity alumni.
* * *
rhe World Congress of Gastroenterology and the
h Annual Meeting of the American Gastroenterologi-
Association will be held in Washington, D. C., at
Sheraton-Park Hotel May 25-31 inclusive, 1958.
e announcement was made by H. M. Pollard, M.D.,
Ann Arbor, Secretary-General of the Congress.
* * *
rhe Peruvian Medical Association announces it is
anizing the first regional medical conference of cen-
1 Peru to take place in Lima from August 11 to
gust 17, 1957. The Peruvian government has de-
red August as the “Month of the Martyr of Peru-
n Medicine, Daniel A. Carrion.”
* * *
t by magic we could eliminate today all new in-
dons, we already have a stockpile of about 50,000,-
) people in this country harboring live, virulent tu-
cle bacilli in their bodies. These individuals will
duce a very substantial number of active cases of
erculous disease year after year for decades to come
ess some means are found to prevent such breakdowns
to destroy the tubercle bacilli now in their bodies.
Iames E. Perkins, M.D., Managing Director, Na-
ral Tuberculosis Association, J. Lancet, April, 1956.
* * *
iecause of the tragic losses of educational records
l official credentials of physicians resulting from wars
1 natural disasters in the past, the 10th General As-
lbly of WMA adopted a recommendation of its Coun-
approving establishment of a Central Repository for
dical Records.
rhis action followed an extended study and consulta-
l with other international organizations, none of
Important
Announcement of
Arteriosclerosis
Treatment
GEROT PHARMACEUTIKA, own-
ers of United States Letters Patent
#2-776-973 issued January 1957 to
Gerhard Gergely of Vienna, Austria,
have licensed MEYER AND COM-
PANY of Detroit, Michigan, to syn-
thesize and market 3, 7-dimethyl-xan-
thine double salt in the United States
of America.
3, 7-dimethyl-xanthine double salt with
oleic acid and magnesium, a stable
compound marketed in Austria since
1950 under the name “Perskleran” and
used in the treatment of ARTERIO-
SCLEROSIS is being marketed by
MEYER AND COMPANY under the
trade name of “Athemol.”
The product is now available in tablet
form.
Literature and clinical samples are
available on request.
Pharmaceutical Manufacturers
16361 Mack Ave.
Detroit 24, Michigan
ly, 1957
Say you saw it in the Journal of the Michigan State Medical Society
927
NEWS MEDICAL
PERSPIRATION PROOF
Insoles do not crack or curl
from perspiration ★
• Insole extension and wedge at inner corner of
heel where support is most needed.
• The patented arch support construction is guaran-
teed not to break down.
^Innersoles guaranteed not to crack or collapse.
• Foot-so-Port lasts designed and the shoe construc-
tion engineered with orthopedic advice.
• Conductive Shoes for surgical and operating room
personnel. N.B.F.U. specifications.
• We make more shoes for polio, club feet and dis-
abled feet than any other shoe manufacturer.
W rite for free booklet on Foot-so-Port Shoes or
contact your local FOOT-SO-PORT Shoe Agency.
Refer to your Classified Telephone Directory.
Foot-so-Port Shoe Company, Oconomowoc, Wis.
A Division of Musebeck Shoe Company
V _ J
All important laboratory exam -
i nations ; including —
Tissue Diagnosis
The Wassermann and Kahn Tests
Blood Chemistry
Bacteriology and Clinical Pathology
Basal Metabolism
Aschheim-Zondek Pregnancy Test
Intravenous Therapy with rest rooms for
Patients
Electrocardiograms
Central Laboratory
Oliver W. Lohr, M.D., Director
537 Millard St.
Saginaw
Phone. Dial 2-4100 — 2-4109
The pathologist in direction is recognized
by the Council on Medical Education
and Hospitals of the A.M.A.
which proposed to develop such a project themselves
All agreed it was urgently desirable and pledged thei;
support and cooperation to WMA in developing thi
plan.
The national medical association in each country i
to act as the “receiving agent” for the records of thi
doctors in that country, to verify such records, and t(
forward them to the WMA Secretariat for deposit.
Fred Drolett, M.D., a Lansinj
physician for fifty years who isn’
thinking of retirement, was single!
out for community recognition b'
members of the Elks Lodge at ;
testimonial dinner on May 11.
Dr. Drolett accepted an awar<
for his long years of service ti
residents of the area.
The public dinner was attendee
by more than 200 devoted friend
and civic leaders. Toastmaster o
the affair was O. B. McGillicuddy, M.D.. MSM!
Councilor from Lansing. One of the featured speaker
for the evening was L. Fernald Foster, M.D., MSM!
Secretary, who cited Dr. Drolett as a “proud example’
of “a great physician who has endeared himself to hi
colleagues, friends and patients.”
Assisting in the arrangements was Lawrence A. Drol
ett, M.D., who, like his father, is an Elk member
Rounding out the proud trio of Drolett doctors at th<
celebration was another son, Donald, a Lansing ob
stetrician.
%1'tA
Fred Drolett, M.D.
The International Society of Internal Medicine wil
hold its Fifth Congress at the Sheraton Hotel, Philadel
phia, April 24-26, 1958. For program and complet
information, write T. Grier Miller, M.D., President c
the Congress, 4200 Pine Street, Philadelphia.
* ■» *
Norvin C. Kiefer, M.D., has been chosen Presidenl
elect of the National Health Council and will assuro
the presidency in March, 1958. Dr. Kiefer, now c
New York City, is an alumnus of the University c
Michigan Medical School.
* * *
The Michigan State Medical Assistants Society hel
its Spring President’s Conference on April 14 in Muski
gon. Thirteen component societies were represente
with a total registration of thirty-seven members.
Keynote speaker was Mr. Judson Perkins, Directt
of Public Relations of the General Telephone Compan
Mr. Perkins spoke on “Human Relations and Commun
cations,” using audio and visual aids to explain propc
telephone procedures and voice qualities. Also on tl
program was Mrs. John VanHaver, Woman’s Direct!
of radio station WKBZ, who conducted a workshop c
how to speak effectively before a group.
The business meeting was chaired by Miss Doi
Jarrad, president, of Lansing. Attendance plans for tl
1957 convention of the American Association of Medic
Assistants were discussed.
928
Say you saw it in the journal of the Michigan State Medical Society
JMSN
NEWS MEDICAL
Perry C. Robertson, M.D., who retired on April 30
is superintendent of the Ionia State Hospital, was
ionored on the eve of his retirement at a community
linner attended by more than 160 community leaders
if that city.
The affair was staged to commemorate the ending
if forty-five years of service with the state mental
lospital program, thirty-one of them as head of the
'onia institution. Having recently purchased a home
n Ionia, the Robertsons will continue to reside in their
* * *
The Genesee County Medical
Society has a new administrative
pilot. Her name is Ethel Mc-
Wethy. Mrs. McWethy assumed
the Executive Secretary’s shoes
previously filled by Mrs. Sara
Warren, who retired April 30 on
the occasion of a testimonial din-
ner in her honor sponsored by
GCMS.
With administrative experience
gained from years of secretarial
ervice at Veterans' Hospital, Dearborn, and the Office
if Vocational Rehabilitation in Columbus, Mrs. Mc-
Vethy has settled in her job with maximum efficiency.
Since 1954, the new executive served as secretary to
the McLaren General Hospital Medical Staff. During
those three years, the Flint doctors were able to observe
her many capabilities. Thus, when Sara Warren re-
tired after seventeen years’ service, Mrs. McWethy
was an obvious and qualified successor.
Looking forward to fruitful years of service to the
medical profession, we say, welcome, Ethel.
MEDICAL TELEVISION SHOWS
Produced by Michigan Health Council
WJBK-TV, Detroit
May 5 — Subject: M.D. Placement — Film — “A Citizen
Participates”
May 12 — Subject: “Hospital Careers” — Guests: Mrs. H.
A. Powell, Mrs. Patricia Ann Allen, Albert
Smitheram, and E. M. Knights, Jr., M.D.,
all of Detroit, and Mrs. Elaine Verska, R.N.,
Dearborn.
May 19 — Subject: Rheumatic Fever — Film — “The Vali-
ant Heart”
May 26 — Subject: Traffic Safety — Film — “According to
the Record”
WKAR-TV, East Lansing
May 9 — Subject: National Hospital Week — “Careers
That Count” — Guests — Sarah Cali, George
M. Fritch, and Doris Loutzenhiser, all of Lan-
sing, and L. G. Parrish of St. Johns.
May 23 — Subject: “Atomic Radiation” — Guest: Donald
Van Farowe, Lansing.
idopted community.
Ethel McWethy
indicated therapy for treatment of
Bursitis, Arthritis, Traumatic Injuries
and a host of other conditions
ULTRASONICS
Conclusive evidence on the value of ultrasonic therapy is
being amassed in thousands of papers being published in
medical journals all over the world. These reports, covering
more than one million treatments, report results that have
been largely excellent, with private communications indi-
cating outstanding, sometimes startling results.
THE NEW BIRTCHER MEGASON V
The finest ultrasonic unit ever placed on the market. Precision
electronic engineering features found in no other unit. The
only machine made with the 5-Way transducer.
NOBLE-BLACKMER, INC.
267 W. Michigan Ave., Jackson, Michigan
uly, 1957
Say you saw it in the Journal of the Michigan State Medical Society
929
NEWS MEDICAL
OQ WEST
Zo ADAMS
SHOE COMPANY
DETROIT 26
MICHIGAN
ENCYCLOPAEDIA RECOGNIZES RIPPLE SOLES®
In its 1957 "Book of the year"*, Encyclopaedia Britannica lists among the
major shoe industry innovations of 1956, "ripple soles to cushion the feet
while walking."
The Hack Shoe Company is pleased to have this recognition of the latest of
its long series of contributions.
'Page 681
PREVENTION + DEFENSE +
PROPER PROTECTION AGAINST LOSS
SfrecuUcjeei Service
ma&ed aur etoc&vi
THE |
Medic AXiBRQT.EGrTiiVEt Company
Koht.Waykk. Imhiama-
Professional Protection Exclusively
since 1899
DETROIT Office
George A. Triplett and Richard K. Wind
Representatives
2405 West McNichols Road
Telephone University 2-8064
'
_
M.D. LOCATIONS
Through June 1, 1957
Placed by Michigan
Health Council
Bert R. Richey, M.D.
Stanley Michael, M.D.
Robert Helmich, M.D.
Leonard Koch, M.D.
Findlay C. Crowe, M.D.
Robert Southworth. M.D.
Assisted by Michigan
Health Council
Robert Riethmiller, M.D.
Milton Hoffman, M.D.
Joseph Schirle, M.D.
John H. Williams, M.D.
James A. Martin, M.D.
Daniel Heffernan, M.D.
L. Edmond Eary, M.D.
Henry N. Smit, M.D.
Joseph C. Brown, M.D.
Location
Addison
Elk Rapids
Detroit
(Residency)
Detroit
(Residency)
White Cloud
Coldwater
Location
Detroit
Detroit
Pontiac
(Waterford Township)
Grosse Pointe
Fenton
Midland
Sparta
Holland
Manistique
Since 1900 heart disease has become more than ever
a disease of middle and old age, Health Information
Foundation says. Today about 70 per cent of all deaths
from this disease takes place at ages sixty-five and over,
and another 25 per cent between the ages of forty-five
and sixty-four.
MERC Y WOOD SANITARIUM
Conducted by Sisters of Mercy
Treatment for Mild Nervous and Mental Disorders
JACKSON ROAD ANN ARBOR, MICHIGAN
NOrmandy 3-8571
930
Say you saw it in the Journal of the Michigan State Medical Society
JMSMf
THE DOCTOR’S LIBRARY
THE DOCTOR’S LIBRARY
Acknowledgments of all books received will be made in this column ,
and this will be deemed by us as full compensation to those
sending them. A selection will be made for review , as expedient.
THE RIDDLE OF STUTTERING. By C. S. Bluemel,
M.D., Fellow of the American College of Physicians;
Fellow of the American Psychiatric Association; Fel-
low of the American Speech and Hearing Association.
Printed in the United States of America. Danville,
Illinois: The Interstate Publishing Company, 1957.
Hard binding, $3.50; paper binding $1.50; Therapy
Records. $3.00.
The difference and distinction between stammering
and stuttering is explained, mostly with usage in Eng-
land and the United States. The theory of causation
and control, and the methods of correction are given
clearly and carefully. This is the best exposition we have
seen of a very discouraging condition.
Stuttering is now recognized as a phase of mental
abberation, a defect of balance and nerve reaction.
Relaxation, deliberation, and soft speech seem to be
necessary in treatment, results and improvement.
DISEASES OF THE NOSE, THROAT AND EAR. By
Howard Charles Ballenger, M.D., F.A.C.S., Professor
Emeritus of the Department of Otolaryngology,
Northwestern University Medical School, Chicago;
Surgeon, Department of Otolaryngology, Evanston
Hospital, Evanston, Illinois, and John Jacob Ballenger,
B.S., M.S., M.D., Associate in the Department of
Otolaryngology, Northwestern University Medical
School, Chicago ; Associate Surgeon, Department of
Otolaryngology, Evanston Hospital, Evanston, Illinois.
Tenth edition, thoroughly revised; with 550 illus-
trations and 11 plates. Philadelphia: Lea & Febiger,
1957. Price $17.50.
The reviewer, in evaluating this book, referred to the
the second edition of “Ballenger” published in 1909 by
William Lincoln Ballenger which he used extensively.
The present authors, who are of the second and third
generations, have followed the lead established so many
years ago and have largely rewritten many sections.
Just as the other editions have been, this present book
is printed in very clear, good, readable type and is very
practical. We like it.
PROCEEDINGS OF THE THIRD NATIONAL CAN-
CER CONFERENCE. Detroit, Michigan, June 4-6,
1956. Sponsored by American Cancer Society, Inc.,
and National Cancer Institute, U. S. Public Health
Service. Philadelphia and Montreal: J. B. Lippin-
cott Company, 1956. Price $9.00.
This presentation of the papers and symposia of the
Third National Cancer Conference is an excellent source
of information for the latest concepts of cancer etiology,
natural history, hormonal relationships and therapy.
The first portion of the conference deals with general
information of cancer including a presentation of the
virus etiology of cancer by Dr. Wendell M. Stanley,
University of California. The remaining and major
July, 1957
portion of this volume deals with all aspects of most of
the common types of cancer.
Discussion of the rationale and efficacy of modes of
therapy assumes a prominent part in the presentation.
In cancer of the breast and prostate, hormonal relation-
ships and effects are thoroughly discussed and the proce-
dures of adrenalectomy and hypophysectomy are evalu-
ated. The volume contains a well presented symposium
on lymphomas and leukemias and a very interesting
symposium on the chemotherapy of cancer.
Other symposia are presented on cancer of the lung,
head and neck, female genital tract and the gastro-
intestinal tract.
The final symposium of the meeting is concerned with
the end results of the treatment of cancer. These results
are concise. Charts and, diagrams are used to advantage
but are not used excessively. In bringing the matter of
cancer treatment up to date, the conference has done
an effective job.
J.W.H.
SOYBEANS. For Health, Longevitv and Economy. By
Philip S. Chen, Ph.D., Professor of Chemistry, Atlantic
Union College, with the assistance of Helen D. Chen,
M.A., National Science Foundation Fellow, Cornell
University. Illustrated. South Lancaster, Massa-
chusetts: The Chemical Elements, 1957. Price $3.00.
Dr. Chen gives a very complete discussion of soybeans,
their culture, prevalence in various parts of the world,
and use as a food for both humans and animals. He
discusses a number of disease conditions which are
SAMMOND PLEASANT LODGE
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rolling grounds, scientifically prepared tasty
meals, congenial companionship. A real
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the Lodge.
For further information write to:
SAMMOND PLEASANT LODGE
124 West Gates Street
Romeo. Michigan
Say you saw it in the Journal of the Michigan State Medical Society
931
THE DOCTOR’S LIBRARY
benefited, mentioning especially the use of soybeans or of
lecithin, an extract, which is of the vitamin variety, in
holding down high blood pressure through its action in
cholesterol. He gives a great many recipes for preparing
the foods and lists many of these foods which are on
the market in various places. Diabetes seems to be
well controlled by soy products.
SURGERY. Principles and Practice. By J. Garrott
Allen, M.D., Professor of Surgery, University of Chi-
cago; Henry N. Harkins, M.D., Ph D., Professor of
Surgery, University of Washington School of Medi-
cine; Carl A. Moyer, M.D., Bixby Professor of Sur-
gery, Washington University School of Medicin°, St.
Louis; Jonathon E. Rhoads, M.D., D.Sc. (Med.),
Professor of Surgery, University of Pennsylvania
School of Medicine and Graduate School of Medicine,
Philadelphia. Philadelphia and Montreal: J. B. Lip-
pincott Company, 1957. Price $16.00.
This is the first edition of a new surgical textbook.
That it is an excellent work and fills some obvious voids
in the current surgical texts becomes more evident as
each chapter is reviewed. Perhaps the highest compli-
ment which could be afforded the authors would be
that of achieving their objectives in writing the text.
These objectives, as stated by the authors and sum-
marized by the publisher, are:
to answer the need for a textbook in surgery, giving
stronger emphasis to basic material in physiology, ana-
tomy, biochemistry and pathology;
to provide in a single volume a thoroughgoing intro-
duction to surgery and the surgical specialties;
to encourage open-mindedness and stimulate research
through a philosophy of surgery which stresses the fact
that surgery is an art as well as a science, and that
in acquiring that art one can never stop learning;
to emphasize contemporary surgery — especially in the
fields of cardiac, vascular and military surgery;
to point up principles rather than concentrate on
minute details;
to cover the physiologic bases of surgical practice in
such a way that the text will serve the resident as a
useful reference in matters of nonoperative care — fluid
therapy, shock, blood transfusions, nutrition — while he
learns his techniques by actual observation and experi-
932
WOLVERINE
the GOODWILL
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ence ;
to outline the pros and cons of surgical treatment as
therapy for a number of important conditions.
D rs. Allen, Harkins, Moyer and Rhoads have success-
fully fulfilled their objectives. Approximately one-half
of the book is written by these authors and the re-
mainder by selected specialists in the different fields.
These men have brought the basic sciences, surgical
technique and the basic surgical principles into a proper
relationship. This text is a welcome addition to the
surgical literature.
R.M.
THE CIBA COLLECTION OF MEDICAL ILLUS-
TRATIONS. Volume 3. A Compilation of Paintings
on the Normal and Pathologic Anatomy of the Di-
gestive System. Part III. Liver, Biliary Tract and
Pancreas. Prepared by Frank H. Netter, M.D.
Edited by Ernst Oppenheimer, M.D. 133 color
plates. Summit, N. J.: The Ciba Company, 1957.
Price $13.00.
The Ciba Company, as a means of enlightened ad- ,
vertising, has for many years distributed to physicians
and medical students, loose-leaf portfolios containing
full color illustrations of normal and pathologic anatomy
painted by Dr. Frank H. Netter. In 1953, the Ciba
Company made arrangements with Dr. Netter to por-
tray, in desirable detail, the major anatomy and pathol-
ogy of all the systems comprising the human organism
and to devote a separate volume of “The Ciba Collec-
tion of Medical Illustrations” to each system. This
particular book, Part III of Volume 3, “Digestive
System,” is edited by Dr. Ernst Oppenheimer. A
concise, descriptive text accompanies each of the full
color plates that illustrate the essential anatomic, func- j
tional and pathologic features of the “large glands of
the digestive apparatus.” A new feature, the bibliog-
raphy, contains over 300 references. The bibliography I
is by no means complete; it was added only as a con-
venience for those interested in checking or following
up certain novel or complex points, which, owing to
Say you saw it in the Journal of the Michigan State Medical Society
JMSMS
THE DOCTOR’S LIBRARY
IFORT 1 A U ID IE RID A l
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GERIATRICS (care of the aging)
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CHRONICALLY ILL, the AGED, and the HANDICAPPED.
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Patients accepted for long or short term care under direction of private physician.
MEDICAL RESIDENT STAFF
FOR information write to
Louis L. Amato, M.D., Medical Director Kenneth A. Dahl, Administrator
e restricted space available for the text, had to be
scussed in a very compact manner.
The Ciba Company, the editor, Dr. E. Oppenheimer,
d the artist, Dr. F. Netter, are to be congratulated
producing a remarkably useful book. It is recom-
:nded for students, internists and surgeons alike.
J. W. Hubly, M.D.
HE COMPLEAT PEDIATRICIAN. Practical, Diag-
nostic, Therapeutic, and Preventive Pediatrics. For
the Use of General Practitioners, Pediatricians, In-
terns, and Medical Students. By Wilburt C. Davison,
M.A., D.Sc., LL.D., M.D., James B. Duke, Professor
of Pediatrics, Duke University School of Medicine,
and Pediatrician, Duke Hospital, Formerly Acting
Head of Department of Pediatrics, The Johns Hopkins
University School of Medicine, Acting Pediatrician
in Charge, The Johns Hopkins Hospital, and Mem-
ber American Board of Pediatrics, Honorary Mem-
ber American Academy of General Practice, Fellow
American Academy of Pediatrics and American Col-
lege of Physicians, Member American Pediatric So-
ciety, and Division of Medical Sciences, National Re-
search Council, and Jeana Davison Levinthal, B.A.,
M.D., Instructor in Pediatrics, University of Michi-
gan School of Medicine. Seventh Edition, Completely
rewritten. Durham, N. C.; Printed by Seeman Print-
ery for Duke University Press, 1957. Price $4.50.
This seventh edition is really a new book. The re-
tting has brought it up to date with fresh material
antibiotics steroids and electrolytes. The book could
>ily be a one-volume library for any pediatrician.
R.L.L.
A WOMAN DOCTOR LOOKS AT LOVE AND LIFE.
By Marion Hilliard, M.D. Garden City, New York:
Doubleday & Company, Inc., 1957. Price $2.95.
This is a book written in a sympathetic and under-
standing manner by a woman who is also a doctor and
who, over the years, has developed a very practical
philosophy of living which she attempts to impart to
her readers. She believes in inevitability, inevitability
of living, of being human, of change, of marriage, and
sometimes even of failure.
This book is her attempt to help women to know
and understand what it means to be female, feeling
that understanding will ultimately bring contentment.
She discusses frankly and realistically the problems as-
sociated with a woman’s first baby, how to tell children
the facts of life, problems of adolescence, monotony in
everyday living, fears which confront women, fatigue,
and old age, plus many other helpful discussions.
The author feels that faith is the antidote for
wretchedness and loneliness. With faith comes love, and
love returns love, something you can’t buy, demand, or
expect — but must give, and once given, it never dis-
appears.
NEW AND NONOFFICIAL REMEDIES. Containing
Descriptions of Drugs Evaluated By the Council on
Pharmacy and Chemistry of the American Medical
Association 1957. An Annual Publication Issued Un-
der the Direction and Supervision of the Council.
The HAVEN SANITARIUM,
Rochester, Michigan
In operation since 1932
M. O. Wolfe, M.D. Ralph S. Green, M.D.
Director of Psychotherapy Clinical Director
A private psychiatric hospital for the intensive treatment
of mental and emotional illnesses.
Telephone: OLive 1-9441
Inc.
Graham Shinnick
Manager
ly, 1957
Say you saw it in the Journal of the Michigan State Medical Society
933
THE DOCTOR’S LIBRARY
PlaiHtoell
5 ahitariutn
PLAINWELL, MICHIGAN
Member American Hospital Association
EDWIN M. WILLIAMSON, M.D.
Psychiatrist-in-Chief
Professional care for the nervous
and mentally ill.
Telephone MUrray 5-8441
Restful Six-acre Estate Overlooking the Kalamazoo River
Philadelphia and Montreal: J. B. Lippincott Com-
pany, 1957.
This new edition is bigger and better than ever.
BOOKS RECEIVED
A MONOGRAPH FOR THE PHYSICIAN: CANCER
OF THE COLON AND RECTUM. Tenth of a
Series on the Early Recognition of Cancer. By Fred-
erick A. Coller, M.D., Professor of Surgery and
Chairman, Department of Surgery, University of
Michigan, Ann Arbor, Michigan. Assisted by Henry
K. Ransom, M.D., and William J. Regan, Jr., M.D.,
American Cancer Society, Inc., 1957.
Classified Advertising
$2.50 per insertion of fifty words or less, with an
additional five cents per word in excess of fifty.
ALLERGY PRACTICE FOR SALE: Splendid oppo:
tunity for some physician who desires to take u
allergy as a specialty. Allergist retiring because (
illness. Practice for sale in a Michigan city of 175,001
Gross cash income $50,000 annually. Would remai
with purchaser sufficiently long for him to becom
familiar with the work. Reply Box 3, 606 Townsen
Street, Lansing 15, Michigan.
VEGETABLE OILS IN NUTRITION. With special WANTED: Young, ambitious general practitioner, fc
reference to unsaturated fatty acids. By Dorothy a private partnership practice with middle aged e
M. Rathmann, Ph.D., Multiple Fellowship of Corn tablished general practitioner in center of progre
Products Refining Company, Mellon Institute, Pitts- sive farming communities. Excellent opportunity
burgh 13, Pa. Published by the Corn Products Re- and hospital facilities. Reply Box No. 1, 606 Towi
fining Company, 17 Battery Place, New York 4, send Street, Lansing 15, Michigan.
N. Y.
THE FORD FOUNDATION ANNUAL REPORT,
MEDICAL SERVICES FOR RURAL AREAS. The
Tennessee Medical Foundation. By William A. Mas-
sie, Chairman, Health Committee, Council of the
Southern Mountains, formerly Field Secretary, The
Tennessee Medical Foundation. Published for The
Commonwealth Fund. Cambridge, Massachusetts:
Harvard University Press, 1957. Price $1.25.
PHYSICIANS AND PSYCHIATRISTS
FOR CALIFORNIA
State Hospitals, correctional facilities and veterans
home. No written examination. Interview only . . .
Three salary groups:
$10,860 to $12,000
$11,400 to $12,600
$12,600 to $13,800
Salary Increases being considered effective July 7957
U. S. citizenship and possession of, or eligibility for
California license required.
Write: Medical Recruitment Unit, Box A, State Personnel
Board, 801 Capitol Ave., Sacramento, California
DENTIST — 1955 LTniversity of Michigan graduate-
being discharged from service in October would lil
to share an office location with a physician in suburba
Detroit area. Kindly contact Capt. Bruce Bille
1607th USAF Hospital, Dover AFB, Delaware.
OBSTETRICIAN - GYNECOLOGIST, Pediatriciai
Ophthalmologist, Board eligible or certified, to joi
14-man group in metropolitan Detroit. $14,00(
$16,000. Lakeside Medical Center, 987 E. Jefferso
Avenue, Detroit 7, Michigan.
OFFICE SPACE AVAILABLE in new building i
down-river area, Detroit, Michigan. Pleasant su
roundings, common waiting room with two establishe
M.D.s. Phone AVenue 2-6612.
LOCUM TENENS WANTED: Three to four week
Former Michigan practitioner, now in Surgical Res
dency. 1952 graduate. Reply: B. F. Shockley, M.D
6601 W. Clarke Street, Wauwatosa 13, Wisconsii
Phone Spring 4-5368.
ALLERGIST in Southern Michigan seeking permaner
associate. Purpose: eventual retirement. Excellei
opportunity for competent ambitious applicant. Write
G. L. Waldbott, M.D., 2930 W. Grand Blvd., Detro
2, Michigan.
934
Say you saw it in the Journal of the Michigan State Medical Society
JMSM
THE JOURNAL
of the Michigan State Medical Society
V OLUME 56 AUGUST, 1957 NUMBER 8
Contributors to This Issue
J. A. Cowan, M.D.
S. E. Miller, M.D.
F. D. Murphy, M.D.
Saul Sakwa, M.D.
C. H. Ross, M.D.
Milton Sorock, M.D.
Table of Contents
Upper Peninsula Medical Society — Sixty-Fourth An-
nual Session 985
History of the Houghton County Medical Society
Simon Levin, M.D 987
Diagnosis and Treatment of Acute Coronary Disease
Francis D. Murphy, B.S., M.D., M.S. (Med.)
F.C.A.P 988
Abstracts of Papers Presented — Upper Peninsula
Medical Society 993
Preoperative Cholangiography as a Routine Proced-
ure in Biliary Tract Surgery
Saul Sakwa, M.D., and Milton L. Sorock, M.D. 995
Geriatric Rehabilitation
C. Howard Ross, M.D 1000
Current Trends in Occupational Health
Seward E. Miller, M.D 1009
The Problem of the Biologic False Positive Serologic
Test for Syphilis
John A. Cowan, M.D., M.S.P.H 1013
President’s Message:
Keeping the Medical Profession Oriented on
Public Opinion 1017
Editorial:
Upper Peninsula Medical Society 1018
Profession at Bay 1018
The Vanished “Physician” 1019
Medicine and Socialism 1019
Promising Forward Steps 1020
The Role of the Doctor in Blue Shield 1021
Conference of Presidents 1021
Michigan State Medical Society — 92nd Annual
Session :
Officers Night Dinner Dance 1023
State Society Night 1024
Meetings of Ancillary Groups 1025
Woman’s Auxiliary Program 1025
Michigan Medical Assistants Society Program 1027
Scientific Exhibits 1027
Annual Reports 1028
Technical Exhibits 1048
Michigan’s Department of Health 1058
In Memoriam 1060
News Medical 1061
The Doctor’s Library 1071
Communication 1074
You and Your Business 948
AMA Washington Letter 956
Fifty-year Club in Tenth Year 958
AMA News Notes 960
Half Million Persons Reached by MSMS Study 962
Editorial Opinion 966
Medical Meetings and Clinic Days 972
© 1957 by Michigan State Medical Society
Wgust, 1957
939
THE JOURNAL
of the Michigan State Medical Society
-VOLUME 56 AUGUST, 1957 NUMBER 8
PUBLICATION COMMITTEE
G. B. SALTONSTALL, M.D., Chairman Charlevoix
WILLIAM BROMME, M.D Detroit
B. M. HARRIS, M.D Ypsilanti
O. B. McGILLICUDDY, M.D Lansing
W. S. STINSON, M.D Bay City
T. P. WICKLIFFE, M.D Calumet
Office of Publication
2642 University Avenue
Saint Paul 14, Minnesota
Editor
WILFRID HAUGHEY, M.D.
610 Post Bldg., Battle Creek, Michigan
Assistant Editor
L. J. BAILEY. M.D.
620 Vinewood Avenue, Birmingham, Michigan
Secretary and Business Manager of THE JOURNAL
L. FERNALD FOSTER, M.D.
441 E. Jefferson, Detroit, Michigan
Executive Director
WM. J. BURNS, LL.B.
606 Townsend Street, Lansing 15, Michigan
All communications relative to exchanges, books for review, manu-
scripts, should be addressed to Wilfrid Haughey, M.D., 610 Post
Bldg.. Battle Creek, Michigan.
All communications regarding advertising and subscription should
be addressed to Wm. J. Burns, 2642 University Avenue, Saint
Paul 14, Minnesota, or 606 Townsend Street, Lansing 15, Michigan.
Telephone Ivanhoe 57125.
© 1957, by Michigan State Medical Society.
Published monthly by the Michigan State Medical Society as its
official journal at 2642 University Avenue, Saint Paul 14, Minnesota.
Entered at the post office at Saint Paul, Minnesota, as second
class matter. May 7, 1930, under the Act of March 3, 1879.
Acceptance for mailing at special rate of postage provided for
in Section 1103 Act of October 3, 1917, authorized August 7, 1918.
Yearly subscription rate, $6.00; single copies, 60 cents. Additional
postage; Canada, $1.00 per year; Pan-American Union, $2.50 per
year; Foreign, $2.50 per year.
PRINTED IN U.S.A.
OFFICERS OF THE SOCIETY
1956-1957
President ARCH WALLS, M.D Detroit
President-Elect G. W. SLAGLE M.D Batde Creek
Secretary L. FERNALD FOSTER, M.D Detroit
Treasurer W. A. HYLAND, M.D .Grand Rapids
Speaker K. H. JOHNSON, M.D Lansing
Vice Speaker J. J. LIGHTBODY, M.D Detroit
Editor WILFRID HAUGHEY, M.D Battle Creek
THE COUNCIL
D. BRUCE WILEY, M.D., Chairman, Utica
W. B. HARM, M.D., Vice Chairman, Detroit
L. FERNALD FOSTER, M.D., Secretary, Bay City
Term
District Expires
A. E. SCHILLER, M.D 1st Detroit 1961
O. B. McGILLICUDDY, M.D 2nd Lansing 1960
H. J. MEIER, M.D 3rd Coldwater 1960
RALPH W. SHOOK, M.D 4th Kalamazoo 1961
C. ALLEN PAYNE, M.D 5th Grand Rapids 1961
II. H. HISCOCK, M.D 6th Flint 1961
H. B. ZEMMER, M.D 7th Lapeer 1957
L. C. HARVIE, M.D 8th Saginaw 1957
G. B. SALTONSTALL, M.D 9th Charlevoix 1957
W. S. STINSON, M.D 10th Bay City 1957
W. M. LeFEVRE. M.D 11th Muskegon 1958
B. T. MONTGOMERY, M.D 12th Sault Ste. Marie....l958
T. P. WICKLIFFE, M.D 13th Calumet 1959
B. M. HARRIS, M.D 14th Ypsilanti 1959
D. BRUCE WILEY, M.D 15th Utica 1960
G. THOMAS McKEAN. M.D 16th Detroit 1960
W. B. HARM, M.D 17th Detroit 1958
WILLIAM BROMME, M.D 18th Detroit 1959
ARCH WALLS, M.D President Detroit
G. W. SLAGLE, M.D President-Elect Battle Creek
K. H. JOHNSON, M.D Speaker Lansing
J. J. LIGHTBODY, M.D Vice Speaker Detroit
L. FERNALD FOSTER, M.D Secretary Detroit
W. A. HYLAND, M.D Treasurer Grand Rapids
W. S. JONES, M.D Past President Menominee
EXECUTIVE COMMITTEE OF THE COUNCIL
D. BRUCE WILEY, M.D Chairman
W. B. HARM, M.D Vice Chairman
W. M. LeFEVRE, M.D Chairman. County Societies Committee
G. B. SALTONSTALL, M.D Chairman, Publication Committee
RALPH W. SHOOK, M.D Chairman, Finance Committee
K. H. JOHNSON, M.D Speaker, House of Delegates
J. J. LIGHTBODY, M.D Vice Speaker, House of Delegates
ARCH WALLS, M.D President
G. W. SLAGLE, M.D President-Elect
L. FERNALD FOSTER, M.D Secretary
W. A. HYLAND, M.D Treasurer
Dermatology and
Wm. T. Kruse, M.D
Chairman
Coleman Mopper, M.D...
Secretary
Syphilology
Grand Rapids
Detroit
Gastroenterology and Proctology
N. D. Nigro, M.D Detroit 1
Chairman
E« J- Tallant, M.D Detroit
Secretary
General Practice
F. P. Rhoades, M.D Detroit 2
Chairman
F. C. Brace, M.D Grand Rapids
Secretary
Gynecology and Obstetrics
J* Beaton, M.D Grand Rapids
Chairman
R. W. McClure, M.D Detroit 26
Secretary
Medicine
J. M. Kaufman, M.D Detroit 26
Chairman
J. W. Hall, M.D Traverse City
Set retary
SECTION OFFICERS
Nervous and Mental Diseases
W. R. Slenger, M.D Ann Arbor
Chairman
S. C. Mason, M.D Ann Arbor
Secretary
Occupational Health
O. J. Johnson, M.D Bay City
Chairman
P. B. Rastello, M.D Detroit 9
Secretary
Ophthalmology and Otolaryngology
B. C. Wildgen, M.D Muskegon
Chairman (Ophth.)
W. K. Locklin, M.D Kalamazoo
Co-Chairman (Oto.)
H. A. Dunlap. M.D Detroit 14
Secretary (Ophth.)
H. L. LeVett, M.D Lansing
Co-Secretary (Oto.)
Pediatrics
C. E. Booher, M.D Grand Rapids
Chairman
A. M. Hill, M.D Grand Rapids
Secretary
Public Health and Preventive
Medicine
J. D. Monroe, M.D Pontiat
Chairman
J. K. Altland, M.D Lansing *
Secretary
Radiology, Pathology, Anesthesiology
R. B. Sweet. M.D Ann Arbo
Chairman (Anes.)
E. R. Jennings. M.D Detroi
Vice-Chairman (Path.)
E. O. Pearson. M.D Kalamazo
Secretary (Rad.)
Surgery
E. T. Thieme, M.D Ann Arbo
Chairman
H. M. Bishop, M.D Saginaw
Secretary
Urology
R. P. Lytle, M.D Detroit
Chairman
J. F. Harrold, M.D Lansin
Secretary
Delegates
W. A. Hyland, M.D., Grand Rapids, Chairman.
J. S. DeTar, M.D., Milan
£. I- Owen, M.D., Detroit
W. D. Barrett, M.D., Detroit
^ Huron, M.D.. Iron Mountain
R. L. Novy, M.D., Detroit
DELEGATES
1957
1957
1957
1958
1958
1958
Section
G. C. Penberthy, M.D. (Surgical
TO A. M. A. Alternates
W. W. Babcock, M.D., Detroit
E. F. Sladek, M.D., Traverse City
O- J. Johnson, M.D.. Bay City
William Bromme, M.D.. Detroit
J. R. Rodger, M.D., Bellaire
G. W. Slagle, M.D., Battle Creek
Delegate
Section) Detroit
.195
195
.195
195
.195
195
940
JMSM
NEW SANBORN
MODEL. 300
full diagnostic accuracy "in “ brief case*’ size
Growing use of the ECG in cardiovascu-
lar work means more locations in which
’cardiograms are being run: in your office
... at your patient’s home ... in hospital
heart stations, laboratories, wards. This im-
mediately focuses attention on instrument
portability — and the obvious value of the
new Sanborn Model 300 VISETTE.
For the first time — in "brief case” size —
is everything needed to take a ’cardiogram
of full clinical accuracy. This remarkable
new transistorized direct writer incorporates
all the best features of earlier Sanborn in-
struments developed over the past 33 years
— plus extremely light weight (18 pounds)
and small size (12 Vs" x 10'i" x 5/4") made
possible by original design and modern
electronic components. New in the "300”,
SANBORN COMPANY
175 WYMAN STREET, WALTHAM 54, MASS.
Detroit Branch Office 13136 Puritan Ave., University 4-6336, 4-6337
too, are such operating advantages as fully
automatic, "one hand” Instomatic action;
automatic "push button” grounding; even
simpler chart loading; and interlock switch
to prevent closing cover with power on.
The doctor with the active cardiac
practice will particularly appreciate these
VISETTE features; but wherever this mod-
ern ECG is used, "convenience” will be the
characteristic by-word. Ask your Sanborn
Representative for full VISETTE informa-
tion, and a demonstration in your office, of
this modern, moderately priced instrument.
The established Sanborn Model 51
Viso-Cardiette is still available for those
who prefer a larger, heavier (34 lbs.) instru-
ment—$785, delivered.
18 lbs,
TRANSISTORIZED
$625 del
'gust, 1957
Say you saw it in the Journal of the Michigan State Medical Society
947
You and Your Business
OFFICERS’ NIGHT DINNER DANCE—
WEDNESDAY, SEPTEMBER 25
You have a date with your lady at the 1957
MSMS Officers Night Dinner Dance, in the Ball-
room of the Pantlind Hotel, Grand Rapids, on
September 25.
The Officers Night Dinner Dance is the top
social feature of the MSMS Annual Session. This
gala party was originated at last year’s Annual
Session in Detroit.
Sponsored by the State Society and its Woman’s
Auxiliary, the subscription dinner is for all mem-
bers of the Michigan State Medical Society, their
ladies, and guests. Those who attend this informal
affair will experience a gay evening of good fellow-
ship and pleasure.
Governor G. Mennen Williams will be guest
speaker at the banquet.
Invitations to all members, with detailed infor-
mation on the interesting program, will be mailed
early in August. Tables may be reserved in groups
of six or eight. Individual reservations also are
invited.
AMEF CHAIRMAN FOR MICHIGAN
C. E. Umphrey, M.D., De-
troit, is the new Michigan
Chairman for the American
Medical Education Founda-
tion, the national fund through
which doctors of medicine are
supporting American medical
schools.
A Past President of the
Michigan State Medical So-
ciety and of the Wayne County
Medical Society, Dr. Umphrey
has assumed his AMEF Chairmanship with his
usual vigor. His first message to all MSMS mem-
bers appeared in last month’s Journal.
Dr. Umphrey invites all doctors of medicine to
look on the AMEF as their own personally chosen
agency to aid them in the judicious administration
of funds necessary for the continuation of the
medical schools of America. The AMEF is a
constant reminder to every doctor of medicine of
his debt to his alma mater and to society for his
present advantages as a practitioner of medicine.
Contributions to A.M.E.F. may be made gener-
ally or be specifically earmarked for one or more
medical schools. Address contributions to C. E.
Umphrey, M.D., Chairman, 15300 W. McNichols
Road, Detroit — and make checks payable to
American Medical Education Foundation.
HIGHLIGHTS OF EXECUTIVE
COMMITTEE OF THE COUNCIL
Meeting of June 20, 1957
• MSMS Market-Opinion Study of Medical Pre-
payment Plans. — Progress report was present-
ed including gratifying information that the
Detroit News and the Detroit Times (total cir-
culation 1,100,000) would feature this MSMS
Survey in their Sunday, July 14, editions anc
would publish the questionnaire and urge the
public to execute it. The additional expense t<
meet this expansion of the Survey was author-
ized.
The Annual Report of the Committee tc
Study Comprehensive Prepayment Plan
(created by 1956 House of Delegates) may be
used as addendum to the Market-Opinion Sur
vey, as well as any other studies or survey
having value to the medical profession o
Michigan and to their patients.
• Medicare. — According to priority among thi
states, the re-negotiation of the Medicare con
tract must be extended to March 31, 1958
Explanation of the necessity for this extensioi
is to be published in the Secretary’s letter t<
all members, which also will invite sugges
tions from individual members to improve th
Medicare program.
• VA Hometown Medical Care Program. — Re
port on final negotiations with the VA wer
made and the Executive Committee of Th
Council authorized Michigan Medical Servic
to sign the contract effective July 1, 1957.
Letters from the Michigan Society of In
ternal Medicine on Medicare and fee schedule
were read, discussed, and referred to the Sec
retary for reply.
• Speaker K. H. Johnson, M.D., announced th
personnel of the Permanent Committee o
Fees, a committee created by the House <
Delegates: Grover C. Penberthy, M.D., Dc
troit, Chairman; Joseph F. Beer, M.D., S
Clair; M. A. Darling, M.D., Detroit; Hard
F. Falls, M.D., Ann Arbor; W. M. LeFevr
M.D., Muskegon; and M. L. Lichter, M.D
Melvindale.
• Site Committee. — The interim report of ff
Site Committee introduced the necessity f<
erecting the new MSMS Headquarters buildir
as soon as possible — to escape rising buildir
costs. The earmarking of $10.00 for the MSM
building, instead of the present $5.00, w;
referred to The Council in July for decision.
• K. H. Johnson, M.D., Lansing, was selectc
(Continued on Page 950)
948
JMSft
$ls the seals of fiood Housekeeping Magazine, Parents Magazine, Rice Leaders
derwriters' Laboratories, and is advpflTsed in the A.M.A.'s "Today's Health.”
Lueen c;
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YOU AND YOUR BUSINESS
HIGHLIGHTS OF THE COUNCIL
(Continued from Page 948)
as Chairman of the Testimonial Luncheon for
Michigan M.D.’s who are presidents of na-
tional medical and health societies, to be held
during 1958 Michigan Clinical Institute in
Detroit.
• Ralph W. Shook, M.D., was appointed as offi-
cial MSMS representative to the National Con-
vention of Medical Assistants, October 4-6.
• The report on the June, 1957, AMA meeting,
New York City, was presented by the Chair-
man of the Michigan delegation, William A.
Hyland, M.D., Grand Rapids.
• Financial Reports for the month and bills pay-
able were approved.
• Appointments. — M. L. Lichter, M.D., Melvin -
dale, was appointed Chairman of the MSMS
Committee on National Defense to fill the
place left vacant by the death of W. H. Gor-
don, M.D.; Josef S. Rozan, M.D., Lansing, was
appointed as MSMS representative to the
Multiple Sclerosis Center Advisory Commit-
tee.
• Committee Reports. — The following commit-
tee reports were presented: (1) Child Welfare
Committee, meeting of May 1; (2) MCI Com-
mittee on Arrangements, May 16, and MCI
Program Committee, May 28; (3) Rheumatic
Fever Control Committee, May 22; (4) Con-
ference on Rehabilitation-Planning Commit-
tee, May 22; (5) Permanent Conference Com-
mittee, May 22; (6) Study Committee on
Package Arrangements between County Med-
ical Societies and Local Welfare Departments,
May 22; (7) Mental Health Committee, May
23; (8) Postgraduate Medical Education Com-
mittee, May 24; (9) Ethics Committee, June
13; (10) Liaison Committee with University of
Michigan, May 15; (11) State Bar Commit-
tee on Medical-Legal Problems, April 27.
• A vote of thanks was extended to Dr. & Mrs.
T. P. Wickliffe, Calumet, for their hospitality
to the members of the Executive Committee
on the occasion of this meeting.
DANGER OF HEAT INJURY
TO RESERVISTS
More than 1,000 cases of heat injury occur
each year in Army personnel, and most cases are
preventable, according to Maj. Gen. Silas B. Hays,
Army Surgeon General.
Heat injury includes heat cramps, heat exhaus-
tion, and heat stroke. Although only a few deaths
occur following heat stroke, where death does not
occur, the individual may thereafter have a low
tolerance for heat conditions, the General said.
In an effort to reduce the number of heat cas-
ualties among Army reserve components during
the summer months under this year’s intensified
training schedule, the Department of the Army has
issued a circular on prevention of heat injury.
The new directive, Circular 40-8, prepared by the
staff of the Office of the Army Surgeon General,
requires that recruits not accustomed to physical
activity under conditions of hieh temperatures and
humidity should be acclimatized to these conditions
by graduated exposure and gradual increase in
workload, particularly during basic training.
In addition to heat injury prevention measures
mentioned in the Circular, General Hays suggests
the following measures which should be applied by
supervisors and trainees:
The heavy meal of the day should be served in the
evening.
An hour of rest following the noon meal is beneficial.
Clothing and equipment should be worn loosely to
permit free circulation of air between the uniform and
body surface.
Water and salt should be consumed in sufficient
amounts to make up for that lost through perspiration.
Training schedules might be modified to place the
most strenuous activities during the cooler parts of the
day.
COURSE IN PATHOLOGY
The Department of Pathology of Harper Hos-
pital will offer a course in ultramicro chemical
methods adapted to hospital laboratory use, Oc-
tober 28 through October 31, 1957. This course
will be open to a limited number of pathologists,
biochemists, residents in pathology or technologists
sponsored by pathologists. Further information
may be obtained from Edwin M. Knights, Jr.,
M.D.. Department of Pathology, Harper Hospital.
NATIONS OLDEST ESSAY CONTEST
The trustees of America’s oldest medical essay
competition, the Caleb Fiske Prize of the Rhode
Island Medical Society, announce as the subject
for this year’s dissertation “Hormonal Relation-
ships in Breast and Prostatic Cancer — Their Prac-
tical Application.” The dissertation must be type-
written, double spaced, and should not exceed
10,000 words. A cash prize of $350 is offered.
Essays must be submitted by December 31, 1957.
For complete information regarding the regula-
tions write to the Secretary, Caleb Fiske Fund,
Rhode Island Medical Society, 106 Francis Street,
Providence 3, Rhode Island.
DISTRIBUTION OF U. S. EMPLOYES
Largest concentration of government workers
is in metropolitan Washington, of course — about
230.000. At close of 1956, state having largest
number was California, with 237,000. Next in
order: New York, 186,000; Pennsylvania, 134,-
000; Texas. 1 18.000. All other states had less than
100.000.
(Continued on Page 952)
950
JMSMS
optimal dosages for atarax,
based on thousands of case histories:
( t.i.d.)
TENSION SENILE ANXIETY MENOPAUSAL SYNDROME ANXIETY PREMENSTRUAL TENSION
PHOBIA HYPOCHONDRIASIS TICS FUNCTIONAL G. I. DISORDERS PRE-OPERATIVE ANXIETY
HYSTERIA PRENATAL ANXIETY • AND ADJUNCTIVELY IN CEREBRAL ARTERIOSCLEROSIS
PEPTIC ULCER HYPERTENSION COLITIS NEUROSES DYSPNEA INSOMNIA
PRURITIS ASTHMA ALCOHOLISM DERMATITIS PARKINSONISM PSORIASIS
perhaps the safest ataraxic known
P€AC€ OF MIND ATARAX
(BRAND OF HYOftOXYZINS)
Tablets-Syrup
Consider these 3 atarax advantages:
• 9 of every ID patients get release from tension,
without mental fogging
• extremely safe— no major toxicity is reported
• flexible medication, with tablet and syrup form
Supplied:
In tiny 10 mg. (orange) and 25 mg. (green)
tablets, bottles of 100.
atarax Syrup, 10 mg. per tsp., in pint bottles.
Prescription only.
\ugust, 1957
Say you saw it in the Journal of the Michigan State Medical Society
951
YOU AND YOUR BUSINESS
(Continued from Page 950)
NEW LAW CONSOLIDATES VET’S
MEDICAL BENEFITS
All Federal laws relating to hospitalization, med-
ical care, pensions and other benefits for veterans
or armed forces have been packaged. President
Eisenhower approved HR 53, the bill consolidat-
ing statutes administered by Veterans Administra-
tion. Within a compact 115-page booklet (of
which an excellent index accounts for twenty-one
pages), existing laws are set forth on compensable
diseases, presumption of service-connection, or-
ganization of VA’s Department of Medicine and
Surgery and salary scales of its personnel, com-
mitment procedures, et cetera.
PHYSICIANS AND DENTISTS LOANS
The physicians and dentists are now, since July
1, 1957, interested in the Small Business Adminis-
tration, which has so far limited its loans and
attention to retail and small industries. The
DMA. is now making loans available to doctors,
dentists, architects, lawyers and other professions
in private practice who wish to borrow money to
build or remodel offices, purchase equipment, or
for any constructive purpose. The Administra-
tion last year liberalized the scope of this activity
by helping construct proprietary hospitals and
nursing homes. This is not being especially pub-
licized ; last year there were only thirty applica-
tions for hospitals and nursing homes, amounting
in all to $2,622,950 — disappointing use.
NEW FISCAL YEAR
The Federal Government’s new fiscal year, 1957-
1958 sees some new law applications. For the first
time in seven years there is no doctor draft law,
it expired June 30, 1957. Also expiring was the
Salk polio vaccine assistance law. The final report
shows $53,200,000 spent, and 75,000,000 shots
given to 29,000,000 children and pregnant women.
It is estimated that as of June 21, there are eight
and a half million cubic centimeters in storage.
A new formula for assistance is in effect for per-
sons receiving public assistance, including dis-
ability insurance for persons over fifty years.
MICHIGAN’S VETERANS HOME TOWN
CARE PROGRAM
Effective July 1, 1957, with the approval of The
Council of the Michigan State Medical Society,
a new contract has been entered into with the Vet-
erans Administration. Michigan Medical Service
will continue to administer the program. Much
of the work formerly performed by Michigan
Medical Service will now be done by the Re-
gional Office of the Veterans Administration in
Detroit.
Some changes have been made relative to ob-
taining authorizations and billing for V.A. patients
with service-connected disabilities. In some cases
(Long Term-LT), you will receive one authoriza-
tion for the full year and in others, a new author-
ization will be required every month. This
monthly authorization must be requested from the
Veterans Administration Regional Office direct.
Their full fiscal year, or “Long Term authoriza-
tion,” as it is known, will have with it an “Invoice
for Medical and Ancillary Service” for each
month, and one quarterly report of medical treat-
ment form (10-2690A).
You should prepare one invoice form to report
each month’s services and it should be forwarded
to Michigan Medical Service, c/o Veterans De-
partment, 441 East Jefferson Avenue, Detroit 26,
Michigan, as payments for services will continue
to be made by Michigan Medical Service after
the V.A. advances the funds. This procedure may
slow up payments for services somewhat.
The quarterly report of medical treatment
should be sent to the Veterans Administration
direct.
Cases referred to as “short-term” will require
that you request a new authorization from the
V.A. each month. Upon your request to the V.A.,
on Form 10-2690C (“Request to Continue Treat-
ment”), you will receive from the V.A. Form
10-2567 (“Authorization for Medical and Ancil-
lary Services”), which you should complete and
return to Michigan Medical Service as at pres-
ent.
Each month, the same procedure is to be re-
peated.
Please be advised that the Veterans Adminis-
tration has approved a fee increase of $2.50 on
Code No. 9 106 A, X-ray, Chest, Flat Plate, effec-
tive July 1, 1957. The new fee is $7.50.
COSTS FOR MEDICAL CARE
PROPORTIONATE
A brief research report by Social Security Ad-
ministration (Division of Program Research) states
that, in 1955, out of every $100 of disposable per-
sonal income $4.14 was required to pay for medical
care. In 1948 the ratio was $3.89 per $100. In-
teresting sidelight: Despite great increase in hos-
pitalization insurance coverage since 1948, out-
of-pocket payments to hospitals have declined neg-
ligibly. Hospitals in 1955 were getting $1.24 for
every $100 of disposable income: 62 cents from
insurance and 62 cents direct from patients. This
compares with 89 cents per $100 in 1948, of which
24 cents came from insurance and remaining 65
cents from patients’ pockets.
Disorders of the heart, blood vessels and related or-
gans caused over 850,000 deaths last year — more than
half the total number of deaths in this country. Health
Information Foundation reports.
952
TMSMS
Comments on PATH I BAM ATE from clinical investigators
' enCdS : 1. Borrus, J. C.: M. Clin. North America,
;s, 1957. 2. Gillette, H. E.: Internat. Rec. Med. & G. P.
69:453, 1956. 3. Pennington, V. M.: J.A.M.A.,
>s, 1957. 4. Cayer, D.: Prolonged Anticholinergic
jy of Duodenal Ulcer. Am. J. Dig. Dis. 1 : 301-309
1956. 5. McGlone, F. B.: Personal Communication to
e Laboratories. 6. Texter, E. C., Jr.: Personal
lunication to Lederle Laboratories. 7. Bauer, H. G.
cGavack, T. H.: Personal Communication
erle Laboratories.
• “I find it easy to keep patients using the drug
continuously and faithfully. I feel sure this is due
to the desirable effect of the tranquilizing drug.”5
• “The results in several people who were pre-
viously on belladonna-phenobarbital prepara-
tions are particularly interesting. Several people
volunteered that they felt a great deal better on
the present medication and noted less of the
loginess associated with barbiturate administra-
tion.”6
• PATH I BAMATE . . .“will favorably influence a
majority of subjects suffering from various forms
of gastrointestinal neurosis in which spasmodic
manifestations and nervous tension are major
clinical symptoms.”7
died: Bottles of 100 and 1000
inistration and Dosage: 1 tablet three times a day
Jtimes and 2 tablets at bedtime. Full
lation on PATHIBAMATE available on request,
your local Lederle representative.
1F^
• “In the patients with functional disturbances of
the colon with a high emotional overlay, this has
been to date a most effective drug.”5
O
/ AzUr. /a J. aA~ . \
cS Oif - .
a
E
LEDERLE LABORATORIES DIVISION, AMERICAN CYANAMID COMPANY, PEARL RIVER, NEW YORK
AMA Washington Letter
THE MONTH IN WASHINGTON
The economy drive to the contrary notwith-
standing, health spending by the Department of
Health, Education, and Welfare for the fiscal year
that began this July already is assured of surpass-
ing last year’s record by some $33 million. This
assumes, of course, that no further requests will
be made by HEW for supplemental funds, a
practice common in government for many years.
Research programs were the most favored by
legislators, many of whom spoke out against fed-
eral spending by other agencies. But when the
health budget came up for debate, the economy
oratory subsided.
In only one instance was a health program cut
back. And to the surprise of many, it occurred in
the Senate which traditionally restores budget cuts
originating in the House. A sum of $45 million
was voted, instead of the House-approved $50
million, for grants to states for sewage treatment
works construction. But then the Senate wrote in
language permitting states to get their maximum
allotments a full year after the fiscal year ends.
The Hill-Burton hospital construction program
received $3.8 million less than last year but only
because the administration asked for $121.2 million
instead of the $125 million appropriated last year.
The National Cancer Institute received the larg-
est dollar increase of any health item in the budg-
et. The increment was $8 million over last year.
The administration had asked for $48.4 million,
the House voted $46.9 million, and the Senate
raised this to $58.5. It was finally compromised
at $56.4 million.
Congress obviously agreed with the views ex-
pressed by the Senate Appropriations Committee:
“ . . . the committee is fully aware that it is pro-
viding funds for cancer research, the outcome of
which is unknown. On the judgment of those who
are scientifically most competent, the committee is
fully willing to risk the investment on the ground
that the chance of a big payoff is a reasonable one.
Such risks are inherent in research.”
The Institute of Arthritis and Metabolic Dis-
eases fared well, too, getting a total of $20,385,000
compared with last year’s $17,885,000. And the
Senate Committee charged the institute with tak-
ing leadership in research on effects of radiation
on the human organism.
The Mental Health Institute’s spending has been
going steadily upward, and this year it was given
another boost with a final appropriation of $39,-
217,000, an increase of about $4 million. Other
research totals for the current year: National
Heart Institute, $35,936,000; Neurology and
956
Blindness Institute, $21,387,000; Allergy and In-
fectious Disease Institute, $17,400,000.
On only one score did the research advocates
lose out. The House view prevailed in conference
on the setting of a 15 per cent ceiling on additional
overhead costs allowed schools and other institu-
tions getting federal grants. This question which
drew considerable attention in hearings is likely
to be reopened. Congress wants a General Ac-
counting Office study by the end of this year.
In voting a $5 million increase (to $22,592,000)
for general public health assistance to the states,
Congress was reaffirming its support of helping lo-
cal health departments increase their professional
staffs and broaden their services. The Senate Com-
mittee report contained this significant language:
“. . . with a population increase of more than
20 million during the past decade, there are no
more organized health departments than there
were 10 years ago. This means that 18 million
people are living in areas with no full-time organ-
ized community health services, and millions more
live in areas where such services are only frag-
mentary.”
A few days later, the Public Health Service an-
nounced plans for a broad survey of rural health
needs, particularly in sparsely settled areas. It
picked for its first study Kit Carson County, Colo-
rado, an area known for its scattered farm popu-
lation, low income level and adverse climatic
conditions.
NOTES:
The President has signed into law a two-year
revision of the doctor draft law permitting selective
call-up of physicians to age thirty-five, if they were
deferred from regular draft service to complete
professional training.
The poliomyelitis vaccine act expired July 1
with all but $400,000 of $53.6 million taken up
by states for inoculation programs. An estimated
29 million children and pregnant women received
70 million injections.
The Public Health Service has conferred with
the American Medical Association on medical
manpower plans in event of an epidemic of the
new Far East influenza.
The National Library of Medicine no longer is
lending books and other material over the counter
to individuals; requests must be channeled through
other libraries.
The administration bill on federal workers health
insurance has been introduced; it combines both
basic and major medical coverage.
JMSMS
unique
derivative of
Rauwql.fi a
canescens
Harmonyl*
combines the full effectiveness of the rauwolfias
with a new degree of freedom from side effects
Harmonyl makes rauwolfia more useful in
your everyday practice. Two years of clinical
evaluation have shown this new alkaloid ex-
hibits significantly fewer and milder side ef-
fects than reserpine. Yet, Harmonyl compares
to the most potent forms of rauwolfia in
effectiveness.
Most significant : Harmonyl causes less
mental and physical depression — and far less
of the lethargy seen with many rauwolfia
preparations.
Patients became more lucid and alert, for
example, in a study1 of chronically ill, agi-
tated senile cases treated with Harmonyl.
And these patients were completely free from
side effects — although a group on reserpine
developed such symptoms as anorexia,
headache, bizarre dreams, shakes, nausea.
Harmonyl has also demonstrated its po-
tency and relative freedom from side effects
in hypertension. In a study comparing vari-
ous forms of rauwolfia2, the investigators
reported deserpidine “an affective agent in
reducing the blood pressure of the hyper-
tensive patient both in the mild to moderate,
as well as the severe form of hypertension.”
They also noted that side reactions were
“less annoying and somewhat less frequent”
with this new alkaloid. Other studies con-
firm that few cases of giddiness, vertigo or
sense of detached existence or disturbed sleep
are seen with Harmonyl.
Professional literature on this unique rau-
wolfia derivative is available upon request.
Harmonyl is supplied in 0.1 -mg., nnn
0.25-mg. and 1-mg. tablets. vJJjuQtT
References: 1. Communication to Abbott
Laboratories, 1956. 2. Moyer, J. H. et al:
Deserpidine for the Treatment of Hyperten-
sion, Southern Medical J., 50:499, April,
1957.
o
* Trademark for Deserpidine, Abbott
iugust, 1957
Say you saiv it in the Journal of the Michigan State Medical Society
957
Fifty-Year Club in Tenth Year
Since 1947, 227 Michigan doctors of medicine
have joined the MSMS Fifty-Year Club.
In Grand Rapids this September, additional
nominees will be inducted into the “exclusive”
group. The club is exclusive because of the diffi-
cult requirement that the physician must have
practiced medicine for half a century — and only a
handful of the state’s 8,458 M.D.’s can qualify each
year.
County medical societies have sent in their nom-
inations for membership and the House of Dele-
gates will receive the honorees on Monday, Sep-
tember 23, at the Pantlind Hotel.
Ten years ago, when the idea of honoring our
senior doctors was born, a total of ninety-seven
M.D.’s were made charter members of the Fifty-
Year Club.
The following is a listing of every Fifty-Year
Awardee through September, 1956, with the year
of induction :
*C. D. Aaron, M.D.. Detroit, 1947
“William F. Acker, M.D., Monroe, 1951
“Emil Amberg, M.D., Detroit, 1947
Bruce Anderson, M.D., Pontiac, 1950
*J. H. Andries, M.D., Detroit, 1947
*A. B. Armsbury, M.D., Marine City, 1947
Noah E. Aronstam, M.D., Detroit, 1948
*J. A. Attridge, M.D., Port Huron, 1947
George Baert, M.D., Grand Rapids, 1947
*J. A. Baird, M.D., Flint, 1947
*W. R. Ballard, M.D., Bay City, 1947
J. W. Barnabee, M.D., Kalamazoo, 1951
*Wm. E. Barstow, M.D., St. Louis, 1955
*C. M. Baskerville, M.D., Mt. Pleasant, 1948
“George Bates, M.D., Kingston, 1947
^Robert Beattie, M.D., Detroit, 1953
“Henri Belanger, M.D., River Rouge, 1947
E. G. Bellinger, M.D., Lansing, 1956
Albert A. Berstein, M.D., Detroit, 1954
Alexander W. Blain, M.D., Detroit, 1956
Wm. E. Blodgett, M.D., Detroit, 1954
Franz L. Blumenthal, M.D., Detroit, 1953
W. P. Bope, M.D.. Decatur, 1947
*A. O. Boulton, M.D., Gladwin, 1947
Phillip D. Bourland, M.D., Calumet, 1956
George H. Boyce, M.D., Iron Mountain, 1954
George F. Brewington, M.D., Mohawk, 1947
*H. B. Britton, M.D., Ypsilanti, 1948
Wm. H. Brock, M.D., Saginaw, 1951
Jacob D. Brook, M.D., Grandville, 1953
“Clark D. Brooks, M.D., Detroit, 1955
*F. W. Brown, M.D.. Watervliet, 1949
D. H. Burley. M.D.. Almont. 1947
L. J. Burch, M.D., Mt. Pleasant, 1947
H. W. Cadieux, M.D., Detroit, 1947
*A. L. Callery, M.D., Port Huron, 1947
*A. M. Campbell, M.D.. Grand Rapids, 1947
Duncan A. Campbell, M.D., Detroit, 1948
“■Deceased.
C. D. Chapin, M.D., Columbiaville, 1954
*W. E. Chapman, M.D., Cheboygan, 1947
*J. H. Charters, M.D., Flint, 1947
“Nancy R. Chenoweth, M.D., Escanaba, 1947
“W. R. Chittick, M.D., Spring Valley, Calif., 1947
*S. W. Church, M.D., Marshall, 1947
“G. E. Clark. M.D., Detroit, 1947
Julius C. Clippert, M.D., Dearborn, 1951
W. E. Colbath, M.D., Adrian, 1949
G. C. Conkle, M.D., Boyne City, 1951
G. A. Conrad, M.D., Sault Ste. Marie, 1951
J. E. Cooper, M.D., Battle Creek, 1952
*W. J. Cree, M.D., Detroit, 1947
Alexander Cruikshank, M.D., Detroit, 1947
J. E. Curlett, M.D., Roseville, 1951
M. E. Danforth, M.D., Detroit, 1952
James D. Davis, M.D., Detroit, 1948
*T. E. DeGurse, M.D., Marine City, 1947
William DeKleine, M.D., Lansing, 1956
*A. J. DeNike, M.D., Detroit, 1953
John C. Dodds, M.D., Detroit, 1953
C. P. Doyle, M.D., Lansing, 1947
*Karl Dubpernell. M.D., Detroit, 1947
*F. C. Dunn, M.D., Lansing, 1949
*S. V. Dusseau, M.D., Erie, 1947
Herman C. Emmert, M.D., Detroit, 1954
Bert U. Estabrook, M.D., Detroit, 1953
Lucious A. Farnham, M.D., Pontiac, 1956
Carl Fettig, M.D., Detroit, 1949
■“Walter D. Ford, M.D., Detroit, 1949
“G. H. Frace, M.D., St. Johns, 1948
B. L. Franklin, M.D., Remus, 1952
*G. E. Frothingham, M.D.. Detroit, 1947
C. B. Fulkerson, M.D., Kalamazoo, 1953
Cyrus B. Gardner, M.D., Lansing, 1955
*H. G. Garner, M.D., Detroit. 1947
Nathaniel Gates, M.D., Detroit, 1955
J. W. Gethings, M.D.. Battle Creek, 1951
James C. Gibson, M.D., Detroit, 1947
“John R. Giffen, M.D., Bangor, 1947
*R. W. Gillman, M.D.. Detroit, 1947
“J. E. Gleason, M.D., Detroit, 1953
Benjamin T. Goodfellow. M.D., Flint, 1955
C. S. Gorsline, M.D., Battle Creek, 1951
F. E. Grant, M.D., Kalamazoo, 1947
W. A. Grant, M.D., Milford, 1952
Frank A. Grawn, M.D., Ypsilanti, 1949
Newton H. Greenman, M.D.. Decatur, 1949
*W. T. S. Gregg. M.D.. Calumet, 1947
“Arthur Griggs, Sr., M.D., Saginaw, 1947
J. C. Grosjean, M.D., Bay City, 1951
*B. C. Hall, M.D., Pompeii, 1947
“Joshua Hanser, M.D., Detroit, 1956
*L. J. Harris, M.D.. Jackson, 1947
“Hugh Harrison, M.D., Detroit, 1947
L. L. Harrison, M.D., Niles, 1956
Clarence L. Hathaway, M.D., Lake Orion, 1954
Wilfrid Haughey, M.D., Battle Creek, 1956
James Henry, M.D., Grand Rapids, 1950
H. A. Herzer, M.D., Albion, 1952
“A. B. Hewes, M.D., Adrian, 1953
L. J. Hirschman, M.D.. Detroit, 1949
“Fred J. Hohn, M.D., Saginaw, 1955
Augustus Holm, M.D., LeRoy, 1951
958
JMSMS
FIFTY-YEAR CLUB IN TENTH YEAR
*W. H. Honor, M.D., Wyandotte, 1953
G. B. Hoops, M.D., Detroit, 1951
*James L. Houston, M.D., Swartz Creek, 1951
Edward V. Howlett, M.D., Pontiac, 1956
*W. F. Hoyt, M.D., Paw Paw, 1947
E. C. Hughes, M.D., Bay City, 1947
A. Milton Humber, M.D., Detroit, 1948
*A. M. Hume, M.D., Owosso, 1947
*W. G. Hutchinson, M.D., Bloomfield Hills, 1949
W. J. Jend, M.D., Detroit, 1952
Ralph S. Jiroch, M.D., Saginaw, 1955
*J. M. Jones, M.D., Bay City, 1947
*W. E. Keane, M.D., Detroit, 1952
*J. A. Keho, M.D., Bay City, 1947
John Kemp, M.D., Saginaw, 1947
* William Kerr, M.D., Bay City, 1947
Wm. T. King, M.D., Ahmeek, 1951
J. R. W. Kirton, M.D., Calumet, 1948
Charles W. Knaggs, M.D., Detroit, 1953
* Herbert W. Landon, M.D., Monroe, 1948
*Clarence P. Lathrop, M.D., Hastings, 1947
*W. W. Lathrop, M.D., Jackson, 1947
H. H. Learmont, M.D., Croswell, 1950
* Abraham Leenhouts, M.D., Holland, 1948
*Simeon LeRoy, M.D., Grand Rapids, 1948
Simon Levine, M.D., Houghton, 1951
L. A. Lewis, M.D., Manistee, 1947
*David Littlejohn, M.D., Dearborn, 1947
George W. Logan, M.D., Flushing, 1951
Horace H. Loveland. M.D., Tecumseh, 1951
*Henry A. Luce, M.D., Detroit, 1955
Frank E. Luton, M.D., St. Johns, 1951
Richard C. Lyle, M.D., Bridgeport, 1955
A. E. MacGregor, M.D., Battle Creek, 1951
Donald MacIntyre, M.D.. Big Rapids, 1947
*Donald K. MacQueen, M.D., Laurium, 1947
E. A. Martindale, M.D.. Hillsdale, 1949
*Reuben Maurits, M.D., Grand Rapids, 1947
*J. C. Maxwell, M.D., Paw Paw, 1947
D. J. McColl, M.D., Port Huron, 1947
Allan McDonald, M.D., Detroit, 1953
O. W. McKenna. M.D., Flint, 1947
*W. E. McNamara, M.D., Lansing, 1953
Donald H. McRae, M.D., Detroit, 1955
Richard E. Mercer, M.D., Detroit, 1948
H. G. Merz, M.D., Lapeer, 1947
Henry Meyer, M.D., Saginaw, 1947
A. H. Miller, M.D., Gladstone, 1955
*G. W. Moll, M.D., Escanaba, 1947
Willard Monfort, M.D., Highland Park, 1949
G. W. Moore, M.D., Bay City, 1951
*Esli T. Morden. M.D., Adrian, 1951
E. T. Morris, M.D., Nashville, 1952
John B. Morton, M.D., Detroit. 1948
L. P. Munger, M.D., Hart, 1947
C. D. Munro, M.D., Jackson, 1947
T. E. Munro, M.D., Jackson, 1953
*Dean W. Myers, M.D., Ann Arbor, 1949
*J. H. Nicholson, M.D., Hart, 1947
* Albert Noordewier, M.D., Grand Rapids, 1951
*A. K. Northrop, M.D., Detroit, 1947
Charles S. Norton, M.D., Detroit, 1954
Charles Norton, M.D., Detroit, 1950
David H. O’Donnell, M.D., Detroit, 1947
L. W. Oliphant, M.D., Ann Arbor, 1949
*W. R. Olmsted, M.D., Detroit, 1953
John W. Orr, M.D., Fenton, 1956
F. W. Ostrander, M.D., Freeland, 1951
*Gertrude O’Sullivan, M.D., Mason, 1947
* Robert J. Palmer, M.D., Detroit, 1949
*E. J. Panzner, M.D., Detroit, 1947
*B. Morgan Parker, M.D., Utica, 1951
*W. R. Parker, M.D., Detroit, 1947
W. T. Parker, M.D., Owosso, 1951
*Marion F. Parrish, M.D., Sturgis, 1947
Christopher G. Parnall, M.D., Ann Arbor, 1955
Louis K. Peck, M.D., Lake City, 1947
R. L. Pfeiffer, M.D., Detroit, 1953
Frank Poole, M.D., Saginaw, 1947
Lunette I. Powers, M.D., Muskegon, 1947
George R. Pray, M.D., Jackson, 1950
Edward B. Ramsey, M.D., Detroit, 1950
*H. E. Randall, M.D., Flint, 1947
G. P. Raynale, M.D., Birmingham, 1952
*G. L. Renaud, M.D., Detroit, 1947
R. Milton Richards, M.D., Detroit, 1948
J. W. Rigterink, M.D., Grand Rapids, 1951
* Arthur J. Roberts, M.D., Jackson, 1947
*Melvin D. Roberts, M.D., Hancock, 1956
Mortimer Roberts, M.D., Grand Rapids, 1947
*A. L. Robinson, M.D., Burr Oak, 1952
Michael Ryan, M.D., Saginaw, 1947
E. D. Sage, M.D., Kalamazoo, 1951
Edward O. Sage, M.D., Detroit, 1950
*Thomas M. Sanford, M.D., Lansing, 1947
*Edward Sawbridge, M.D., Stephenson, 1947
R. L. Schorr, M.D.. Detroit, 1947
Alvin H. Seibert, M.D., Grosse Pointe Park, 1955
H. T. Sethney, M.D., Menominee, 1955
DeWitt L. Sherwood, M.D., Detroit, 1954
*B. R. Shurly, M.D., Detroit. 1947
*C. E. Simpson, M.D., Detroit, 1953
Frank J. Sladen, M.D., Detroit, 1956
Claude A. Smith, M.D.. Dearborn, 1956
W. J. Smith, M.D., Cadillac, 1955
*Jeanne C. Solis, M.D.. Ann Arbor. 1947
*1. L. Spalding, M.D., Hudson. 1949
Wm. J. Stapleton. Jr.. M.D.. Detroit, 1950
Clarence T. Starker, M.D., Pontiac. 1956
Thomas C. Starrs, M.D., Detroit, 1956
Lewis L. Stewart, M.D., Jackson, 1950
E. L. Thirlby, M.D., Traverse City, 1953
J. O. Thomas, M.D., North Branch, 1947
*A. B. Thompson, Sr.. M.D., Grand Rapids, 1947
* Alexander Thomson, M.D., Detroit, 1947
*Otto Toepel, M.D., Detroit, 1947
*M. J. Uloth, M.D., Ortonville, 1952
L. N. Upjohn, M.D., Kalamazoo, 1951
*Thomas Van Urk, M.D., Kalamazoo, 1948
J. E. G. Waddington. M.D., Detroit, 1947
*E. C. Warren, M.D., Bay City, 1947
*J. A. Wessinger, M.D., Ann Arbor, 1947
J. B. Whinery, M.D., Grand Rapids, 1947
*W. G. Wight, M.D., Yale, 1947
E. P. Wilbur, M.D., Kalamazoo, 1947
^Herbert H. Wiley, M.D., Algonac, 1951
Clayton Willison, M.D.. Sault Ste. Marie, 1947
Leslie L. Willoughby, M.D., Flint. 1955
*H. R. Wilson, M.D., Saginaw, 1951
*W. J. Wilson, Sr., M.D., Detroit, 1947
W. H. Winchester, M.D., Flint, 1951
G. E. Winter, M.D., Jackson, 1947
Robert A. C. Wollenberg, M.D., Detroit, 1955
W. J. Wright, M.D., Ypsilanti, 1949
A. S. Youngs, M.D., Kalamazoo, 1947
Aloysius J. Zaremba, M.D., Bay City, 1955
ugust, 1957
959
AM A News Notes
ENDORSE PRINCIPLE OF PERIODIC HEALTH
APPRAISAL OF CHILDREN
A new program endorsing periodic health appraisal
for children sponsored by the National Congress of
Parents and Teachers has won support of the AMA’s
Council on Medical Service. At a recent meeting, the
Council voted to approve the following resolution: “The
Committee on Maternal and Child Care of the Council
on Medical Service, AMA, reaffirms its approval of the
principle of continuous health supervision of children
from birth through their school experience rather than
only a program of a single appraisal on school entrance.
It also recommends that, where possible, this should be
done by the physician and dentist who normally serve
that child and family, preferably his personal physician
and dentist. The Committee welcomes the support of
the National Congress of Parents and Teachers.”
AMA STUDIES CHEMICAL LAWS
A hodge-podge of state and federal laws regulating
the labeling of hazardous chemicals and the need for
a uniform chemical law recently were revealed by an
American Medical Association study. Sponsored jointly
by the AMA’s Committee on Toxicology and Law De-
partment, the study was made in preparation for
drafting a model chemical labeling law. A conference
of interested representatives of government, industry and
medicine will be called this fall to draft a model law
which then can be submitted to legislative bodies.
The proposed legislation is intended to reduce care-
less and ignorant handling of potentially harmful prod-
ucts in and around the home, small businesses and
other areas where control of over-exposure to chemicals
is not as efficient as in the manufacturing process. This
law will require informative labeling, including listing
of possibly harmful ingredients, their potentialities for
danger, directions for safe use and first-aid instructions.
“TODAY’S HEALTH” CONTEST
WINNERS HONORED
Top prizes for selling the largest number of subscrip-
tions in the Today’s Health 1957 Woman’s Auxiliary
contest went to the states of New Mexico, Kansas, In-
diana and Pennsylvania.
The forty dollar awards were presented in June
during the Woman’s Auxiliary convention in New York
City. This has been one of the most successful contest
years, reports the national TH chairman, Mrs. C. Rod-
ney Stoltz of Watertown. S. D. During the period from
June 1, 1956, through midnight April 15, 1957, a total
of 75.409 and 6/12 subscription contest credit points
were earned — an increase of 18.849 and 7/12 over the
number of credits produced the previous year.
State winners and their chairmen: Group I (member-
ship 1 to 1,000) — New Mexico, Mrs. Frank B. Nord-
strom, Farmington; Group II (1,001 to 2,000) — Kan-
sas, Mrs. Francis Basham, Eureka; Group III (2,001 to
3,000) — Indiana, Mrs. Jack Shields, Brownstown ; Group
IV (3,001 or over) — Pennsylvania, Mrs. LeRoy Cooper,
York.
County winners and their chairmen: Group I (mem-
bership of 1 to 35): 1st prize — Huron county, Ohio,
Mrs. T. H. Smith, New London; 2nd prize — Green-
wood-Woodson counties, Kan., Mrs. Robert Obourn,
Eureka; Labette county, Kan., Mrs. A. L. Berggren.
Chetopa. Group II (36 to 75): 1st prize — Larimer
county, Colo., Mrs. Duane Hartshorn, Fort Collins;
2nd prize — Cobb county, Ga., Mrs. Edgar A. Vaughan.
Marietta; 3rd prize — Indiana county, Penna., Mrs.
Ralph Waldo, Indiana, Penna.
Group III (76 to 100): 1st prize — Clark county,
Ohio, Mrs. Donald Guyton, Springfield; 2nd prize —
Escambia county, Fla., Mrs. J. W. Douglas, Pensacola:
3rd prize — Yellowstone county, Mont., Mrs. Wayne
Roney, Billings. Group IV (101 or over): 1st prize —
Sedgwick county, Kan., Mrs. Paul A. Lovett, Wichita;
2nd prize — St. Joseph county, Ind., Mrs. Robert F.
Reed, Mishawaka; 3rd prize — Broward county, Fla..
Mrs. Richard D. Owen. Fort Lauderdale.
AMA ISSUES NEW GUIDES ON
VOLUNTARY AGENCIES
A new “Guides to Relationships Between Medical
Societies and Voluntary Health Agencies” has been pub-
lished by the American Medical Association. Prepared
by the Committee on Relationships Between Medicine
and Allied Health Agencies, the booklet points up the
nature of voluntary health agencies, the questions that
need to be answered in evaluating such agencies, the
medical society’s obligations to voluntary agencies, and
the voluntary agency’s obligations to the medical society.
Last fall the committee issued a brief outline on this
subject which stimulated such interest among medical
societies that the more detailed and comprehensive set
of guides was prepared. The committee is composed of
Drs. Sidney J. Shipman, San Francisco, chairman; Paul
A. Davis, Akron; Paul C. Swenson, Philadelphia; Leon-
ard W. Larson, Bismarck, N. D. ; Dwight H. Murray.
Napa, Calif. ; Louis A. Buie, Rochester, Minn., and
David A. Wood. San Francisco.
Copies of the Guide may be secured from the Council
on Medical Service.
FILM DESCRIBES ROLE OF RADIOLOGIST
ON MEDICAL TEAM
A new color motion picture dedicated to the radiolo-
gist— a physician who specializes in the use of x-rays,
radium and radioactive materials in the diagnosis and
treatment of diseases — has been added to AMA’s Film
Library. “First a Physician” tells the dramatic story
of what a radiologist is, what he does and how he
serves patients. In this twenty-seven-minute film, you'll
(Continued on Page 1060)
960
JMSMS
NEW BENEFITS
PLUS OUTSTANDING FEATURES
stabilized, soluble, better tasting,
remarkably free of side effects
iscible in water, milk, formula,
or drop directly on tongue
losage is easy, one drop per
pound body weight per day
iccur;
10 cc. plastic dropper-type bottle
(orange-flavor), 100 mg./cc.
(approx. 5 mg. per drop)
LEDERLE LABORATORIES DIVISION. AMERICAN CYANAMID COMPANY, PEARL RIVER. N. Y.
.UGUST, 1957
Say you saw it in the Journal of the Michigan State Medical Society
961
Half Million Persons Reached by MSMS Study
The MSMS study of public wants and needs in
medical-surgical coverage by insurance and pre-
payment plans has asked for opinions from more
than a half million Michigan citizens.
In addition to the 60,000 survey questionnaires
sent to householders by the Michigan Health
Council, which conducted the public survey for
the MSMS, publication of the survey form in
two metropolitan newspapers provided unprece-
dented coverage.
While the mail survey by the Michigan Health
Council received the most public attention, other
survey methods were employed and additional in-
formation areas probed.
A highly accurate and detailed personal inter-
view survey was conducted by the Market-Opinion
Research Company of Detroit, in which one thou-
sand households throughout the state were con-
tacted personally by trained researchers.
Also, by means of a special questionnaire, the
doctors were asked their views on the operational
methods and philosophies of Michigan Medical
Service (Blue Shield).
In addition, there was an evaluation of the pub-
lic’s willingness to pay for the services they voted
most essential, as well as an estimation of the
public’s medical needs.
The public questionnaire is reprinted here just
as it appeared to over 500,000 Michigan residents.
MICHIGAN HEALTH COUNCIL
706 North Washington Ave.
Lansing 6, Michigan
July, 1957
Return to:
Michigan Health Council
Box 671
Lansing 3, Michigan
Dear Friend:
This is your chance to tell doctors exactly what kind of medical expense protection you want. You are one of 50,000
persons in Michigan who has been selected to voice an opinion on voluntary, prepaid medical and surgical care plans
and health insurance coverage. Since you, as a Michigan citizen, are a partner in any plan or system of medical care,
we feel that you should have this opportunity to state your views. You will not subsequently be contacted personally
as a result of your answers.
It’s one sure way Michigan's doctors of medicine can find out what you really want. That’s why the Michigan Health
Council in cooperation with the Michigan State Medical Society is sending you this questionnaire. Would you please
take a few minutes to fill it out completely and return it? THANK YOU.
J. K. Altland, M.D., President
Michigan Health Council
All answers are strictly confidential.
Check the answer that expresses your opinion.
1. Do you have any kind of insurance or plan that
pays all or part of your or your family’s medical and
surgical expenses?
Yes □ 1 No □ 2 1
If “Yes,” go to question number 3.
If “No,” answer question number 2, then skip to
question number six (6) and remaining ques-
tions.
2. Would you please check the most appropriate an-
swer as to why you and your family are not now
covered by any surgical and medical insurance?
Have had no opportunity to obtain □ 1 2
Have had unsatisfactory experience with in-
surance . □ 2
Too expensive □ 3
Unfamiliar with coverage offered by policies □ 4
Other □ 5
If you checked “other,” please fill in reason 3
3. With what medical-surgical plan or insurance com-
pany are you or your family now covered in whole
or in part? (If more than one policy is held, chedb
each company.)
Michigan Medical Service (Blue Shield) □ 1 A
Metropolitan Life Insurance Company □ 2
Bankers Life & Casualty Company (White
Cross) □ 3
Travelers Insurance Company □ 4
Mutual Benefit Health and Accident As-
sociation (Mutual of Omaha) □ 5
Other □ 6
If you checked “other” please fill in
name of company.)
Is any part or all of the cost paid for by your em
ployer?
All □ 1 Part □ 2 None □ 3 f
Does this plan(s) cover:
Self only □ 1 Husband & Wife □ 2
Family □ 3
962
JMSMi
4i
HALF MILLION PERSONS REACHED BY MSMS STUDY
1. Have you ever had to call upon your insurance
company (or companies) to pay benefits?
Yes □ 1 No. □ 2 8
5. The last time you used your medical insurance, were
there any medical or surgical expenses (other than
hospital expense) that were not covered by your
insurance?
Yes □ 1 No. □ 2 9
If so, what were they?
. 10
About how much did you pay? 11
6. The benefits normally covered by many medical in-
surance policies for services provided in the hospital
are listed below. (THESE DO NOT INCLUDE
HOSPITALIZATION EXPENSES). Such a policy
would cost your family approximately $5.00 a month
or $55.00 per year.
(Remember, this cost estimation does not include
your hospitalization. For example, Blue Shield pays
medical expenses and Blue Cross pays hospital ex-
penses— other companies often have separate policies
too.)
Surgical Emergency first aid
Fractures and dis- Anesthetic
locations X-ray
Maternity
Which of the following benefits would you MOST
like to have ADDED to the coverage of the above
policy? (Check one or as many as you would like
to add.)
Medical benefits in hospital: Would Add
Blood transfusions
□
1
12
X-ray (for outpatients)
□
2
Diagnostic services
□
3
Medical treatment in doctor’s
office:
Diagnostic service
□
1
13
Surgical
□
2
Fractures and dislocations
□
3
X-ray
□
4
Dressings and casts
□
5
Treatment by doctors in your
home:
Emergency house calls
□
1
14
Dressings and casts
□
2
Do you think nursing care should be
covered for:
Private nurses in hospital
□
1
15
Nursing care in home
□
2
7. If the benefits you checked in question 6 were
added to such a policy, how much increase in
premium per month do you think you would be
willing to pay?
$ per month □ 16-17
8. In order to keep down the premium cost caused by
the added benefits, would you want to drop any of
the benefits normally included:
Would Drop
Surgical □ 1 18
Fractures and dislocations □ 2
Maternity □ 3
Emergency first aid □ 4
Anesthetic □ 5
X-ray □ 6
9. In order to reduce the monthly cost of medical-
surgical insurance would you favor paying a de-
ductible amount of the expense per each illness or
disability (similar to deductible feature of auto-
mobile insurance) ?
Yes □ 1 No □ 2 19
(a) If “YES,” how much deductible expense would
you be willing to pay?
$25.00 ' □ 1 20
$50.00 □ 2
$100.00 □ 3
10. Should prepaid medical and surgical plans or in-
surance cover only the major cost items of an illness
or operation, or should they cover all minor items
as well?
Major costs only □ 1 21
Minor costs and major costs □ 2
Minor costs only □ 3
11. So that your answers may be grouped with others
in the analysis, please check the categories below de-
scribing yourself:
Single □ 1 22 Your place of residence:
Married □ 2 Rural □ 1 23
Divorced □ 3 Town under 2,500 □ 2
Widowed O 4 Town 2,500-9,999 □ 3
Town 10,000-24,999 □ 4
Female □ 1 25 Town 25,000-99,999 □ 5
Male □ 2 Town 100,000-500,000 CD 6
Town over 500,000 □ 7
Age group:
15-24 □ 1 24
25-34 □ 2
35-44 □ 3
45-54 □ 4
55-64 □ 5
Over 64 □ 6
Name of county you live in: 26-27
12. And also these two facts about your immediate
family:
How many children under 18 years of
age? __ 28
What was your family income last year (1956) ?
Under $2,500 □ 1 $7,000-9,999 □ 4 29
$2,500-4,999 □ 2 $10,000 & over □ 5
$5,000-6,999 □ 3
13. And about the man or chief breadwinner in your
household:
Type of occupation: Hourly rated
Manager or owner □ 1 worker □ 5 30
Executive professional □ 2 Housewife □ 6
Farmer or farm worker d 3 Retired □ 7
White collar employe □ 4 Unemployed Q8
And finally, what, if any, occupational or profes-
sional organizations does the man or chief bread-
winner in the household belong to?
Farm:
Labor Union:
Farm Bureau
□ 1
CIO
n 4
Farmers Union
□ 2
AF of L
□ 5
Grange
□ 3
Other
□ 6
Professional and Business:
Dental-Medical
□ 7
Legal
□ 8
Business Associate
□ 9
Name (OPTIONAL)
Address (OPTIONAL)
Please ignore small numbers next to the boxes. They are used for our coding purposes only.
\ugust, 1957
963
levels
one dose
a day. . .
964
Say you saw it in the Journal of the Michigan State Medical Society
JMSMS
announcing...
a new practical
and effective method
for lowering blood
cholesterol levels...
Just one dose a day effectively
lowers elevated blood cholesterol
. . . while allowing the patient
to eat a balanced . . . nutritious . . .
and palatable diet
Each tablespoonful of Arcofac contains:
Linoleic acid 6 Gm.
Vitamin B6 0.6 mg.
(sodium benzoate as preservative)
Arcofac is effective in small doses
and is reasonable in cost
to the patient
THE ARMOUR
LABORATORIES
A DIVISION OF ARMOUR AND COMPANY
KANKAKEE. ILLINOIS
Editorial Opinion
WILL PRIVATE PRACTICE
CEASE TO EXIST?
Think of the peculiar changes which happened
in the private practice of medicine. We are ob-
serving the terrific trend for industry, labor, gov-
ernment, insurance companies, hospitals and
related groups to control all health activities.
Does this mean that private practice will cease
to exist? I ask the question, because I think we
have something here to think about. Yes, there
is imminent danger of the private practice of
medicine losing its status as a professional art and
being forced into the mold of a trade.
Various industries over this country are build-
ing hospitals and organizing medical service plans
for employes and dependents which are staffed by
salaried and closed panel physicians.
Labor also is establishing hospitals and complete
medical service plans, staffed by salaried and
closed panel physicians to care for their members
and their dependents. Dr. Edwin F. Bailey, Vice-
President of the Health Insurance Plan of Greater
New York (HIP), has predicted that organized
labor will soon establish the pattern of medical
care in the LTnited States.
As all of you know the Veteran’s Administra-
tion is providing hospital care and medical service
for an ever-increasing number of nonservice con-
nected disabilities. It is possible that in the not
too far distant future dependents of veterans will
be included.
Take a look at Social Security and its medical
provisions. Most physicians do not realize what is
happening to them in the Social Security legisla-
tion. The disability program in any form means
to me the ultimate nationalization of medicine and
the end of private health and accident insurance.
These changes will not take place over night, to
be sure, but they will gradually take place as
each new Congress that meets will be urged to
broaden more and more the coverage. When
physicians are brought under government control
for a permanent and total disability program, even
if only for medical certification, the next moves
will urge more for cash benefits for temporary ill-
ness, followed by medical care for short-term
sickness. And there you go with the final step as
national compulsory federal health insurance.
Attention should be given to the Hill-Burton
money and some of our experiences in Arkansas
with it. We have accepted federal money in
Arkansas — Hill-Burton money — for one-time grants
for bricks and mortar to build hospitals. What
has happened recently? In three instances now
certain doctors were denied staff memberships for
good reasons it was thought in three different
hospitals. These doctors have gone to court, have
won their cases and forced themselves on to the
hospital staffs. I ask you to remember the state-
ment of Supreme Court Justice Robert H. Jack-
son in 1942 “it is hardly lack of due process for
the government to regulate that which it subsi-
dizes.” The cases I am referring to have been
carried to their limit in court I might tell you.
The Supreme Court indicates that a hospital
built with a portion of tax funds is subject to dif-
ferent legal principles than a private hospital ; that
in such a hospital a doctor as a citizen if he has
a legal license to practice medicine cannot be de-
nied the use of the particular hospital and that
the staff rules and regulations of such a hospital
are subject to court supervision. This is what you
are confronted with when you accept public funds
— tax money — for bricks and mortar. — Guest Edi-
torial by R. B. Robins, M.D., in The Journal of
the Arkansas Medical Society, June , 1957 .
SHALL WE ABANDON
BLUE SHIELD?
One hears, too often, the expressed opinion that
Blue Shield has served its purpose, and that we
should now turn the job over to commercial insur-
ance carriers. This, they say, would get us out of
the insurance business and leave us with the assur-
ance that the people can have protection from
other sources. Those who espouse this idea must
believe that the social-economic-political problems
that fathered the conception of the prepaid medi-
cal care have been solved or have ceased to exist.
It should be obvious that the social need for
prepaid medical care is still with us. No matter
how cheap the dollar nor how many cheap dollars
pass through the hands of each of us, relative
values remain unchanged. There is, and there
always will be, a large segment of our population
to which the advent of a medical catastrophe
remains catastrophic. Those making up this large
group are good people. They deserve the best
available medical care. They cannot buy it in-
dividually, but, collectively it can be available to
them at a price they can afford to pay.
This same group constituted the foundation
upon which the socialistically minded people in
our government rested their demand for universal,
compulsory, government-controlled health insur-
ance (state medicine to us). Their needs formed
the basis of arguments for the often repeated
"Murray-Dingle” bills. Blue Shield and Blue Cross
constituted the fundamental positive answers by
the medical profession — answers that led to the
(Continued on Page 968)
966
JMSMS
Trasenline-
C I B A
Summit, N. J.
integrated relief . . .
mild sedation
visceral spasmolysis
mucosal analgesia
TABLETS (yellow, coated), each containing
50 mg. Trasentine® hydrochloride (adiphenine
hydrochloride CIBA) and 20 mg. phenobarbital.
August, 1957
Say you saw it in the Journal of the Michigan State Medical Society
967
EDITORIAL OPINION
SHALL WE ABANDON BLUE SHIELD?
(Continued from Page 966)
defeat of these bold attempts at socialization of
medicine. The defeat of successive bills lulled
some of us into a tranquil state of mind. It did
not, however, discourage the socialist group that
has been and still is so strong and so well en-
trenched in the social-security wing of H.E.W.
This group has simply adopted a more suave and
less bold method of approach. What is more im-
portant, they are succeeding. It will be surprising
if any Congress comes and goes without taking a
nibble from the freedom of medical practice. The
doubter needs only to remember H.R. 7225 and
watch for similar chiseling on our liberty.
It is our desire to furnish to the people who
need it the quality and quantity of medical care
to which any American may aspire, at a price
within their means. We must do this under poli-
cies formulated and approved by doctors of medi-
cine and with no governmental interference. We
are in the insurance business at no profit as
measured in dollars and cents. Our recompense
is the accomplishment of the aim stated above as
free physicians and with no third-party interfer-
ence.
Would the commercial insurance people have
the same goals and accomplish the same ends in
similar manner? They would not. Certainly, we
are glad to have commercial insurance companies
in the field of health insurance. These companies
will help attain the goal of supplying health insur-
ance to the vast majority of our populace. If the
commercial companies did not have the thorn in
the side — the competition of a vast nonprofit Blue
Shield that has now supplied protection to many,
many millions of people, the whole effort would
sink to the level of business for profit only. It
could not be expected that these insurance com-
panies would maintain an altruistic approach,
would worry much about doctor-patient relation-
ship, nor exert themselves unduly to avoid sociali-
zation of the practice of medicine.
The social-medical-political problem involved in
health insurance as looked at from our viewpoint,
is a continuing problem. It must have a continu-
ing answer. The most effective tool, thus far, has
been Blue Shield-Blue Cross. We must not aban-
don this effective tool unless we are ready to capit-
ulate.— Editorial, Nebraska State Medical Jour-
nal, May, 1957.
OUTCOME OF IOWA LITIGATION
On April 3, 1957, the State Legislature of Iowa
enacted a new law pertaining to the practice of
pathology and radiology in the hospitals of that
state. The important features of the act are as
follows:
The ownership, maintenance and operation of the
laboratory and X-ray facilities are proper functions
of a hospital.
Pathology and radiology services performed in hos-
pitals are the product of the joint contribution of
hospitals, physicians and technicians but these services
constitute medical services which must be performed
by or under the direction and supervision of a phy-
sician, and no hospital shall have the right, directly or
indirectly, to direct, control or interfere with the pro-
fessional medical acts and duties of the physician in
charge of the pathology or radiology facilities or of the
technicians under his supervision.
Unless the department is leased, or unless the hospital
and physician mutually agree otherwise, technicians
and other personnel, not including physicians, shall be
employees of the hospital, subject to the rules and reg-
ulations of the hospital applicable to employees gener-
ally, but under the direction and supervision of the
physician in charge of the department.
The contract between the hospital and physician in
charge of the laboratory or X-ray facilities may contain
any provision for compensation of each upon which they
mutually agree, provided however that no contract
shall be entered into which in any way creates the
relationship of employer and employee between the
hospital and the physician. A percentage arrangement
(for compensating the hospital) is not to be construed
to be unprofessional conduct on the part of the phy-
sician or in violation of the statutes (of Iowa) upon
the part of the hospital.
The hospital admission agreement signed by the pa-
tient or his legal representative shall contain the fol-
lowing statement:
“Pathology and radiology services are medical services
performed or supervised by physicians, and the person-
nel and facilities are or may be furnished by the
hospital for said services. Charges for such services are
or may be collected, however, by the hospital on behalf
of said physicians pursuant to an agreement between
said physicians and the hospital, and from said charges
I consent that an agreed sum will be retained by the
hospital in accordance with an existing agreement be-
tween the physician and the hospital."
The hospital bill shall properly include the charges
for pathology and radiology services as long as the name
of the physician is stated and it fairly appears that the
charge is for medical services. The said hospital bill
shall also contain a statement substantially in the follow-
ing form:
“The pathology and radiology charges are for medical
services rendered by or under the direction of the
physician listed above and are collected by the hospital
on behalf of the physician, from which charges an
agreed sum will be retained by the hospital in accord-
ance with an existing agreement to which retention you
consented at the time of your admission to the hospital.”
Fees for radiology and pathology services must be
paid for as medical and not hospital services. In all
cases where payment is to be made by a corporation
(insurance), payment for radiology and pathology serv-
ices shall be made by a medical service corporation
and not by a hospital service corporation.
This legislation should terminate an unpleasant
controversy which began in 1952 over the extension
of Blue Shield benefits to include the services
of pathologists, radiologists and anesthesiologists.
A thirteen-week trial in district court in which
thirty-four Iowa hospitals were plaintiffs and the
Iowa State Medical Society defendent ended with
the verdict (in part) that (a) pathology and radi-
(Continued on Page 1073)
968
JMSMS
HTis JOURNAL
of the Michigan State Medical Society
Issued Monthly Under the Direction of the Council
VOLUME 56 AUGUST, 1957 NUMBER 8
Upper Peninsula Medical Society
The Upper Peninsula Medi-
cal Society was organized in
Marquette, Michigan, in the
old Superior Hotel in the year
1896 by a group of Marquette
physicians. Its function was to
be both educational and social
and to serve as the medium for
acquainting the doctors of
northern Michigan with one
another.
The first annual meeting was
held in 1897, and a meeting has been held every
year since. The society is unique in that it has
endured for sixty-one years without constitution or
by-laws. The meetings are rotated between Iron
Mountain, Escanaba, Menominee, Houghton,
Sault Ste. Marie, Marquette, and Ironwood, with
the county societies in the area acting as hosts.
The only elected officer is the president-elect, the
other officers being of the county society which is
acting as host.
Originally the meetings were held during the
month of August but a few years ago the time was
moved up to June so it would not be competitive
with the meeting of the state society.
That it has fulfilled its original purpose is evi-
dent by the large attendance each year.
D. P. Hornbogen, M.D.
President-Elect
Sixty-Fourth Annual Session
The sixty-fourth annual session was held at
Houghton, Michigan, June 21-22, 1957, with T.
P. Wickliffe, M.D., Calumet, president; D. P.
Hornbogen, M.D., Marquette, president-elect; and
F. W. Lawson, M.D., Houghton, secretary.
Elaborate arrangements were made for enter-
tainment, exhibits, and meetings, with an outstand-
ing scientific program. A dinner was held at the
Douglass House on Friday evening, and on Sat-
urday evening, cocktails, a reception, dinner and
dance were held at the Onigaming Yacht Club.
L. E. Irvine, M.D., Iron Mountain, was made
President-elect for 1958.
The scientific program for Friday, June 21, was:
“Welcome”
T. P. Wickliffe, M.D., President, Upper Peninsula
Medical Society
August, 1957
Moderator: Simon Levin. M.D.
“Application of Smear Technique in the Diagnosis of
Cancer”
R. J. Rodgers, M.D., Director, Upper Peninsula Cytol-
ogy Laboratory, Menominee, Michigan
“Regional Enteritis”
Arnold Jackson, M.D., Department of Surgery, Jack-
son Clinic, Madison, Wisconsin
(Dr. Jackson was unable to attend at the last minute,
owing to the sudden illness of his son, but Grover Pen-
berthy, M.D., of Detroit, who was on the program
and who is a native of this north country graciously
substituted for him and gave a masterful talk on Dr.
Jackson’s subject.)
“Diagnosis and Treatment of Acute Coronary Disease”
Francis Murphy, M.D., Chief, Department of Medi-
cine. Marquette University. Milwaukee, Wisconsin.
(This essayist has been Professor of Surgery at Mar-
985
UPPER PENINSULA MEDICAL SOCIETY
quette for thirty years. A friend recently gave $350,-
000 to the University to establish a Murphy Chair of
Surgery, to be a full-time professorship at a generous
salary, but, since Dr. Murphy doesn’t wish to devote
full time to teaching now, he will later designate his
successor, when another gift will follow and the chair
made permanent.)
“Present Day Trends in Infant Feeding”
Moses Cooperstock, M.D., Pediatrics, Marquette, Mich-
igan
“Treatment of Burns”
Grover C. Penberthy, M.D., Surgery, Detroit, Michigan
(Since Dr. Penberthy had substituted for Dr. Jack-
son, he called upon Dr. N. S. Gumbel, of Wayne Uni-
versity, Detroit, to give the talk on burns.)
Moderator: A. M. Roche, M.D.
“Mediastinal Tumors”
Joseph Gale, M.D., Department of Surgery, Univer-
sity of Wisconsin Hospital, Madison, Wisconsin
“General Principles in the Management of Fractures”
Harrison McLaughlin, M.D., Clinical Professor, Or-
thopedic Surgery, Columbia University, New York City
“Present Ideas of Treatment of Varicose Veins and Ul-
cers”
Carl Moyer, M.D., Department of Surgery, Wash-
ington University School of Medicine, St. Louis, Mis-
souri
Moderator: Percy Murphy, M.D.
“Constitutional Disease”
Harold Falls, M.D., Professor of Ophthalmic Surgery,
University of Michigan Hospital, Ann Arbor, Michigan
“The Fractured Wrist”
G. J. Curry, M.D., Orthopedic Surgery, Flint, Mich-
igan
“Some Recent Studies on the Abnormalities of Pigmen-
tation”
A. C. Curtis, M.D., Professor and Chairman, Depart-
ment of Dermatology, University of Michigan Hospital,
Ann Arbor, Michigan
Addresses by F. Foster, M.D., Secretary, Michigan
State Medical Society, and Tom Paton, Michigan
Medical Service Representative
Women’s Auxiliary Activities. — Women’s Auxil-
iary activities at this meeting were as follows:
Friday, June 21
Registration and Continental Breakfast in the Hospitality
Room
District Auxiliary Luncheon and Meeting: 12:30 at
Douglass House
Mrs. J. J. Burke, District Director, Chairman
Guest Speaker: Mrs. A. C. Stander, President Wom-
en’s Auxiliary to MSMS
Cocktails and Dinner: 6:00 P.M. at Douglass House
Public Address: 8:30 P.M. at Houghton High School
Arch Walls, M.D., President Michigan State Medical
Society
Saturday, June 22
Registration: 10:00 to 11:00 A.M.
Dutch Lunch at Onigaming Yacht Club 12:00 to 1:00
Afternoon: Swimming, boating at Onigaming. Golf at
Portage Lake Gulf Club
Cocktails: 6:00 P.M. at Onigaming
Courtesy Michigan Medical Service. Followed by Din-
ner and Dance
Upper Peninsula Medical Assistants Society. —
The medical assistants society held its first annual
meeting in conjunction with the sixty-fourth an-
nual session of the Upper Peninsula Medical So-
ciety. Their program was as follows:
Thursday, June 20
Cocktails and Buffet, Onigaming Yacht Club
Friday, June 21
Registration, Douglass House
Luncheon with Medical Auxiliary, Douglass House
Guest Speaker: Mrs. A. C. Stander, President of
Michigan State Medical Society Auxiliary
Hostess: Anna Warner
Tour, Michigan Department of Health Laboratory, Mich-
igan College of Mining and Technology Campus
Host: Mr. Alden Scott, Director
Tea, Union Building, Tech Campus
View of Exhibits, Union Building
Executive Board Meeting, President’s Suite, Douglass
House
986
JMSMS
History of the Houghton County Medical Society
Simon Levin, M.D.
Houghton, Michigan
^T*HE Houghton County Medical Society was
organized in the late 1890’s and affiliated with
Michigan State Medical Society which granted
the Houghton Society a charter on September 20,
1902. Since then, the Society has become an in-
tegral portion of the State Medical Society, and
has become quite active. The application for
charter was signed by Drs. A. F. Laubaugh and
W. K. West, and was countersigned by Councilor
T. A. Felch of Ishpeming.
In about the last fifteen years Houghton has
joined with Baraga and Keweenaw Counties to
carry out monthly meetings and health department
work, making it more efficient for the neighboring
counties with smaller groups.
At the beginning, the society had a membership
of forty-eight, but industrial conditions changed,
and there now are only twenty-five members. One
half of the practicing physicians were hired by the
copper mining companies. They were so-called
“company doctors,” who were on stipulated salar-
ies with privilege of outside practice as well. All
were general practitioners doing all types of prac-
tice, making calls with horse-drawn vehicles in
winter and summer, doing obstetrics in houses,
and having facilities of modern sized hospitals
equipped with x-rays, laboratories and surgical
facilities. The large companies, like the Calumet
and Hecla Mining Company, and the Copper
Range Mining Company, had their own hospitals,
but the smaller companies had the use of small
community hospitals. As the industrial mining
decreased within the county, the mining company
hospitals closed, and now we have two very
well-equipped and accredited hospitals in the
county — St. Joseph’s Medical Center at Hancock,
Michigan, the Memorial Hospital at Laurium,
Michigan, and the Memorial Hospital at L’Anse,
Michigan, where excellent work in medical, surgi-
cal, x-ray and laboratory work can be carried out.
The medical center at Hancock (St. Joseph’s Hos-
pital) has a full-time pathologist and radiologist
connected with its service. These specialists are
available to the surrounding hospitals, which have
no such personnel, making for more thorough
early scientific diagnostic conclusions. The ensu-
ing of thorough treatment thus gives more satis-
factory results.
A very interesting feature of the change of time
and condition is shown in Medical Society dues.
In 1902, the annual dues were $7.50, in 1921.
$10.00, in 1925 $15.00, in 1938 $17.00, in 1945
$32.00, in 1946 $42.00. Now dues are $85.00 per
year, including the extra dues paid to the Ameri-
can Medical Association.
We have had, and have today, many medical
men who advanced in the stride of the develop-
ment of scientific medicine and surgery. It is my
pleasure and privilege to have known these men
personally, as I commenced my medical practice
in the very beginning of this century.
The cry of today is, “Do things in a modern
way, and keep pace with the advancement.” In
a community like ours, situated far from the large
centers of learning, it is with assurance that we
remain in the ranks, keeping pace with modern
advancing medicine. Therefore, we have a feel-
ing of satisfaction in our work and a keen desire
to assist in advancing the standards, which keep
us on our toes in this changing medical develop-
ment of our time. This we must do in fairness
to the people whose medical care is intrusted to us.
To violate this trust in any way, or to commer-
cialize it, would contribute to a distinct lessening
of the standards and quality of medical practice,
which should be our highest and strongest call
to service. Permit me here to emphasize that
service, which must be scientific, and always ac-
curate, gracious and kindly, thorough and fair,
and must stand out as our guiding star in the
advancement of our wonderful profession.
We have had the pleasure and honor of acting
as hosts to the Upper Peninsula Medical Society
members in the Copper Country on three or four
occasions since our induction. This year brings to
us another meeting, and from the excellency of
the papers by noted men of authority in their
(Contiued on Page 1008)
August, 1957
987
Diagnosis and Treatment of
Acute Coronary Disease
Francis D. Murphy, B.S., M.D., M.S. (Med.) F.C.A.P.
Milwaukee, Wisconsin
TIJ’OR the past thirty-five years there has been
a progressively increasing interest in diseases
of the coronary arteries. The emphasis and inter-
est in coronary disease are not due to any signifi-
cant discovery, such as insulin in the treatment
of diabetes or the antibiotics in infections, but the
increasing number of cases of coronary disease
among the middle and older classes of patients
augments its importance. It must be kept in
mind, however, that thirty-five years ago much
less was known of coronary artery disease than
now. Surely, the diagnosis of angina pectoris was
familiar, but coronary thrombosis had just begun
to be recognized by the profession. In those days
the diagnoses of acute myocarditis, acute myo-
cardial insufficiency, and even acute indiges-
tion, were usually made. Of course, the introduc-
tion into practical work of the electrocardiograph
helped in the recognition of certain kinds of
coronary disease and was a significant factor in
our present-day concept of conorary disease.
Heart disease is the leading cause of death
in the United States, and, in this category, cor-
onary disease of the heart accounts for the major-
ity of cases. Formerly, it was common practice
to differentiate angina pectoris from coronary
thrombosis, but today the differentiation must go
much further, and it is these various types of
diseases of the coronary arteries that shall be
discussed.
Classification
Before one can make a diagnosis of coronary
artery disease, an adequate classification of the
disease must be kept in mind. Although volumes
Dr. Murphy is professor and director, Department of
Medicine, Marquette University School of Medicine,
and Medical Director, Milwaukee County Hospital,
Milwaukee, Wisconsin.
Presented at the sixty-fourth annual session of the
Upper Peninsula Medical Society, Houghton, Michigan,
June 21, 1958.
have been written upon this subject and many
classifications have been advanced, the simplest
approach to the problem would be to consider
four stages of coronary disease.
Stage 1. — In this stage there is a beginning loss
of elasticity and resiliency of the coronary arteries.
It is the stage when very little change may be
seen in the artery, and tests, as electrocardio-
graphic tracings, reveal nothing. It is the stage
of angina pectoris provoked by exercise or by a
great emotional strain -and to which the term
angina pectoris of effort is applied.
Stage 2- — The arteriosclerotic changes some-
where in the coronary system have become more
pronounced, the narrowing is greater, elasticity
and resiliency have become less, and there may
be some electrocardiographic changes in a few of
these patients. The angina pectoris occurs on
slight provocation, and frequently the attacks of
pain in the chest occur while the patient is sitting
in a chair or lying in bed. This stage is called
angina pectoris decubitus.
Stage 3. — The arteriosclerosis has become more
marked, but as yet no complete occlusion has oc-
curred. In certain cases, however, the ischemia
becomes so great that small areas of infarction
on the endocardial surface of the heart develop,
and this has been called acute coronary insuffi-
ciency (Master).
Stage 4. — The coronary artery in this stage is
plugged with a thrombus and the classic picture
of acute coronary thrombosis (occlusion) occurs.
As a result of this, an infarct develops which
extends from the endocardium through the heart
wall to the pericardium. This is called a through-
and-through infarction and is the real old-fash-
ioned coronary thrombosis. This is the most serious
event that takes place in heart disease and one
that causes death in about half of the patients
988
JMSMS
ACUTE CORONARY DISEASE— MURPHY
within the first week. It is in this stage that a
physician’s entire skill and experience are called
upon for the most vigorous kind of treatment if
the patient’s life is to be saved.
This kind of classification can easily be subjected
to criticism, but it illustrates what is seen in prac-
tice and may be helpful in management.
Diagnosis and Treatment
As pain in the chest is the most common and
significant symptom of coronary disease of the
heart, it requires careful consideration. A com-
plete history is the most important part of the
examination. The diagnosis of coronary disease
in the earlier Stages one and two, that is, angina
pectoris of exercise and angina pectoris decubitus,
is made almost entirely upon a careful, detailed
history. These painful episodes may be simulated
by other disorders which may be placed under
the letters spelling out P-A-N-G, in the following
manner:
P ( Pericardifts
(Pleurisy
(Primary carcinoma of the lung
(Pneumonia
A (Aortitis
(Arthritis
(Aneurysm
N (Neuritis (herpes zoster)
(Neuralgia (intercostal)
(Nervous tension or anxiety syndrome
G (Gallstone disease
(Gastric ulcer (consider also cardiospasm
and hiatus hernia)
Angina pectoris is not just any kind of a pain
in the chest. It has distinctive features. The pain
originates, as a rule, under the upper part of the
sternum. It may radiate down the left arm or
the right arm, up into the neck or in all three
places. The pain is difficult for many patients to
describe, but is not a stabbing, throbbing, nor
cutting type of pain. It is usually more of a
constricting kind that causes the patient to be
almost breathless for the time being. It is a type
of pain which the patient feels he would be unable
to tolerate for a very long period of time; but,
fortunately, the pain lasts not more than five
minutes to ten minutes and recedes, as a rule,
automatically. Furthermore, it is relieved im-
mediately by nitroglycerine. When the pain dis-
appears, the patient feels about as well as he did
before the anginal attack occurred. Another feature
is that the pain in angina pectoris in the early
stage occurs after exercise or after an emotional
strain. Months may elapse between the first attack
of angina pectoris and subsequent episodes.
Anginal pain sets in suddenly, after exercise
or emotional strain; it is vague in type and short
in duration. A pain which has been coming on
for several hours is not anginal.
The prognosis of angina is usually good, but,
of course, it may develop progressively into a
more serious coronary insufficiency and end with
coronary thrombosis. It should be emphasized,
however, that it is a mistake to treat angina pec-
toris too severely and to modify the life of the pa-
tient too greatly, as the patient may develop an
apprehensiveness and fear of death which is not
justifiable.
A simple modification of the patient’s occupa-
tion, such as giving up two jobs and taking care
of one, an adjustment of the patient’s habits,
such as excessive smoking or drinking, and, par-
ticularly, the giving up of coffee either entirely
or almost entirely may be beneficial for patients
with the anginal syndrome. Such drugs as peri-
trate, nitroglyn, aminophylline, or some of the
other vasodilators are frequently of great help. If
overweight prevails, reduction of weight is always
advised.
In angina pectoris decubitus, that is Stage two,
conditions change a little. Exercise no longer is
necessary to precipitate pain, but the angina may
occur at rest or lying down, and frequently in this
stage slight exertion, as walking a block, may pre-
cipitate the attack of angina pectoris. Sweating,
dizziness, and dyspnea are not features of these
early stages of coronary disease. The pain of
angina pectoris decubitus is frequently brought
about by lying down, but this is not always true.
It may come on spontaneously when the patient
is sitting up. The prognosis, in this condition usu-
ally becomes worse.
Angina pectoris decubitus is treated quite like
angina of exercise, but more consideration must
be given to this disorder. The pains are more
frequent and the outlook is more serious than in
angina pectoris of exercise. Angina pectoris de-
cubitus, for example, may require that the patient
give up his occupation, at least for a while, and
control the painful symptoms as best possible.
Within recent times the question of the use of
a diet in the treatment of angina or early coronary
disease to control the atherosclerosis of the coro-
August, 1957
989
ACUTE CORONARY DISEASE— MURPHY
naries has attracted more than ordinary attention.
In the diet the control of cholesterol is considered
to be a valuable procedure. Without going into
this phase deeply, the following ideas may be
briefly epitomized.
1. There is no unanimity of opinion as to how much
value low cholesterol diet has in the treatment of any
coronary condition.
2. The relationship between the cholesterol in the
diet, the blood cholesterol, and the atherosclerosis of the
coronary system has not been completely formulated
(Page).
3. The blood cholesterol on practically every patient
should be determined with any type of coronary disease.
If the blood cholesterol is high, for example, 300 or
above, he should be on a low fat, low cholesterol, diet
in an effort to control the hypercholesterolemia.
4. There is little doubt that hypercholesterolemia has
a relationship to the atherosclerosis of the coronary sys-
tem, but how much of a factor it is and what the other
factors are has not been explored completely.
5. Unless there is a positive hypercholesterolemia, it
is not considered justifiable to modify a patient’s diet
or his life to try to obtain a result which may not be
obtainable or even desirable.
In stage three, the term acute coronary insuffi-
ciency has been used to designate this type of epi-
sode. As stated before, in these cases the coro-
nary artery is not entirely plugged, but the
circulation has been diminished to a point where
small areas of infarction develop, especially in
the endocardial area. How, then, does this dif-
fer from angina pectoris described above? One
used to have considerable difficulty trying to make
a proper diagnosis when a patient had an anginal
type of pain which lasted two or three hours or
more instead of for five to fifteen minutes and
who later failed to have the accustomed picture
of coronary thrombosis. Masters seems to have
solved the problem quite satisfactorily when he
introduced the term “acute coronary insufficien-
cy” to designate these minor types of infarction,
differentiating them from acute coronary throm-
bosis. In such cases, the pain starts as angina pec-
toris but continues for a number of hours. The
patients in this category do not suffer the shock
and collapse that is so common in acute coronary
thrombosis. The pain subsides and the patient
feels fairly comfortable. The electrocardiogram
usually reveals distinctive changes, but not those
of a genuine myocardial infarction. The main
thing is that the prognosis is entirely diff erent than
in an acute coronary thrombosis, in that most pa-
tients with acute insufficiency usually recover and
the length of time required for treatment is a
matter of two weeks or three compared with six
to eight weeks or longer in the other type.
While the term “acute coronary insufficiency”
is not the most desirable designation for group 3,
it has become fairly well established in the liter-
ature and its features have been well delineated.
The concept of “acute coronary insufficiency” as
distinct from coronary thrombosis is not entirely
new, as it first appeared in German literature in
the early 1930’s. The belief is that the incidence
of this acute coronary insufficiency is much greater
than that of coronary thrombosis, but since the
attack of acute coronary insufficiency is rarely
fatal, postmortem studies have been meager. Mas-
ters thinks that while there are an estimated one
million attacks of coronary thrombosis annually
in the United States, probably one and one-half to
two million attacks of acute coronary insufficiency
occur each year. However, acute coronary insuffi-
ciency must not be taken too lightly, as it does
represent a type of attack of coronary disease which
may terminate fatally. It is a stage of coronary
insufficiency which is more severe and serious
than angina pectoris on one side and less serious
and severe than coronary thrombosis on the other.
The treatment naturally differs from acute cor-
onary thrombosis in the following ways: (1)
Shock is not present; (2) the patient may be out
of bed sitting in a chair after one week; (3) the
home treatment may be for a period of one to
two weeks; and (4) anticoagulants in treatment
are not necessary. Most patients make complete
recovery within a period of several weeks and may
resume their occupation.
Stage four, the stage of the acute coronary
thrombosis with a myocardial infarction, which
extends through the wall from the endocardium
to the pericardium, usually is ushered in dramat-
ically by pain in the chest, shock, sweating, vom-
iting and collapse. The diagnosis is not usually
difficult, provided the history reveals previous
bouts of chest pain. However, in the absence of
a careful history, such things as acute abdominal
emergencies, perforation of a peptic ulcer, gall-
stone colic, mesenteric thrombosis, hemorrhagic
pancreatitis, dissecting aneurysm or acute bowel ob-
struction may have to be considered carefully.
Failure to operate upon some of these acute ab-
dominal emergencies spells death for the patient,
while, on the other hand, an operation on a pa-
990
JMSMS
ACUTE CORONARY DISEASE— MURPHY
dent with acute coronary disease carries the same
disastrous prognosis.
The chart below may help to differentiate the
acute coronary disease from abdominal catastro-
phies.
Coronary
1. Pain seldom localized
in abdomen. Usually
well above nipple line.
2. Abdomen may be dis-
tended.
3. Patient not content to
lie flat on back.
4. Neck veins full and
distended.
5. Cyanosis, dypnsea, and
cough significant.
6. Electrocardiogram
helpful.
Abdominal Disease
1. Pain localized in ab-
domen.
2. Abdominal wall rigid.
3. Patient lies flat and re-
mains as quiet as pos-
sible.
4. Patient pale, pasty and
appears bloodless.
5. Cyanosis, dyspnea and
cough absent.
6. X-ray reveals free air
in abdomen in case of
perforation of an or-
gan.
Pulmonary embolism may develop and it some-
times causes great confusion with the coronary
artery disease. Further, coronary artery disease
and pulmonary embolism may occur almost co-
incidentally. The shock and collapse in acute
coronary thrombosis is rather characteristic, and
the fall of blood pressure is not merely a drop of
15 to 20 millimeters of mercury but it is extensive,
let us say from 150 to 80, associated with the
shock syndrome.
The usual method of management of the patient
with acute coronary thrombosis (myocardial in-
farction) is set in a fairly rigid pattern. For
example, shock must be combated, the pain con-
trolled, and the arrhythmias, or heart failure,
which may accompany the attack, must be treated
carefully.
The usual, almost automatic, routine for the
treatment of this condition will be discussed briefly;
first, the controversial aspects of treatment which
have developed within recent times will be con-
sidered.
Shock requires attention first. Vasopressor
drugs, particularly norepinephrine (Levophed) in
doses of 5 mgm. per liter of five per cent glucose
in water may be given two or three times a day,
if necessary. However, if heart failure is imminent,
the amount of intravenous fluid must be controlled
more cautiously. Therefore, Wyamine may be
given intramuscularly, or intravenously without the
large quantity of fluid. The use of blood trans-
fusions is not as popular today as it was formerly,
since they have not proved to be very effective in
the treatment of the shock of coronary thrombosis.
The pain of coronary thrombosis is seldom of
such intensity that drastic measures are necessary.
Relief of pain may be obtained best by moderate
doses of Pantopon or Demerol rather than mor-
phine. Morphine more frequently causes nau-
sea, vomiting and respiratory depression. How-
ever, in some rare cases, one must resort to mor-
phine. If the pain tends to be prolonged over an
hour or two, the use of 100 milligrams of heparin
intramuscularly repeated every few hours is often
effective. Although nitroglycerine under the ton-
gue is usually of no help in the case of acute cor-
onary thrombosis, nitroglyn may prove of value
two or three times a day.
Oxygen is given automatically and routinely in
all patients with acute coronary attacks, and the
patient’s chest is elevated to dispel dyspnea and
orthopnea. Since acute pulmonary edema of left
ventricular failure may occur, this constitutes an
important complication. The dyspnea, the frothy
sputum and the bubbling rales in the chest are the
chief features. When this occurs, it is best to have
the patient sit in a chair rather than lying in bed.
Pantopon or morphine may save the situation.
However, Demerol may even be better. Rapid
digitalization is necessary, and the best way to pro-
ceed is to give immediately .45 milligrams of Cedil-
anid or Digoxin intravenously, repeated three or
four times a day as needed. Aminophylline in
doses of l/i grains in 20 cc. of 5 or 10 per cent
glucose may be given intravenously slowly, and
then 2 cc. of a mercurial diuretic given intramus-
cularly will act as an adjunct agent in the treat-
ment.
During an attack of acute coronary thrombosis,
paroxysmal ventricular tachycardia may constitute
a major threat to the patient. The chief treat-
ment consists of giving quinidine or Pronestyl oral-
ly, repeated every few hours until the arrhythmia is
controlled. Pronestyl may be given intravenously
in serious cases. Ordinarily, the total dose should
not exceed one gram. It must be pointed out, too,
that if an A-V block or a dissociation occurs, these
constitute a contraindication for quinidine or
Pronestyl. At times, auricular flutter or fibrilla-
tion sets in suddenly. In this case, the oral or
intravenous administration of Digoxin or digitoxin
may be given and repeated until the arrythmia is
August, 1957
991
ACUTE CORONARY DISEASE— MURPHY
controlled. Quinidine may then be used to con-
vert the flutter of fibrillation into sinus rhythm.
Controversial Issues in Treatment
Within recent years there has been no unan-
imity of opinion regarding the use of the follow-
ing in coronary disease : (a) Anticoagulants, (b)
the armchair method of treatment, and (c) blood
transfusions in the treatment of shock.
It is becoming clearer that most, but not all,
patients with coronary occlusion should receive the
necessary anticoagulant treatment. As pointed
out by Wright, there are over one million coronary
occlusions in this country in a year and the death
rate is 20 per cent. He and his followers believe
that anticoagulant treatment should be started
in every case where a diagnosis of coronary occlu-
sion is made. Russek, on the other hand, has been
an exponent of the idea that one can divide
patients with acute coronary occlusions into good
and bad risks. He believes that in good risks,
anticoagulants, such as Dicumarol, may be more
detrimental than beneficial; he agrees that in the
bad risks anticoagulants are indicated. All agree
that anticoagulant treatment (Dicumarol) is con-
traindicated in case of liver damage, especially
from congestion, hepatitis with jaundice, ulcers,
particularly gastrointestinal ulcers or ulcers which
hemorrhage from any place, or in any case where
there is a hemorrhage in the body, especially in
acute cerebral hemorrhage.
Experience with the anticoagulant drugs em-
phasized the need for very careful prothrombin
studies, as the giving of anticoagulants in the
absence of these studies is a dangerous procedure.
Naturally low prothrombin time has occurred in
congestion of the liver, nephritis, especially the
hemorrhagic type, ulcers, and so forth. Within
the past four or five years the almost routine use
of anticoagulants has predominated in the man-
agement of patients with coronary occlusion.
The early ambulation of the patient with cor-
onary occlusion is nothing new. Years ago, all
patients were treated after a rest of three or four
days, and the results were not very good. It has
become almost automatic to keep the patient with
acute coronary occlusion or thrombosis in bed at
least six weeks. This procedure has become some-
what modified lately and now it is more common
to individualize the patients. Some may require
a long period of bed rest and others about half
as much. Levine has been the sponsor to a large
992
extent of the armchair method of treatment. In
the chair position, the legs are in a dependent
position. The venous return to the heart is re-
duced as well as the load on the left ventricle.
This eventuates in a reduced load on the heart,
but it increases the cardiac output. From a per-
sonal standpoint, I prefer to keep the patient in
bed for at least a few weeks, unless heart failure
develops, when chair treatment is certainly advan-
tageous.
The use of a transfusion when there has been
blood loss or following an operation has advan-
tages that are not exhibited nor to be expected
in the shock of coronary thrombosis. There is
danger in the use of a transfusion in coronary
thrombosis, giving rise not only to a fear of over-
burdening an already harassed heart, but also
to the fear of a renal shutdown. Intra-arterial
transfusions have proved unsatisfactory. Although
a transfusion may be beneficial in a few cases,
there is very little significant benefit observed in
those given a transfusion over those who had none.
Personally, I prefer not to use them.
Summary
Coronary disease has been considered in four
stages in which the disease may progress, from
Stage one to Stage four. In Stage one, which is
Heberden’s angina pectoris, only palliative treat-
ment is required. Stage two, the angina decubitus,
may indicate that an acute coronary thrombosis
is imminent. Stage three occupies a position be-
tween angina pectoris and coronary thrombosis.
This stage, known as acute coronary insufficiency,
has a characteristic clinical picture, a clear-cut
type of prognosis, and a fairly definite type of
pathologic change in the coronary system and the
heart itself. The treatment and prognosis are quite
different from either angina or a coronary throm-
bosis. In Stage four, coronary thrombosis, the
diagnosis is usually made without any great diffi-
culty. The prognosis in these cases, in distinction
from Stages one, two and three, is bad. The
treatment of acute coronary thrombosis is asso-
ciated, in the hands of the most skillful, with a
mortality rate of from twenty per cent to twenty-
five per cent during the acute attack. In treat-
ing acute coronary thrombosis, the automatic rou-
tines practiced by nearly everyone have been re-
viewed, and the controversial aspects of the use
of anticoagulants, blood transfusions and the period
of bed rest necessary have been discussed briefly.
.TMSMS
Upper Peninsula Medical Society
Annual Meeting, June 21-22, 1957
Abstracts of Papers Presented
REGIONAL ENTERITIS
By Arnold S. Jackson, M.D.
Milwaukee, Wisconsin
Since President Eisenhower’s illness and surgery,
interest in regional enteritis has been reawakened
and the controversy regarding its proper treatment
has increased.
The writer feels that the term regional enteritis
is preferable to terminal ileitis, since the disease
may occur in any part of the small or large intes-
tine. In 1937, a report of four cases, one of
which occurred in the jejunum, was reported and
the disease designated as regional enteritis. The
etiology of this condition is unknown, and opin-
ion differs as to whether resection or a short-cir-
cuiting operation is preferable. Many cases go
unrecognized for a long time, and frequently the
patient is subjected to an unnecessary appendec-
tomy.
The important signs and symptoms of the dis-
ease are reviewed, together with the roentgeno-
logic findings, and its surgical treatment is con-
sidered. Brief abstracts of the author’s case his-
tories are presented and conclusions presented.
THE FRACTURED WRIST
By G. J. Curry, M.D.
Flint, Michigan
The upper extremity is just as good as the hand
on its distal end. A functioning hand is dependent
upon a functioning wrist joint. Wrist fractures
that heal well in a satisfactory position, but with
stiff fingers are bad results. Those that heal with
a residual deformity but with good neighboring
wrist joint function may be classified as good re-
sults. A compromise is apparent. A functioning,
useful hand, at the expense of a deformity follow-
ing reduction and healing, is more acceptable than
the reverse.
This presentation will be a discussion of frac-
tures involving the distal radius and ulna. Diag-
nosis, management and objectives will be empha-
sized according to generally accepted principles in
fracture care.
The fractured wrist represents an injury to a
person, specifically involving a part. The regime
of management must be planned with the constant
philosophy of functional restoration to the neigh-
boring joints and should embody some type of ade-
August, 1957
quate fixation that will permit a mobility poten-
tial.
PRESENT TRENDS IN INFANT FEEDING
By M. Cooperstock, M.D.
Marquette, Michigan
The past several decades have witnessed radical
changes in the nourishment of infants. The sim-
plification of artificial feeding, together with the
modern tempo of living, have greatly influenced
the trend away from breast feeding, despite its rec-
ognized advantages and the well-known fact that
the majority of women are potentially able to nurse
their babies successfully in the early months of life.
The so-called self-demand method of infant
feeding presently in vogue represents a radical de-
parture from the rigid techniques of the recent
past. This swing to a Dermissive attitude in infant
feeding has tended to encourage practices not in
keeping with basic, scientifically established stand-
ards. The present self-regulatory method, in
which the infant is permitted to consume as much
as he likes when he likes, often leads to a caloric
intake greatly in excess of requirements, with re-
sultant abnormally large gains in weight and ac-
companying gastro intestinal disturbances. The
present tendency to the early introduction of solids
often compounds these difficulties and, in fact,
has no sound rationale. For the infant with an
allergic background, the early introduction of solids
may both accelerate and exaggerate allergic ten-
dencies.
There also appears to be an inclination toward
too early employment of unmodified whole cow’s
milk. While under ordinary circumstances no
harm may ensue, recent studies point strongly to
inherent dangers in the use of unmodified milk
in the early months of life. By virtue of its high
protein and ash content, unmodified cow’s milk
imposes upon the immature kidneys of infants a
much greater solute load to be disposed of than
does breast milk or properly modified milk for-
mulas. The infant receiving unmodified milk in
the early months may find himself in serious straits
during periods of heat stress. The margin of safe-
ty against dehydration, already refuced by loss
of water from fever, vomiting, diarrhea or sweat-
ing, may be further comprised by the increased
water requirements necessary for the disposal by
the kidneys of a large solute load.
993
UPPER PENINSULA MEDICAL SOCIETY
GENERAL PRINCIPLES IN THE
MANAGEMENT OF FRACTURES
By Harrison L. McLaughlin, M.D.
New York, New York
A fracture is not a broken bone; it is an injured
person. The goal of fracture treatment is neither
bony union in good position, full joint motion and
strength, nor even full function and a complete
absence of symptoms; it is to return the patient
to his usual activities as soon and as nearly normal
as possible. The way to treat a fracture is not
to put the ends of the bone together and immo-
bilize in a plaster dressing until union occurs; it
is to accomplish a reduction which inflicts a mini-
mum of additional tissue damage, to establish fix-
ation which interferes a minimum amount with
the continued function of the uninjured adjacent
structures, and to maintain maximum total func-
tion of the injured person throughout the healing
period.
THE TIME FACTOR IN THE CARE
OF EXTENSIVE BURNS
By Grover C. Penberthy, M.D., and
Nicholas S. Gimbel, M.D.
Detroit, Michigan
The survival of the extensively burned patient
depends not only upon the procedures that the
physician decides to carry out, but also upon his
sense of timing. Bum care will be analyzed from
the standpoint not only of what should be done,
but when and how rapidly. Shock therapy, blood
transfusion, nutrition, debridement, anesthesia, and
skin grafting will be discussed from the stand-
point of time and rate.
From the Surgical Department, Wayne State Univer-
sity Medical College.
TREATMENT OF URINARY
TRACT INFECTIONS
By Harold J. Walder, M.D.,
Duluth, Minnesota
Infections of the urinary tract are second only
to respiratory infections as the most common types
afflicting man. A challenging problem is chronic
urinary infections caused by a choliform-aerogenes
group of bacteria. Before instituting therapy, data
on in vitro activity of the drugs against the offend-
ing organisms or desirable in selected cases.
Mandelamine continues to be a valuable urinary
antiseptic, and is frequently used in many types
of infection, particularly in patients who are not
to be under constant observation, such as post-
operative urinary calculi patients and patients who
have undergone prostate surgery. The sulfon-
amides are still effective therapeutic agents, when
used alone, or occasionally in combination with
antibiotics in indicated cases. Nitrofurantoin has
limited application, and is reserved for use when
other drugs, including antibiotics, have failed to
give expected response to therapy. Penicillin,
streptomycin and novobiocin are rarely indicated
for chronic infections. Chloramphenicol and the
tetracycline drugs are valuable for infections due
to Gram-negative organisms, while polymyxin is
specifically indicated for infections due to Pseudo-
monas aeruginosa. Neomycin has a wide range of
activity against a wide range of organisms, al-
though it has serious toxic side effects.
Attention is called to shock caused by invasion
of the blood stream by Gram-negative organisms.
Prompt therapy requires not only antibiotics but
pressor agents as well, and at times corticosteroids.
It is obvious that all physicians may not have ac-
cess to a bacteriologist who can isolate and identify
infecting organisms. Efforts to obtain such fa-
cilities will be rewarded by obtaining favorable
results in otherwise chronic and undesirable fail-
ures. No rules or charts can take the place of
judgment which is necessary in the treatment of
each patient.
From the Duluth Clinic.
From the reports available, it must be concluded that
ACTH and cortisone have extensive potentialities for
research annd limited therapeutic application in the
field of cancer.
* * *
The use of hormones as therapeutic agents is limited
to those cases in which more generally accepted meas-
ures have failed or are not applicable by reason of the
nature of the tumor or of its spread.
* * *
ACTFI and cortisone have limited value in the ther-
apy of acute leukemia, myeloma and malignant lym-
phoma.
A high index of suspicion and a thorough investiga-
tion on the part of the first physician to see the patient
with cancer is the sine qua non of early diagnosis.
* * *
Of 162,731 people having chest x-rays for tuberculosis,
eleven were found to have cancer of the lung, a rate
of 19.2 per 100,000.
* * *
The prognosis for cure of gastric cancer has remained
bleakly discouraging, but some progress in curative surg-
ical therapy has been achieved.
994
JMSMS
Peroperative Cholangiography as a Routine
Procedure in Biliary Tract Surgery
T) EROPERATIVE cholangiography is a useful
and informative procedure in biliary surgery,
but its acceptance as a routine part of the gall-
bladder operation has been met with reluctance.
We have noted, and this is well substantiated in
the literature, that the number of calculi found
in common ducts increase with the number of
ducts explored. Lahey1 stated that 39 per cent
of his patients with proven common duct stones
had no history of jaundice. For the above reason,
and other similarly related ones, along with the
simplicity of the procedure, we have made per-
operative cholangiography a routine part of our
gall-bladder surgery.
The procedure and its advantages have been
known for many years, although it has never been
widely utilized. Reich2 first described its use in
1918 when he investigated an external biliary fis-
tula by injecting the fistulous tract with a thin
mixture of petrolatum and barium paste. By this
method he obtained an accurate roentgenographic
pattern of obstructed bile ducts. In 1929 Cotte3
suggested the advisability of contrast cholangiog-
raphy at the operating table, but he soon dis-
missed the procedure as difficult and not too con-
venient to perform. In 1931 Overholt4 reported
its first use in the United States. Professor Miriz-
zie5 of Argentina published the first large collected
series of ninety-one cases in 1932. Since that time
there have been numerous articles in the litera-
ture concerning the value of peroperative cholangi-
ography along with various modifications in its
technique.
The term peroperative cholangiography refers
to a roentgenographic examination of the gall-
bladder system by direct injection of a dye into
the biliary tree. It has the same indications1 for
its use as exploration of the common duct, that is,
(1) history of jaundice, past or present, (2)
thickening and dilation at the ducts, (3) small
fibrotic gall bladder, (4) cirrhosis of the liver,
(5) small stones in the gall bladder, (6) thickened
muddy bile, (7) suspected or palpated stones in
the common duct and (8) enlargement of the
Saul Sakwa, M.D., and Milton L. Sorock, M.D.
Detroit, Michigan
head of the pancreas. In addition to the reasons
above which have been enumerated by Lahey,
we list (1) anomalies of the biliary tract, (2) dis-
tortion or interruption of continuity of the biliary
tract and (3) the location and number of stones
present in the biliary tract as additional important
indications for its use.
As we have stated above we feel that cholangi-
ography done in the operating room should be a
routine procedure in all gall-bladder surgery.
Most of the cases operated upon will fall into
the enumerated indications above. Several years
ago it was noted that the mortality in cholecystec-
tomy was 6.5 per cent. This increased to 10 per
cent when choledochostomy was added. In the
present day the mortality from cholecystectomy
and choledochostomy is practically negligible. The
danger today is not in performing common duct
exploration but in avoiding it and overlooking
common duct stones. This could lead to one or
more multiple subsequent operations. The sub-
sequent operations are usually for a developed
complication and this of course would increase
the morbidity and even mortality.
Because we know that every patient having
stones in the gall bladder is a potential candidate
for calculi in the extrahepatic ducts, some method
of exploring the ductal system should be per-
formed. Intravenous and oral cholangiography
are of some help but are not the final answer.
Most surgeons will admit that they have missed
calcui even after opening the common duct and
exploring mechanically. Most of us will agree
that if we can make a satisfactory diagnosis con-
cerning the status of the extra hepatic ducts
without opening them, it would be most desirable
since any trauma to the ducts by physical means
would then be avoided. In our experience per-
operative cholangiography has given us another
very satisfactory tool to add to our armamentari-
um for use in gall-bladder surgery. Our series
has not been extremely large, but it has been
sufficient to present convincing statistical data. In
our hospital it has been convincing enough so
August, 1957
995
BILIARY TRACT SURGERY— SAKWA AND SOROCK
that almost every surgeon has used the procedure
since we first presented our results. In many of
these latter cases the results have been most
gratifying.
The method we employ is a simple one and
we wish to emphasize certain points regarding
the technique and ease of performance of the
procedure. The patient must be in a horizontal
position so as to avoid shadows which may be
superimposed by the vertebrae. A cassette holder
is placed under the patient in the proper position
and a preliminary 8x10 film is taken before the
patient is anesthetized. This insures us that the
x-ray equipment is working satisfactorily and that
the proper focus has been obtained. This will
allow for corrections in the timing and exposure
of subsequent films. Following this the patient is
anesthetized and prepared in the usual manner
for surgery. Towel clips and other metal objects
are kept out of the field as they might produce
obscuring shadows on the film. The cystic duct
is carefully dissected and exposed. A ligature is
then placed around the duct. A small transverse
incision is made in the duct to expose the lumen
and a No. 6 ureteral catheter is threaded towards
the common duct. The previously placed ligature
is then tightened around the cystic duct and
catheter. This prevents extravasation of dye and
bile into the field. Following this all instruments
are removed from the operative site and a sterile
towel placed over the wound. The x-ray machine
is properly positioned over the operative site. The
anesthetist then hyperventilates the patient to ob-
tain a control period of apnea in order to avoid
blurring due to respiratory motion. When the
anesthetist and x-ray technician are ready, 10 to
15 cc. of 35 per cent Diodrast is injected into the
ureteral catheter and a film is taken. Care must
be taken to avoid the presence of any air bubbles
in the syringe as these may simulate calculi in
the common duct. Following performance of the
above procedure we usually wait for the results
of the roentgenogram. In our hospital this takes
from three to four minutes. We have noted that
others proceed with the removal of the gall blad-
der during this waiting period in order to save
time. We hesitate to do this as there may be an
occasional instance when the use of the gall blad-
der for an anastomosis would then be indicated or
an anomaly of the ductal system may be demon-
strated. For these reasons we explore the duct if
our cholangiogram so indicates and then remove
996
the gall bladder as a final procedure. If our
roentgenogram report is normal, we of course
avoid any further exploration of the ducts.
There are other methods used in performing
peroperative cholangiography, and these should
be mentioned. One may open the gall bladder
and thread a catheter into the cystic duct. We
have done one case by this method with good re-
sults. At times there may be a complete stenosis
of the cystic duct or it may be difficult to thread
a catheter into the duct because of an impacted
calculus or a blockage of the catheter by the valves
of Heister. When this occurs, injection of dye
directly into the common duct by a needle and
syringe may be necessary. In several of our cases,
patients having had previous cholecystectomies
gave indications for common duct exploration be-
cause of symptoms such as jaundice. It is obvious
that in these patients opening and exploration of
the common duct by mechanical means was nec-
essary. Following exploration a T-tube is inserted.
In such cases we strongly stress the fact that no
patient should leave the operating room unless a
choledochogram is performed through the T-tube
prior to abdominal closure. This will prevent the
embarrassment of overlooked calculi and the re-
turn of the patient to the operating room for an-
other operation. In our small series two such oper-
ations might have been prevented. In a series of
406 cases reported by Mixter, Hermanson and
Segel,7 they found that out of 146 patients in which
cholangiography through the T-tube was per-
formed, nineteen (13 per cent) showed stones
still present after the common duct had been
explored. These calculi would have been left
behind had not a roentgenogram been performed
before closure of the wound.
Our series, although comprising only thirty-
seven cases, has given us some very interesting
data and has made many of our colleagues aware
of the need for performance of peroperative
cholangiography. The predominant symptoms
noted in our patients were colic, jaundice, pru-
ritus, and some form of epigastric distress, as il-
lustrated in Table I. The methods employed were
the ones we have enumerated above and listed in
Table II.
In most of the. cases we desired and attempted
to obtain x-rays prior to surgery either by the
oral intake of dye or intravenous cholangiography.
We then used these preoperative results and com-
pared them with the technique employed at the
.TMSMS
BILIARY TRACT SURGERY— SAKWA AND SOROCK
TABLE I. SYMPTOMS
Colic 35
Jaundice 8
Pruritus 1
Epigastric distress 37
operating table. Although we are fully aware of
the information to be gained by intravenous chol-
angiographic studies preoperatively, we still feel
that direct injection of dye into the ducts is the
most accurate method of determining the status
of the biliary tree. Fifteen of our thirty-seven
patients had intravenous cholografin studies prior
to surgery. In seven of these patients (46.6 per
cent) we found disagreement with the results ob-
tained at the operating table. This is noted in
Table III. In six of these patients we had pre-
operative evidence for performing choledochos-
tomy in one case the cholografin study was de-
scribed as normal. At operation the six cases
presented a normal peroperative cholangiogram,
and the common duct was not explored. These
patients have subsequently done well with no
postoperative complaints. In the one case in
which we had a normal study preoperatively, a
calculus was noted in peroperative x-ray examina-
tion and a choledocholithotomy was performed.
We are well aware of the fact that changes can
occur from the time the patients are seen pre-
operatively and the time they are taken to the
operating room. For this reason we advocate that
not one single diagnostic procedure is sufficient
and that peroperative cholangiography should be
performed with all biliary tract surgery.
In our thirty-seven cases we have found sixteen
in which there were definite indications for the
use of peroperative cholangiography. This in-
cludes the cases previously mentioned in whom
preoperative intravenous cholografin studies were
performed. In two of the cases choledocholithot-
omy was performed with no check x-ray on the
operating table following surgery. A postopera-
tive T-tube cholangiogram revealed calcui in the
common duct, and these people were returned to
the operating room for further surgery. Six of
the cases showed complete or partial obstruction
of the dye at the duodenum. In all six cases the
ducts were opened and explored. Calculi were
found in four and a carcinoma of the ampulla
of Vater was found in two. Many surgeons ex-
perience difficulty in outlining the pattern of
the biliary tree either because of anomalies or
TABLE II. METHODS EMPLOYED
Catheter in cystic duct 12
Open gall bladder and thread catheter into cystic duct 1
Inject directly into common duct 3
Inject through T-tube 21
Total Cases 37
TABLE III. COMPARISON OF INTRAVENOUS
CHOLOGRAFIN STUDIES WITH
OPERATIVE FINDINGS
Intravenous cholangiography Operative x-ray findings
1 Calculus in common duct None found
1 Dilatation of common duct Normal ducts
2 Poor visualization of common duct Normal ducts
1 Question of calculus in the common duct Normal ducts
1 Unsatisfactory film Normal ducts
1 Normal biliary tree Common duct calculus
because of distortions resulting from previous in-
flammatory reactions in the operative area. This
was noted in three of our patients, and the ex-
cellent x-rays obtained were helpful in deter-
mining our situation and allowing us to procede
with assurance. These patients were spared pos-
sible trauma to the ductal system. In three other
patients common duct explorations were avoided
by the use of peroperative cholangiography. These
three patients gave possible evidence of common
duct pathology on the basis of previous intra-
venous cholografin studies. One of the cases pre-
viously mentioned concerned the removal of a
calculus in the duct after a previous cholografin
study was read as normal. Our final case was
interesting in that our patient’s oral cholangio-
gram revealed retention of dye within the gall
bladder for almost forty-eight hours. A blockage
at the cystic duct was suspected, but no pathologic
condition in the common or hepatic duct was
noted at the operating table and so confirmed
with peroperative cholangiography. Only chole-
cystectomy was performed in this particular case.
Case Reports
Case 1 .■ — Mrs. E. F., aged forty-six, was admitted
with a long history of colic and fatty food intolerance. On
admission, patient was jaundiced. An intravenous cho-
langiogram was taken before surgery and read as normal.
At surgery an operative cholangiogram was taken with
a catheter in the cystic duct. This revealed a dilated
duct and no dye entered the duodenum. The common
duct was then explored and the calculus found at the
ampulla of Vater. Repeat x-ray through a T-tube fol-
lowing the choledocholithotomy showed normal passage
of dye into the duodenum (Figs. 1, 2 and 3).
Case 2. — Mrs. C. F., aged fifty-seven, was admitted
with two attacks of colic but no jaundice. Preoperative
August, 1957
997
BILIARY TRACT SURGERY— SAKWA AND SOROCK
Fig. 1. (left) Intravenous cholan- Fig. 2. (center) Peroperative chol- Fig. 3. (right) Calculus removed
giogram. Common duct between ar- angiogram. Catheter in cystic duct. from common duct. Now have free
rows. Read as normal. Common duct visualized. No dye flow of dye into duodenum.
enters duodenum. Reflex up pan-
creatic duct.
Fig. 4. (left) Oral cholangiogram, Fig. 5. (center) T-tube chol-
preoperative. Calculi noted in gall blad- angiogram eight days postop-
der and common duct. eratively, showing calculus re-
maining in common duct.
Fig. 6. (right) Operative cholangio-
gram taken after patient returned to
operating room and calculus was re-
moved.
intravenous cholangiogram revealed calculi in the com-
mon duct and gall bladder. Patient was taken to the
operating room, and a cholecystectomy and a choledo-
cholithotomy was performed. No x-ray was taken before
patient left the operating room. Prior to patient’s dis-
charge from the hospital a T-tube cholangiogram was
performed and a common duct calculus noted. This
necessitated return of the patient to the operating room
for a second procedure (Figs. 4, 5 and 6).
Case 3. — Mr. A. G., aged fifty-eight, was admitted
with a six-week history of jaundice. Patient was taken
to the operating room and explored. The common duct
was opened and nothing was found. A T-tube was
placed in the common duct and a cholangiogram per-
formed. No dye passed into the duodenum. The duo-
denum was then opened and a carcinoma at the ampulla
of Vater was discovered (Fig. 7).
Case 4. — Mrs. L. S., aged fifty-seven, was admitted
with a one-year history of colic and one episode of
jaundice. An oral cholangiogram taken preoperatively re-
vealed calculi within the gall bladder. In the operating
room a catheter was placed in the cystic duct and a
998
.TMSMS
BILIARY TRACT SURGERY— SAKWA AND SOROCK
cholangiogram taken. This revealed a common duct
which was dilated and contained several calculi. There
was also partial obstruction at the duodenum with re-
flux of dye into the pancreatic duct. After choledo-
cholithotomy the cholangiograms were normal and dye
passed freely into the duodenum (Figs. 8, 9 and 10).
Summary and Conclusion
The routine use of peroperative cholangiogra-
phy in all biliary tract surgery is suggested. Def-
inite indications for its use, methods employed and
the technique we prefer is discussed. A series of
thirty-seven cases is presented. This series, al-
though small, points out the advantages in using
a direct examination of the biliary tree. A com-
parison between peroperative and intravenous
cholangiography is made. Finally, four interesting
cases are presented demonstrating convincing evi-
dence for employing peroperative cholangiography
as a routine procedure in all biliary tract surgery.
Fig 7. T-tube cholangiogram at time of
surgery, revealing constriction at ampulla.
Fig. 8. (left) Oral cholangiogram.
Calculi within the gall bladder noted.
Fig. 9. (center) Peroperative chol-
angiogram. Catheter in cystic duct.
Partial obstruction at ampulla with
reflux of dye into pancreatic duct.
Fig. 10. (right) Peroperative chol-
angiogram after choledocholithotomy.
Free flow of dye into duodenum. Ob-
struction relieved.
References
1. Lahey, F. H. : In discussion on Best, R. R., and
Hecken, N. F.; Cholangiographic demonstration of
biliary dyskinesia and other obstructive lesions of
the gall bladder and bile ducts. J.A.M.A., 107:
1615-1620 (Nov. 14) 1936.
2. Reich, A.: A petrolatum bismuth paste in bile ducts.
J.A.M.A., 71:1555, 1918.
3. Cottee, G. ; Sue l’exploration radiologique directe
avec injection deliprodal expres cholecystectomies.
Bull et mem. Soc. Nat. de chir., 8630871, 1929.
August, 1957
4. Overholt, R. : Biliary tract visualization with ra-
diopaque oils. Surg., Gynec. & Obst., 52:92-97,
1931.
5. Mirizzi, P. L.: Cholangiography during operations
on the biliary tree. Bal y Trab, de la soc. de cir de
Buenos Aires, 16:1133-1161, 1932; Operative
cholangiography. Surg., Gynec. & Obst., 65:702-
710, 1937.
6. Lahey, F. H.: Common and hepatic duct stones.
New England J. Med., 207:685-690, 1937.
7. Mixter, C. G. ; Hermanson, L., and Segel, A. L. :
Operative cholangiography: evaluation of 406
cases. Ann Surg., 134:346-350, 1951.
999
Geriatric Rehabilitation
TTTITH the expediting of principles relating
’ * to geriatric rehabilitation, one must doff the
scientific hat to Howard Rusk. He has become a
modern reincarnation of Sir Francis Bacon. It
was he, indeed, “who rang the bell that called the
wits together.”
In our great rehabilitation centers — be they the
numerous university hospitals or the “name
clinics” such as Mayo, Lahey, Ford — there is
created a saturation point in partially repaired
human beings, short of discharge.
Now comes the day, when the fearful and the
halt must leave the institution and continue their
rehabilitation at home.
At this point, I must rely upon the metaphor
of the bergamot plant. You recall that it occa-
sionally sends a bold shoot from the center of
the flower, bearing a bud that eventually unfolds.
That is what the geriatric reha'bilitant must do
— he must bloom again.
The friends and relatives of this half-repaired
creature must forever eradicate the false notion
from their brains that they are dealing with a sec-
ond class citizen. At once the motto should mate-
rialize: “Here is a first class citizen, who is but
temporarily disengaged.”
The Home Physician
Somewhere, after discharge and before the pas-
sage of a millenium, an essay must be composed
by the rehabilitation hospital of initial procedures
and forwarded to the doctor on the firing line.
This message need not be filled with smoke-
screen trivia, but must boldly hew to some verities
for immediate reference and future guide.
From past experiences, I would nominate an
outline of its contents as follows:
1. A working diagnosis is greatly desired. Such
words as “guarded” and “undetermined” do not
sound as though the master might be speaking.
2. There should follow some reasonable medi-
Presented before the Rehabilitation Work Shop, An-
nual Conference on Aging, Ann Arbor, Michigan, July
10. 1956.
Courtesy, Journal of The American Geriatrics Society,
March, 1957.
C. Howard Ross, M.D.
Ann Arbor, Michigan
cal exploration of thought that might support the
diagnosis.
3. What instructions were given to the patient
on discharge?
4. What prescriptions did the hospital phar-
macy pour into his lap? Are these bottles decently
labeled, indicating the actual drug content within?
Are such outmoded expressions: “Take as di-
rected” given new birth to plague both patient
and home physician? If Nervous Nellie labels
confuse the patient, don’t think for a moment that
they will enlighten the attending man.
5. What are the specific instructions from the
master-minded clinic to the Medico in the home
field?
It is sad to relate that a lapse of time performs
a disservice to the continuation of proper therapy.
It is sadder to record that a total absence of a
letter of instructions plays havoc with all medical
efforts. And to tease the elasticity of faith still
further, a poorly written and “C minus” type
of theme might as well have reached the dead
letter office, rather than bang together frayed wits
and battling exasperations.
Home Base
Now comes the evaluation of home base for the
partially rehabilitated. Shall the leash be 25,000
miles long with all the world to rove in, including
spa visits? Are there limitations to the county,
the township, the town? Is just the immediate
neighborhood permissible for roaming? There are
some who can endure only house and yard. Others
will be satisfied to settle for bed, bath and com-
mode. Some can manage bed and wheel chair.
Alas, we must face it, finally comes the last group
involving bed patients only.
Regular Follow-up
The physician who attempts to carry on the
procedures of rehabilitation must bounce in upon
the patient both physically and spiritually. The
fatherly statement, “If you need me, call me,”
never fills the bill that aggressive instructions and
follow up will do. When the doctor’s face is
1000
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GERIATRIC REHABILITATION— ROSS
eternally absent, a new gloom settles in the sick-
room. “He’s too busy” is the answer. “Too busy
with what?” He deals not with dogs and cats and
horses but with human beings. This one soul
under discussion belongs to that latter category.
To be pompous, to be hurried, to be detached — -
gain no notes of response. If one cannot heal, then
he must, at least, inspire. Here are some modified
Ruskisms to tuck within your philosophy:
“It is still worth while to recover.”
“If I cannot restore the organ, then I will restore
the man.”
“Do not mourn for that which is lost, but rejoice for
that which is left, and live and work with it.”
“Avoid the fiddle-faddle of inconsequence.”
“Learn to thrive on short clover.”
Patients’ Needs
The half-healed victim requires certain bodily
and spiritual aids that are evident from the first
moment of care. Besides cleanliness of teeth, body
and feet, and the usual amenities of civilization,
there arises the “cry of the bowels” and “the wail
of constipation.”
I find that most patients, partly rehabilitated,
can permit their intestinal tracts to profit from
the following formula of fruit compote:
/i pound dried apricots.
14 pound dried prunes.
/t pound dried figs.
14 pound raisins.
Soak over night in equal quantity of water,
pound for pint. That results in two pounds of
fruit in two pints of water. In the morning, bring
to a boil. Immediately, turn down the burner to
simmer for an hour. This produces plumpish and
appetizing fruit bodies. Cool and place in refri-
gerator. Each morning serve a liberal bowl of
compote, covered with fresh fruit juice, varying
each day for flavor change.
Just before breakfast, insert a glycerine rectal
suppository. Just after breakfast, expect a bowel
movement. If no bowel movement results, offer a
pint of warm tap enema, with patient on left side.
Eventually, we obtain a “breakfast bowel,” and
later the compote need be served only twice a
week.
At this stage, it is high time that a religious
comforter make his regular appearances, be he
rabbi, priest, preacher or Christian Scientist prac-
titioner. No physician in his right mind would
exclude those who preach hope and who have
developed a broad philosophy of life. Dogma
may be left with a baby sitter in the parking lot.
I have had no problems with the Christian
Scientists. Once the healing process sets in, and
the level of expectancy is outlined, there is the
same philosophical positivity that is expressed in
other faiths.
The matter of diet deserves more than passing
interest. It has been shown on numerous occasions
that old folks, under duress, fail 25 per cent in
proper food intake. Proteins and iron-bearing
foods are on the “dodge list.” A legitimate tonic
of vitamin content is always permissible for both
physical and psychic stimuli.
I have a favorite “pep pill” that I offer the old
folks twice a week, which improves the appetite
and aids the consumption of 75 to 90 grams of
protein a day. It is concocted as follows:
Place a scoop of steamed spinach or other green
vegetable upon a goodly slab of partially broiled
liver. Hollow the spinach to hold a dropped-in
raw egg. Sprinkle over the top some Parmesan
cheese and lay on two rashers of partially cooked
bacon. Place this concoction under the broiler
and cook till the egg has jelled. By this time the
other ingredients are done to a nice turn.
I once had an old lady serve this type of
“pep pill” to an entire assemblage of rehabilitated
geriatric guests.
Established Routines
As the days become established, routines of care
must of necessity follow logically. There are occa-
sions for toilet, moments of exercise and massage,
time for bath, rest, wheel chair rides through the
garden, and later: occupational therapy.
The patients’ complaints must be listened to and
some degree of alleviation obtained. The patient
who suffers from perseveration may even break
his sad routine and offer a new thought. If so,
take him up on it.
The routine of the day must be sound but not
deadly. A few moments of diversion always get
under the skin, such as the new baby next door,
newly hatched chicks, the pups in the kennel,
the shelf of African violets, the artistic endeavors
of some member of the family and the mutually
created endeavors in some neighborhood work
shop.
August, 1957
1001
GERIATRIC REHABILITATION— ROSS
Danger Marks
The mop board should possess a wee night
lamp for proper guide to the bath room.
All scatter rugs should be removed. Let us not
add a broken hip to the present calamity. Grandpa
plus slide equals disaster.
Non-skid rubber mats, bearing mild corruga-
tions, should pave the passage ways. All steps
should be removed or ramped or conquered with
hand rails or parallel bars plus firm treads.
Strong hand bars must be installed over the
bath tub. Better yet, a rubber tabbed chair can
be placed in the tub or shower. Whenever pos-
sible, avoid the sponge bath and let the patient
shower himself under his own steam. Such mild
activities, if at all permissible, will prevent stale-
ness of mind and body, to say nothing of decubital
ulcers. A fixed hot water thermostat will prevent
scalding.
I try to avoid all barbiturates. They are inclined
to make the patient stiff of limb and contrary of
mind. There is the possibility of deterioration of
character. A warm drink and reassurance are good
assets. A mild pain reliever, combined with codeine
or tranquilizer, offers comfort occasionally. There
is no success as good as lying down and simply
going to sleep after a fruitful day.
Relatives will please deposit their favorite
gadgets in the nearest gravel pit. I have had good
progress delayed or exploded by some fast-talking,
gadget-minded relative, plunging all gain to a
standstill. I am thinking of electric belts and mis-
information flitting between ultra-violet and
infra-red lamps, to say nothing of vibrators. A
loud and thumping vibrator over the heart of a
coronary patient was not appreciated nor was
the tachycardia quickly controlled.
The toys of the grandchildren function as death
traps. Grandma on a false leg takes a ride to her
doom on a loose roller skate. Let the children
bring in their smiles and their kisses but keep their
toys beyond the reach of geriatric trip-ups.
The same advice holds regarding sloppy house-
keeping. When piles of unused materials begin to
show and when articles are disposed of by tossing
them into the corners, it is time to fire the house-
keeper. If an enfeebled person steps out of bed
onto a blob of splashed water or a tossed cloth or
a dirty tray and loose dishes, slippery from recent
egg and syrup, that is the purified sign of crimi-
nal negligence.
Rubbish must be disposed of in regular and
orderly fashion. In a sick room, I once witnessed
a hurried and worried daughter pile up clean
diapers, dirty diapers, groceries and rolled garbage
into a foul and stinking, leaning tower of Pisa,
awaiting the first breeze or fickle whim of gravity
to splash danger and disaster onto an enfeebled
ancestress.
Education
Years ago, my father attempted to prove that
you can teach an old dog new tricks. His subject
was a fourteen-year-old mongrel. The educational
period lasted only seven days, but the eager old
canine chalked up a repertory of six well-estab-
lished stunts in that short time.
In like manner, these geriatric and partially
incapacitated people may be educated along many
lines, beyond the mere demands of physical re-
habilitation. While the body is being taught to
mend and to establish newer and different meth-
thods of self care, the mind and the crafts can
also be reassociated. I have had a one-armed
accountant painfully learn to write and figure
with his left hand. But better still, he assumed
newer powers of mental arithmetic and arrived at
conclusions in faster time than his competitors.
He finally was dubbed the “human adding-ma-
chine.”
Grandma Moses has been reincarnated so many
times that I hesitate to bruise her further. Just
the same, in my practice I am caring for a hemi-
plegic, who has learned to paint with her left
hand. The first proud nautical scene hangs above
her fireplace for all to see and admire. Even I
admit, without confusion, the separate identities
of water and ships! Daily victories must be won.
An intensity of accomplishment produces the after-
glow. The gladiator fights with a paint brush!
Kindly refer to the summary for variations on
this theme extending to other fields.
Personal Appearance
Nothing is so depleting as the reflected view in
the mirror of a haggard old man or a hag view
of the female. Doll up Grandma and urge the
elderly male to shave and put on clean clothes.
When orderly appearances becomes an expected
routine, the better the opportunity for other fea-
tures of personal hygiene to appear.
Self care and the conquering of the toilet needs
become the poured concrete foundation of all
1002
JMSMS
GERIATRIC REHABILITATION— ROSS
geriatric rehabilitation. It is useless to discuss
prosthetics without emphasizing esthetics. Here
enters Dr. Bortz’s human husbandry. Here is the
keystone in the arch of psychic rehabilitation. If
we are denied a whole man, let us settle for a
partial man, but may he be a sanitary individual.
Freshness from without will inculcate durability
within.
Practical Applications
The previous discussion has set the pace gener-
ally. I will select some practical suggestions in the
post-diagnostic and therapeutic fields as follows:
The Hemiplegic. — Many of these patients never
reach the rehabilitation centers but are cared for
at home by relatives or friends. Such care may
be of the so-called occasional and drop-in variety
and is, therefore, dangerous, as there is no con-
sistency to its quality and no persistency to its
drive. The physician must lay down the law of
human care, to avoid hopelessness in attempting
to escape from calamity.
Let us assume that a proper course of hypoten-
sives has been instituted and that thundering
orders have been given regarding care of bowels,
bladder and skin.
To describe a hemiplegic, one must conjure
the thought of a so-called healthy person who
suffers a headache of unusual intensity and sud-
denly becomes helpless in one leg and arm, with
or without unconsciousness and with or without
facial distortion.
The affected upper extremity is apt to be found
in adduction and internal rotation, with flexion
of elbow, wrist, and fingers. The lower extremity
may be merely weakened or may demonstrate
complete helplessness with flexion and abduction
at the hip joint. The knee may be flexed partially,
and the ankle is, on occasion, found to be plantar-
flexed, with some degree of supination. Rusk
recommends a posterior ankle splint to prevent
shortening of heel cord. He places a pillow in
the axilla to prevent abduction and internal rota-
tion of the shoulder. Passive movements are
started early, including abduction, external rota-
tion and overhead position. These movements are
repeated several times a day to prevent “frozen
shoulder.” Rusk deplores this shoulder deformity
and the shortened heel cord.
If the relatives are ignorant people, they can
at least be trained in full-range passive motion
and mild stretching, to say nothing of infra-red
bakes, and Epsom salts fomentations and mild
massage. In a simple home of lowly folk, I have
obtained excellent results merely because the
attendant and the victim never gave up and
insisted upon improving upon residual disa-
bilities.
When walking begins, one can employ Rusk’s
double-bar short leg brace with stump attachment.
The patient is less apt to suffer fear in flexing the
knee and hip with such an arrangement. Walking
begins by moving right arm and left leg forward ;
then the left arm and right leg. Try not to let the
affected arm hang motionless. Parallel bars soon
enter in. The helpless hand may be attached to a
sliding ferrule, to ease the glide and prevent
excoriation. Progress and prognosis vary with
the original lesion and the Id of the patient.
Right hemiplegia in a right-handed person
demands newer skills and further education for
the left hand. While difficult, it can be done.
As soon as muscle tone is partially established,
muscles must be re-educated to begin actively
what has been accomplished passively. Rotate the
shoulder, flex the arm, pronate and supinate the
hand, rotate the arm internally and externally and
extend the fingers.
Victory is declared for only small accomplish-
ments such as the first lifted piece of bread to
the mouth, though they fall far short of final
expectations. A handy rocking fork with knife
edge becomes a universal feeder.
As soon as possible the patient makes it to the
commode or the bathroom toilet. A wheel chair
with disappearing toilet vent may be wheeled
directly over the toilet. Soon the patient can
strong-arm himself onto the toilet seat itself.
There are long plastic handles that enclose proper
wads to perform cleansing toilet strokes to be
followed by damp application if desired.
There are many one-armed devices that aid in
self-assistance, such as the one-handed typewriter
keyboard, one-handed telephone aid, one-handed
wheel chair drive with removable arm rest.
Speech therapy may require a specialist in the
field. However, most patients partially recover
their wordy needs with aid of family and physi-
cian, beginning with word-naming episodes of
life and climbing up to expressions describing
every day situations.
A close member of my own family remained
August, 1957
1005
GERIATRIC REHABILITATION— ROSS
unconscious for weeks, yet finally learned to walk
again, to talk after a fashion and to play the
piano with much resounding vigor, albeit there
were a few limps in the sextet from Lucia.
One must hope for enough improvement in
four to five months to prognosticate eventual levels
of rebuilding. Deformities should be prevented but
treated when and where they occur.
The Paraplegic. — My experience with the para-
plegics begins when the rehabilitation center has
left off. A typical case is the elderly man with
the traumatized spinal cord or suffering from
other pathology. He is apt to be a wheel-chair
and bed invalid. However, the folding chair per-
mits rides in the car. He must be trained to
manipulate himself to the toilet, to his bed and
bath.
There is gross weakness in the lower limbs,
which may demonstrate some spasticity. The legs
may be flabby and atrophic or somewhat stiff
and heavy. As the disease progresses, the tendon
and plantar reflexes become diminished or disap-
pear. The patient may subjectively suffer from
burning, tingling or coldness. There is generalized
wasting. Jerky movements of the ankles may
produce traumatic and slow-healing ulcers over
the tendo-Achilles.
The bladder problem assumes a high position
in family care. Condom-catheter drainage is an
ever present aid, but urinary infections must be
guarded against. There is some slight hope of
bladder training. The gloved finger titilation may
start the morning bowel function. An occasional
enema and the employment of the fruit compote
both are legitimate aids.
The family physician becomes a giant of
strength. He must buoy up morale, watch the
general nutrition with critical eye and think in
broad terms of general health. The patient must
be severed from his bed by his own power or by
the power of the hovering attendant.
As much rehabilitation as the traffic will bear,
with a plus bonus, should be insisted upon and
followed up. Here is where hope beyond vanity
and courage beyond audacity enter the picture
and blot out the element of retreat.
A high protein diet, with good skin care, hovers
in the background of constructive morale. If a
decubital ulcer develops, simple warm compresses,
mild infra-red therapy and powder-puff all are
of assistance. Far advanced cases may require
skin graft.
Active motion of the entire mobile portion of
the body must be indulged in daily. Passive mo-
tion of all flaccid members, plus heat, wet and
dry, and massage are daily musts.
The patient sets a standard to manipulate him-
self from chair to bed and back to chair; from
chair to toilet and back to chair; from chair to
tub seat or shower seat and back to chair.
Later, with push ups, he may so strengthen his
shoulder muscles that he may push himself to
the car, enter and with hand controls and hand
brakes, succeed in driving with safety.
The patient becomes adept at buttons, snaps,
zippers. Pretied elastic shoe laces are a gift from
modern invention.
The economic and social disasters must be
overcome. Relatives and close family members
must not yield to discouragements. The family
physician, the psychiatrist, the physiotherapist and
the visiting nurse must rehearse in advance to
secure a united front of positivity.
Educational adventures for the mentally alert
may take them well past self-care. Walking with
braces may be accomplished. Such extension
courses as illustrative art and accounting could
fill the spare moments of the day. In my prac-
tice, a paraplegic earns a partial living in crea-
tive advei'tising art. An elderly professional man
has now become a bookkeeper and wheels himself
to his office quietly and efficiently.
One must avoid a return to infancy and de-
pendency. Accomplishments become majestic in
scope. Vegetative existence, with deterioration in
mental outlook, can be squashed by physical and
psychic exercises that could bear economic fruit.
The patient can become more self-reliant as his
productivity mounts. His irascible moods subside
to those of moderation and relaxation. He un-
dergoes a second maturation in his older years.
The Amputee. — In discussing the amputee, I
will confine my remarks to those geriatric pa-
tients who are not mentally afflicted. There must
exist an urge to improve and an ability to be
taught the logistics of the battles of rehabilitation.
Whether the amputation resulted from trauma
arteriosclerosis, Raynaud’s, diabetic gangrene 01
Buerger’s disease, the principles of self-care anc
the conquering of handicaps remain within thf
close confines of related solutions.
1004
TMSM!
GERIATRIC REHABILITATION— ROSS
We hope to inherit a patient with well-healed
stump and without flexion deformity. I can well
recall a man seventy-seven years of age who was
sent home from his surgeon with palliative below-
the-knee stump following arteriosclerotic gang-
rene. There was no thought of ambulation
the time of amputation. At home both patient
and physician brought up the subject, against
the prejudice of the relatives. A one-legged,
prosthetic-wearing representative from a rehabili-
tation firm came to call on demand. He brought
along a one-legged, well-prosthetized assistant and
a one-legged, excellently prosthetized salesman.
These three angels of rehabilitation hopped about
the home, up and down stairs, in and out of doors,
with the agility of male fleas. Our patient was
fascinated. We fitted his prosthesis with an extra
heavy stump-stocking and gave him a walker.
By the next month, he was out hoeing his garden!
Since he was already retired, our strong endeavors
were to return him quickly to his self-care, his
gardening, his wood-carving, musical instrumenta-
tion and other avocational hobbies. He lived long
and died happy.
Many a geriatric patient must first walk on a
pylon or a mid-leg prosthesis before the high
artificial limb may be attempted. A walker, a
crutch, parallel bars for all are aids, but Grandpa
must eventually take off. Shoes must be well-
filled, both on the remaining foot of flesh and
the foot of the prosthesis. The toe nails must
secure good nontraumatic trimming, and im-
promptu paring operations are to be avoided.
As walking begins, it should be given in doses;
frequent rest periods, alternated with activity, give
the best results. This prevents muscle cramps and
psychic discouragement. Exposure to severe cold
and heat should be avoided. The patient re-
quires coaching as to clothing selection, body
care and personal hygiene. Swimming becomes
wonderful exercise, provided the pool is not too
chilly.
Soon comes the adjustment to home or job
or avocation. All associates must avoid psychic
trauma, and the element of pity falls to the
discard. The competitive visitors, who are trau-
matic snobs, may be excluded. “My stump is
worse than your stump” is no slogan for the day.
If an amputee has not yet retired, I see no
broad reason why he should do so. His work may
become modified to his new needs or he may take
on a part-time job. An executive may now be-
come a clerk. A mechanic may become an ap-
prentice instructor. A part-time hobby could
blossom into a livelihood.
The family must now look at itself in the mirror
and stop “mothering” the patient. Overprotec-
tion becomes deadening. The sad sack can now
be promoted to the efficient titan.
Bilateral above-the-knee amputations for the
elderly are almost, by definition, creators of
wheel-chair invalids. Some have succeeded in
becoming dwarfs with low fitting prostheses. For
myself, I would rather be metamorphosed into
an active dwarf than an inactive has-been.
The elderly arm amputee may select a masked
glove hand on his prosthesis, realizing that one
arm is for function and one is for show. How-
ever, my experience has covered a few men,
past sixty-five, who were properly fitted with
functional hooks on their prostheses. A farmer did
his own chores and could sling a bale of hay with
great ease. A mechanic, who owned his own
repair shop, maintained his earning power and
economic independence and could manage fine
calipering and delicate tooling.
I am certain that the ground has only been
scratched in the re-education of the elderly am-
putee. Much research in veterans’ rehabilitation
centers, including pectoralis loops, will eventually
be reflected into geriatric rehabilitation.
The Coronary Patient. — Several score of cardi-
acs would present a more challenging experience
for me than the multiple problems of one miser-
able sufferer from Parkinsonism. It is for this
reason that I shall dwell on the former and as-
sign the latter to minds more attuned to solving
such problems than my own. Also, my experience
has covered the placement of many coronary suf-
ferers back on the job, which so far is not true
in the case of Parkinsonism.
My activities with geriatric myocardial infarc-
tion begin with the home visit, continue through-
out hospital care and eventually take us back to
the home, and finally to work or satisfactory re-
tirement functions. These patients vary from the
amputee, in that I do not inherit them from
another service.
For the purposes of this paper, the patient has
been properly treated in the hospital and is now
home in the bosom of his family following dis-
charge. A typical selection could well be a pro-
August, 1957
1005
GERIATRIC REHABILITATION— ROSS
fessor, past sixty-five but not yet retired. He is
at his best mental peak, lectures with success and
is in the midst of writing a book. His rehabilita-
tion is essential for his family welfare and for his
own emotional and professional future.
The coziness of the hospital is now past. The
competition of life’s aggressiveness will soon be-
gin. The physician on the job must dig behind
the camouflage of casualness, that he may prevent
the creation of a chronic invalid on his hands.
“I am a heart patient” need not be quoted from
now to eternity.
The proud professor — who once looked down
his nose at his less fortunate brothers and thought,
“Oh, you miserable ones, how you must envy
me” — cannot now do an “umgekehrt” and say,
“Oh, you fortunate ones, how you must pity me.”
Throughout all of this “shall I, shan’t I”
episode, the physician assumes the stance of op-
timism. There may be sixty to ninety days in
and about home before responsibility in the work
or profession is again resumed. A year’s delay
would be deadly.
The awakening of sexual desire is, indeed, a
good sign and is the first evidence that life does
indeed go on.
The cardiac function and the patient’s physical
capacity must now be weighed medically. The
identity of the job at hand or the modification
thereof should be within the family doctor’s acute
consciousness as he evaluates the patient's possi-
bilities.
A home on one floor is desirable, but stairs can
be managed slowly and with measured tread.
A poorly informed physician and a well-healed
disability insurance policy make a bad combina-
tion to eliminate a functional neurosis.
In the younger geriatric group, sixty-five to
seventy-five, about two-thirds of my patients re-
turn to their jobs, to modified jobs, or to con-
structive retirement activities. Such disasters as
cardiac failure and cerebral accidents may enter
the picture, but so do they in other medical fields.
It is a mark of wisdom and world accomplish-
ment to go right back on the job and begin
where one left off. There is surety of knowledge.
That is where years of happiness were piled up
into a head of accomplishment and appreciation.
When a geriatric coronary patient has yielded
to the urge of invalidism for one or two years,
it is like lifting a horse over the fence to get him
into a gainful occupation, but with skill and
proper psychic sharp-shooting it can be done. A
community geriatric center and work shop may
serve as a good compromise. To do nothing is
to grow stale and musty. T o do something is a
sip of rich wine to the haggard. The physician
can well be the agent to higher level morale, with
independence and stimulus for life itself.
One of my amputees was transformed into a
coronary patient. He was in his eighties. When
he became ambulatory again, his first task was
to replace his prosthesis; his next step was a slow
stride through the parallel bars and then he set-
tled down to caning chairs for the bride next door.
The geriatric coronary farmer has much to
offer. The son or hired man can perform the
“slug work” but 50 per cent of the tasks are yet
available for father’s happiness, following his con-
valescence.
The plastic industries have done well with such
patients and have found them to be meticulous
in small matters and advisers in large affairs.
Witness, please, that great numbers of older
physicians, each one of whom has indulged him-
self in a myocardial infarction, then settled down
to a 50 per cent or plus practice with joy and
husbanded security.
Summary
In the matter of geriatric rehabilitation, I have
presented some of the problems and a number
of the victories.
Many classifications have been omitted due to
my ignorance or limited experience in undiscussed
fields.
I have outlined some of the phases of rehabili-
tation of the elderly: dealing with the family
physicians, the rehabilitation centers, home base
for the patient, follow-up techniques, patients’
needs, established routines, danger marks, educa-
tion and personal appearance.
There have also been included some practical
applications, having to do with the following
classifications of rehabilitants : the hemiplegic,
the paraplegic, the amputee, the coronary pa-
tient.
Let me repeat that activity and hope are the
two watchwords that brew the wine in an old
man’s soul.
In any community memorial center, a proud
multi-purpose social wing may be reserved for
(Turn to Page 1007)
1006
JMSMS
GERIATRIC REHABILITATION— ROSS
(Continued from Page 1006)
he geriatric citizenry, where the rehabilitants
nay mingle with their more fortunate fellows or
■quals.
As they come trooping in, whole or half-whole,
hink of these possibilities for their fulfillment:
1. Creative writing in the prose, poetry and
foreign language fields.
2. Styling creations and style shows.
3. Dramatics, both creative and recitative. Here
is a good opening for “The Man Who Came
to Dinner.”
4. Ceramics. In another paper, I have outlined
a quickie mix, consisting of powdered mold-
ers’ clay, powdered cement, dry water-mix
masonary paint and water to putty texture.
5. Artistic endeavors, including oil, water colors
and finger painting.
6. Wood carving, cabinet making, combined
with home endeavor.
7. Musical compositions and Geriatric concerts.
The public may come and applaud.
8. Dancing, by the lively ones and square dance
calling by the handicapped. Don’t think
that age prevents one from being “hep.”
9. Public speaking. Coach and be coached.
.0. Flower arrangements and gardening instruc-
tions. One can wield a hoe from a wheel
chair.
. 1. Pet shows and pet care. Mate up the para-
keets and watch the babies come.
12. Swimming participation. Unbuckle the pros-
thesis and hop in.
13. Ice review. The rehabilitants may create the
artistry. I once knew an old lady, who took
first prize in ice-skating at age eighty-one.
14. Camera clubs and prize displays.
15. History section. Original papers may be pre-
pared in conjunction with the local historical
Society.
16. Travelogues. Here one displays his glorious
past.
17. Leather work. Lesser dubs may be taught
by better dubs.
8. Hammered metal work. Noise does not mat-
ter.
9. Basket weaving. Carry home one product
in another.
10. Knit and purl groups. Even the proud male
may compete.
1. Americanization program. Here the foreigner
in our midst may absorb from the wise ones,
with heads still intact.
22. Tail-tale Club. There is no limit.
23. Stamp and coin hobbies. Much swapping
gets under way.
24. Doll making, and toy repairing for the grand-
children.
25. Health forums. Panel discussions are popular.
26. Typing classes. See text regarding one-armed
typist.
27. Nature study and bird watching. Nostalgic
reminiscing is permissible.
28. Food classes. Here Grandma can add pro-
teins, vegetables and fruits to her tea and
toast mainstay.
29. Marketing discussions. The dollar sign and
the calories are formally introduced.
30. Extension courses. These are available from
the nearest university.
31. Card playing. Other parlor tricks are not
excluded.
32. Practical nursing instructions. Fortunate re-
habilitants may be taught to care for the
less fortunate old folks.
You will note that by my state of breathless-
ness, I will not be able to bring up the subject
of Bingo. I have mentioned thirty or more pos-
sibilities. There are a hundred further slants in
these categories. Where will the instructors come
from? The old folks will sprout their own talent.
My remarks are directed and especially dedi-
cated to the younger family physicians of America.
These budding hopefuls must plunge into the
situations of rehabilitation in the geriatric fields,
where the rest of us have so timidly been treading,
up to this very moment of scientific penumbra.
References
1. Abramson, Arthur S., and Ebel, Alfred: Rehabilita-
tion in the management of prolonged illness. M.
Clin., North America, 37:915-932 (May) 1953.
2. Arthur, Juliette K.: How To Help Older People.
Philadelphia: J. B. Lippincott, 1954.
3. Bahlke, Anne M.: Rehabilitation of the handi-
capped. M. Clin., North America, 37:933-941
(May) 1953.
4. Bortz, Edward L.: Making life longer and better.
Geriatrics, 8:510-516 (Sept.) 1953.
5. Bortz, Edward L.: New goals for maturity. J.
Gerontology, 9:67-73 (Jan.) 1954.
6. Bortz, Edward L.: Stress and aging. Geriatrics,
10:93-99 (March) 1955.
7. Chalfen, Leo: Planning leisure-time activities of the
aging. Geriatrics, 10:245-247 (May) 1955.
8. Eisert, Otto: Dynamic exercises after lower ex-
tremity amputation. Rehabilitation of the elderly
amputee. Geriatrics, 11:65-70 (Feb.) 1956.
.ugust, 1957
1007
GERIATRIC REHABILITATION— ROSS
9. Feuer, S. G. : A realistic approach to rehabilitation
in geriatrics. J. Am. Geriat. Soc., 1:840-844 (Dec.)
1953.
10. Gitman, Leo: Blueprint for a geriatric center.
Geriatrics, 10:487-490 (Oct.) 1955.
11. Harpuder, K.: Rehabilitation of the patient with
arterial disease of the limbs. Geriatrics, 10:451-455
(Oct.) 1955.
12. Homburger, Freddy: The Medical Care of the
Aged and Chronically 111. Boston: Little, Brown
& Co., 1955.
13. Johnstone, Rutherford T.: The importance _ of
geriatrics in industrial medicine. J. Am. Geriat.
Soc., 3:117-119 (Feb.) 1955.
14. Kaufman, Jerome C., and Becker, Marvin C.:
Rehabilitation of the patient with myocardial in-
farction. Geriatrics, 10:355-361 (Aug.) 1955.
15. Levy, Robert L.: The coronary problem in relation
to aging. J. Am. Geriat. Soc., 1:821-825 (Dec.)
1953.
16. Lyons, Julia S., and Trulson, Martha F.: Food
practices of older people living at home. J. Geron-
tology, 1 1:66-72 (Jan.) 1956.
17. Mathiason, Geneva: The continued employment of
older workers. Geriatrics, 10:137-140 (March)
1955.
18. McClellan, Walter S.: Spa therapy and rehabilita-
tion of the aged. Geriatrics, 10:333-336 (July)
1955.
19. Mclntire, Ross T.: America needs the older handi-
capped worker. J. Am. Geriat. Soc., 2:203-209
(April) 1954.
20. New, Harold N. : Rehabilitation, the third phase
of medical care. Nebraska State M. J., 38:315-320
(Sept.) 1953.
21. Ross, C. Howard: Geriatric exercise. J. Michigan
M. Soc., 55:1222-1227 (Oct.) 1956.
22. Ross, C. Howard: Geriatrics and the aging person-
ality. J. Michigan M. Soc., 54:545-549 (May)
1955.
23. Rusk, Howard A.: Rehabilitation — a vital part of
civil defense. Geriatrics, 10:496-497 (Oct.) 1955.
24. Rusk, Howard A.: Total rehabilitation. J. Nat.
M. A., 45:1-16 (Jan.) 1953.
25. Rusk, Howard A., and Marks, M.: Rehabilitation
following cerebro-vascular accident. South. M. J.,
46:1043-1051 (Nov.) 1953.
26. Stieglitz, Edward J. : Constructive medicine in
aging. Geriatrics, 10:151-157 (Apr.) 1955.
27. Stieglitz, Edward J. : Geriatric Medicine. Medical
Care of Later Maturity. 3rd edition. Philadelphia:
J. B. Lippincott, 1954.
28. Stroud, William D.: Patients with healed myo-
cardial infarction should work. Geriatrics, 10:184-
188 (Apr.) 1955.
29. Tibbitts, Clark: Living through the older years.
Proceedings of the Charles A. Fisher Memorial
Institute on Aging. Ann Arbor: University of
Michigan, 1949.
30. Wachs, Moses: A day activity program in a home
and hospital for the aged. Geriatrics, 11:220-222
(May) 1956.
31. Walker, Weldon J.: Should the patient with a
healed myocardial infarction avoid physical exer-
cise? J. Am. Geriat. Soc., 3:959-963 (Dec.) 1955.
HISTORY OF HOUGHTON COUNTY MEDICAL SOCIETY
(Continued from Page 987)
fields, with a profuse exhibit, we have most de-
lightful prospects of a meeting to be remembered.
Dr. T. P. Wickliffe, President of the Upper Penin-
sula Medical Society, and his efficient committees
assure us of this.
I desire to mention a few of our men who have
added honor and medical advancement to our
Society. Dr. A. F. Laubaugh, of Calumet, served
as President of the Michigan State Medical So-
ciety in 1908. In fact, he was a pioneer surgeon
of note, doing laparotomy for a large abdominal
cyst, and operations for appendiceal abscess in
the early 1890’s, with success at Phoenix, located
far out in the Keweenaw Peninsula where he was
the mine doctor. His judgment was very keen,
and contributed much in consultations with the
doctors of this section. He passed away in 1921.
Drs. W. K. West, J. G. Turner, E. T. Abrams, H.
J. Joy, A. B. Simonson, and many others were
good practitioners. Specialists appeared upon the
horizon later. I take much pride in having known
these men very well, and in having had the op-
portunity for close association with them for many
years.
It is to the credit of the present active men in
the county that they are all maintaining the
standards of medicine established in the earl)
days, although under more favorable condition;
and with more assistance. Furthermore, our mean;
of transportation has greatly improved, and oui
association with clinics and greater centers o:
learning has given more and better contacts, fo
easier, better and more thorough advancemen
in medical learning.
1008
IMSM
Current Trends in Occupational Health
Seward E. Miller, M.D.
Ann Arbor, Michigan
RECENTLY, a leading industrial physician
made the statement that the development
of industrial health has been influenced more by
social change than by medical progress. This ob-
servation has been largely borne out in the meta-
morphosis which occupational medicine has un-
dergone in the past four decades. In the course
of this evolution, three distinct phases may be
identified: the accident and safety phase; the
occupational disease or industrial hygiene phase;
and the broad preventive industrial phase.
The first phase had its origin in the early part
of this century with the passage of workmen’s
compensation laws. Whereas, previously a work-
er could be discarded when he became disabled,
he now had a new security and some protection
under these laws. This social development pro-
vided an added incentive for industry to take
positive steps in accident prevention. In this ac-
cident and safety phase, industrial medicine con-
cerned itself almost wholly with traumatic sur-
gery and compensation medicine.
The occupational disease, or industrial hygiene
phase initiated by a broadening of the compen-
sation laws to include occupational diseases as
well as the industrial accidents, started around
1930. A sound basis existed for this legislation since
prior research had identified numerous occupa-
tional diseases. However, it should be noted that
even today in 1956 not all States provide for oc-
cupational disease compensation. During this era
industrial health services were largely confined to
traumatic surgery, industrial hygiene and com-
pensation medicine.
The broad preventive industrial health phase,
or health maintenance stage, started about 1940
just prior to World War II when a serious short-
age of industrial manpower was first experienced
in this country. It then became necessary to think
in terms of conserving the health of the worker
and fully utilizing the handicapped and older
Presented at the 91st Annual Session of the Michigan
State Medical Society Section Meeting, Detroit, Sep-
tember 26, 1956.
Dr. Miller is Director of the University of Michigan
Institute of Industrial Health, Ann Arbor, Michigan.
August, 1957
workers. Since that time, industrial health services
increasingly have given more and more attention
to preventive measures designed to maintain the
health and productivity of the worker.
Industrial Health Services
The changing character and scope of industrial
health programs have been largely dictated by
the prevailing social concepts of industry’s role
and responsibility for worker health. Thus, the
early industrial health services were primarily
based upon medical care for industrial illness and
injuries and the prevention of accidents and occu-
pational diseases. The physician’s work, there-
fore, consisted largely of pre-employment exami-
nations, traumatic surgery and compensation med-
icine. With an abundance of labor, pre-employ-
ment examinations at that time were primarily
designed to screen out of employment all but the
most physically fit. As industry has come to rec-
ognize the importance of conserving the total
health of the worker to keep him on the job,
industrial health services are becoming increas-
ingly oriented to the early detection and pre-
vention of all diseases — not only those related to
the occupation. The need for broad preventive
services and health maintenance programs is being
accentuated by the advancing age level of the
working population and the rising incidence of
chronic and degenerative diseases. This factor,
together with a tightening labor supply, has also
influenced the concept of the pre-employment
examination. Today, pre-employment examina-
tions are most properly termed preplacement ex-
aminations. They are designed to facilitate the
placement of the worker in accordance with his
physical and mental fitness so as to assure the
best utilization of his abilities and to safeguard
the health and safety of the individual and his
fellow workers. The matching of the worker’s
physical and emotional capacities to the job is
usually a joint activity with the plant personnel
department.
Likewise, periodic health examinations, especi-
ally of workers exposed to occupational disease
1009
OCCUPATIONAL HEALTH— MILLER
hazards and of those who need special follow-up,
have become an important function of many plant
health services. Periodic health examinations serve
to re-evaluate the physical and mental fitness of
the worker for his job, to detect early any adverse
effects from the occupational environment, and to
assist workers in maintaining good health. They
are particularly useful in the detection of non-
occupational disabilities before significant symp-
toms have arisen. In this early stage, many
disabilities are correctable without resulting im-
pairment of bodily function. Together with the
pre-placement examination, periodic examinations
offer unique opportunities for early case finding
of chronic diseases.
Recently, there has been a growing trend to
utilize more fully the opportunity afforded by the
preplacement and the periodic health examina-
tions for promoting and maintaining the health
of the worker. This is achieved not only through
the early detection of incipient developing disa-
bilities, but also by helping the worker solve his
health and emotional problems through health
counseling and appropriate utilization of com-
munity health and social resources. Corollary to
this trend, there has been a move toward special
education and training in health maintenance and
occupational diseases for industrial physicians and
nurses with emphasis on the preventive aspects.
It is being increasingly recognized that health
education and counseling are essential compon-
ents of effective health maintenance programs
in industry. With appropriate emphasis on such
health principles as the advisability of seeking
early treatment for illnesses, the importance of
adequate diet, and understanding of emotional
stresses, and the necessity for proper rest and rec-
reation, these services assist the worker to improve
and maintain his health status and efficiency, in-
crease his well-being, and prolong his years of
productivity.
Further, there is growing awareness that health
education and counseling have special contribu-
tions to make in reducing or alleviating the psy-
chosomatic symptoms resulting from the stress dis-
orders of modern life. These disorders are of
sufficient magnitude to pose a serious problem
to industry in terms of employe health and effi-
ciency. In addition to the neuroses and other
psychiatric conditions, a large area of lesser psy-
chosomatic illnesses exists which requires careful
attention. These developing emotional disturb-
ances frequently may be detected by alert, sym-
pathic and understanding industrial health per-
sonnel.
In the early phase, many emotional disturbances
do not necessarily call for a trained psychiatrist
but rather for a physician or nurse familiar with
psychological and emotional reactions who knows
the temperament of the individual, his occupa-
tional, home and community situation, and who
will give him sympathetic attention, understand-
ing and counseling. Properly trained industrial
physicians and nurses frequently can recognize
and assist the worker to solve a wide variety of
problems relating to home, family and finances,
as well as emotional conflicts relating to his work.
Through counseling, guidance and appropriate
referrals to medical and social community re-
sources, employes can be assisted to recognize and
overcome even more deep-seated emotional prob-
lems. To function effectively in his particular area,
as well as in the over-all field of employe health
maintenance, the industrial physician and nurse
must be familiar not only with the plant person-
nel and operations, but also with the community’s
health and social facilities.
Another development in the industrial health
field which holds great promise is the variety of
efforts being carried on to find ways and means
of providing health services to workers in small
plants. Such services are still not available to
about 70 per cent of our working population.
How to economically and effectively bring medi-
cal and nursing services to the workers in small
establishments represents one of the greatest pres-
ent challenges in the field of occupational health.
To date, three general types of industrial health
programs for small plants have evolved:
Community Sponsored Programs. — An excel-
lent example of community-sponsored programs is
the service offered by the Birmingham, Alabama,
Industrial Health Council. Established in 1947
at the instigation of the Chamber of Commerce,
the Birmingham Industrial Health Council now
serves over 300 small industries and business estab-
lishments.
In addition to a central clinic where preplace-
ment and special examinations are performed, the
Industrial Health Council provides mobile units
in which a battery of laboratory diagnostic tests
are given to each employe. These tests include
1010
JMSMS
OCCUPATIONAL HEALTH— MILLER
chest x-ray for tuberculosis, heart pathology and
lung cancer; blood test for syphilis; rapid blood
sugar test for diabetes; blood pressure reading;
weight and height measurements; electrocardio-
gram for all employes forty years of age or older;
eyesight test and tonometer reading to find glau-
coma; hearing test; hemoglobin determination;
and routine urinalysis. For follow-up care, pa-
tients are referred to their personal physician.
Each plant also is provided regularly with health
education materials and services.
Cooperative Programs. — An industrial health
service may be operated by several independent
establishments that jointly engage one or more
health personnel to provide regular services to
their employes at facilities in each of the several
establishments. In this type of program, a small
clinic or office is maintained in each of the co-
operating plants, and a physician travels on a
regular schedule to all in turn, spending as many
hours as the size of the plant and the nature of
the health problems dictate. It is important that
the plants be located reasonably near each other,
otherwise the physician’s travel time will be ex-
cessive. Many medium-sized plants with this type
of program complement the physician’s activities
with full-time or part-time nursing services. A
plan of this general type has been operated in
Hartford, Connecticut, for many years, and a
similar one was recently started in New Haven,
Connecticut. In each instance, six to eight small
and medium-sized firms have joined together to
share the services of a full-time industrial physi-
cian.
An industrial health service may also be oper-
ated by several establishments that cooperate in
engaging one or more health personnel, a physi-
cian and one or more nurses usually, to provide
regular health services exclusively to their em-
ployes at a single (central) facility which these
several establishments jointly maintained for that
purpose. In operations of this type, time lost by
the physician in traveling is eliminated, although
the employes must travel to and from the clinic.
The success of this type of operation depends
considerably upon how convenient the clinic lo-
cation is to the establishments using it since man-
agement and workers alike are reluctant to expend
too much time in travel.
Individual Programs. — In many areas of the
country, individual physicians have established
central industrial clinics to provide industrial med-
ical health and nursing services to surrounding
small industries. Such clinics may be found in
many cities, including Newark, New Jersey;
Cleveland, Ohio; Buffalo, New York; Seattle,
Washington; Portland, Oregon, and Milwaukee,
Wisconsin.
Some of these clinics are broadening their serv-
ices and are scheduling regular visits by the
physician and nurse to each of the participating
establishments for plant inspections, consultation
and services. This growing practice of bringing
the medical service to the work place by industrial
medical clinics is based on two acknowledged
needs : ( 1 ) that the industrial physician and nurse
know the working conditions and the physical
and emotional demands of the various jobs in
the establishments which they service, and (2)
that the industrial physician and nurse be regu-
larly available in the plant for service and for
health counseling and guidance.
The industrial medical clinic at Portland, Ore-
gon, illustrates the type of services offered by
such facilities. Its services include pre-employ-
ment and periodic physical examinations, im-
munizations, survey of work places for elimina-
tion of toxic and sanitation hazards, treatment of
occupational injuries and diseases, with emphasis
on early rehabilitation, and cooperation with the
local health department and voluntary agencies in
case finding, in controlling infectious and chronic
diseases, and in worker health maintenance.
Industrial Hygiene Services
With the increasing emphasis on non-occupa-
tional health measures, care must be taken to
avoid complacency toward the safety and indus-
trial hygiene aspects of industrial preventive
health services. New materials and processes are
being introduced daily into industrial establish-
ments. Physicians and nurses must know the
health hazards involved and work closely with
the industrial hygienists to carry out their joint
responsibility in protecting the worker’s health.
Where no industrial hygienist is available, the
physician must assume this responsibility and care-
fully familiarize himself with the particular haz-
ards involved.
Industrial hygienists and physicians are being
asked to participate in an ever-widening variety of
activities. More and more, their counsel is being
sought in planning new plants and redesigning
August, 1957
1011
OCCUPATIONAL HEALTH— MILLER
old ones, since this method of excluding potential
hazards has proved less expensive and more ef-
ficient than attempting to control hazards after
a building has been completed. Moreover, when
a change in manufacturing processes is contem-
plated, the industrial physician and/or hygienist’s
advice is being sought increasingly before hazard-
ous materials or processes are introduced. Pre-
ventive construction in all its phases is being rec-
ognized as a vital foundation stone of preventive
industrial health programs.
With the rapidly increasing utilization of atomic
energy and various forms of ionizing radiation in
industrial processes, industrial physicians and hy-
gienists are being called upon to protect workers
against a new and potent hazard, one you cannot
feel, hear, see, smell or become cognizant of
through any of our human senses. This has re-
quired learning how to use new instruments to
measure these hazards and to devise new tech-
niques to control harmful exposures. Here again,
industrial physicians and hygienists must work
closely with construction engineers to exclude
potential hazards as far as possible. At the same
time, the physician must plan for continuing per-
sonal protection of all exposed workers. In this
connection, let me urge every physician responsi-
ble for workers incurring exposures to any type
of ionizing radiation to keep accurate records of
the amounts of radiation each worker receives.
With the continuously mounting community
concern over air pollution, many industrial phy-
sicians and hygienists are studying the possible
health hazards involved. Both because of the po-
tential health hazards in air pollution and to con-
serve valuable materials now being lost, indus-
trial hygienists and engineers are being called
upon to devise economical ways and means for
reducing the amounts of materials being emitted
into the air from industrial establishments.
The control of health hazards on the farm is
also drawing upon the knowledge and skills of
industrial physicians and hygienists. They have
rendered particularly valuable assistance in de-
veloping safe methods for the handling of various
highly toxic pesticides and chemicals now being
used so extensively in modem agriculture.
Noise in industry is another problem that has
recently become of grave concern to the industrial
physician and hygienists, for exposure to excessive
noise may affect auditory acuity. To protect
workers from this hazard, the industrial physician
and hygienist have been required to master new
techniques and instruments for the measuring and
assaying of noise. In addition, they must exer-
cise great ingenuity in devising means of elimi-
nating, reducing and confining noise. At the
University of Michigan, a new technique is being
developed to determine the susceptibility of in-
dividuals to loss of hearing from exposure to ex-
cessive noise.
Discussion
The development and expansion of preventive
health services for workers in plants, both large
and small, require the united efforts of both in-
dustrial management and the health professions.
No one group has the responsibility, technical
knowledge, or skills required to do the complete
job. It requires joint study and planning on
the part of industry, management and the medi-
cal, nursing and engineering professions to evolve
satisfactory industrial health services to meet the
health needs of all workers in our rapidly progres-
sing technological society.
Two major situations need improvement: (1)
some type of industrial health program should be
brought to the seven workers in ten now largely
without preventive health sendee of any kind, the
majority of whom are employed in small estab-
lishments; (2) the health programs now available
to the remaining workers, employed mainly in
large establishments, in many instances need to be
expanded in the area of prevention or health
maintenance.
Today, in our efforts to expand and improve
industrial health services, we should take cog-
nizance of four cardinal factors that have been
found essential to the effective operation of in-
plant health programs:
1 . The primary aim of all such programs must
be to benefit the employe although indirectly, of
course, management also benefits. Programs con-
ceived and pursued wholly in management’s in-
terest are shortsighted and never become fully
effective.
2. The program must have management-labor
interest and support. The industrial health de-
partment must have assured status and be direct-
ly responsible to top management.
3. The medical personnel must be interested
( Continued on Page 1022)
1012
JMSMS
The Problem of the Biologic False Positive
Serologic Test for Syphilis
John A. Cowan, M.D., M.S.P.H.
Lansing, Michigan
1^ ECENTLY Earl Moore of Johns Hopkins
University was quoted in the literature as
stating that 40 per cent of 500 patients routinely
discovered to have positive serologic tests for
syphilis (STS) reactions were shown by means
of treponema pallidum immobilization (TPI)
tests not to have syphilis; they were biologic false
positive reactors. This figure of 40 per cent, even
considering the high economic-social level of the
patient, appears to be considerably higher than
reported by most other investigators. Nevertheless,
it would seem from information available at the
Michigan Department of Health and statistics
from other sources that the problem of the bio-
logic false positive is becoming increasingly great;
one that should be of considerable practical sig-
nificance to the practicing physician in his diag-
nostic activities. There are large numbers of
routine serologic tests for syphilis made every year
on the general population: routine physical ex-
aminations as part of the admission processes in
general hospitals, pre-employment examinations
in industry, premarital and prenatal examinations,
and as part of other legal requirements. If only
a small number of these tests are possible biologic
false positives, the total number of these cases
which would then be presented to the physician
as a diagnostic problem presents a major dilemma.
Although the major problems in connection
with biologic false positive serologic reactions pre-
sent themselves in relation to the diagnosis or
exclusion of syphilidc infections, recent medical
literature has pointed out an additional problem
in terms of diagnosis which appears to be of in-
creasing significance. There seems to be very little
question now that there is a relatively close re-
lationship between the chronic biologic false posi-
tive serologic reaction and the so-called collagen
diseases. More will be said about this later.
In the fiscal year 1954-1955 there were 4,858
new cases of syphilis reported in Michigan, with
approximately 400,000 serologic tests performed at
Dr. Cowan is Director, Division of Tuberculosis and
Adult Health, Michigan Department of Health.
August, 1957
the Michigan Department of Health laboratories
during that same period. In all probability, there
were an equal number of STS’s performed in local
registered laboratories throughout the state. The
majority of these are done for the diagnosis or
exclusion of syphilis. In most instances, the results
of such tests are reported on a qualitative basis
as either positive, negative, or doubtful. In all
biologic tests it is well known that there is pos-
sibility for error. Serologic tests for syphilis are
no exception to this rule. In spite of the fact that
this test has been considerably maligned in recent
years, all factors considered, it is one of the more
accurate of our laboratory tests. False positive
serologic tests do occur; whether these are as
frequent as some people think we are not sure.
However, it should be recalled that there are
also false negative results. False positive serologic
tests can be classified in two categories: the tech-
nical false positive and the biologic false positive.
The technical false positive can mean a laboratory
error, a mix-up in the reporting of the laboratory
results, or an error on the part of the physician
or technician in sending in a mislabeled specimen
of blood or serum. The other class of false posi-
tives, the biologic false positive, can be classified
under two categories, also.
Moore and Mohr1 in 1952 brought out the con-
cept that there are two types of biologic false posi-
tive reactors, “acute and chronic.” The acute
variety is characterized by its appearance during
or shortly after any one of a wide variety of acute
infectious diseases of varying etiology and by its
spontaneous disappearance (reversal to sero-nega-
tivity within a short time) after a few days, weeks
or months, rarely if ever exceeding six months
(after subsidence of the causative acute illness).
The chronic variety, on the other hand, “is
characterized by the fact that there is no identi-
fiable acute infection as a precipitating cause, and
that sero-positivity with standard STS does not
spontaneously disappear, but instead persists for
many years, perhaps even for a life time.”
Methods ordinarily used to determine whether
1013
SEROLOGIC TEST FOR SYPHILIS— COWAN
or not a positive STS might be a biologic false
positive include: (1) History of infection or treat-
ment (although histories in venereal disease are
notoriously inaccurate) ; (2) physical examina-
tion; and (3) history of certain diseases or con-
ditions which potentially may result in biologic
false positive reactions, such as infectious mono-
nucleosis, a recent bout of malaria, upper respira-
tory infection with fever, recent vaccination par-
ticularly with virus antigens, and sometimes preg-
nancy. It is characteristic of false positive reac-
tions that they tend to be of low titre. Frequently
there is a disagreement between precipitation tests
(Kahn, Kline, Mazzini, Hinton, V.D.R.L.) and
complement fixation tests (Kolmer, Wassermann) .
They also tend to vary in degree of positivity from
day to day and between laboratories. Often it is
necessary to carry such cases under observation for
many months before a decision can be made.
Complement fixation and precipitation tests are
ordinarily performed with a nonspecific antigen.
False positive reactions, given sometimes by both
complement fixation and flocculation tests, have
not been completely eliminated by improvement
in the methods, techniques, and materials used
today. Attempts to grow virulent treponema
pallidum in artificial culture media and thereby
provide sufficient specific antigen with serologic
tests, have hitherto failed. However, a new ap-
proach to the problem was made when Nelson and
Mayer2 devised the Treponema pallidum immo-
bilization (TPI) test for syphilis. Virulent T.
pallida were extracted from rabbit testes into a
special anaerobic media in which they were kept
alive and virulent for several days. This relatively
tissue-free suspension of living treponema was im-
mobilized when mixed with syphilitic serum in
vitro in the presence of active complement. No
such immobilizing effect was obtained with nor-
mal or a serologically false positive serum or in
the absence of fresh complement. Since a virulent
strain of T. pallidum was used, the TPI test was
considered a specific test for syphilis involving a
specific anti-treponema antibody. The validity
and specificity of the TPI test has been quite
well demonstrated by many observers including
Moore, Almon, Curtis, Shaffer, Miller, Chaco,
and others.
It has been established that under certain limita-
tions TPI tests can be utilized to distinguish the
biologic false positive phenomenon from syphilitic
infection with a marginal error of about 2 per
cent. Unfortunately, the TPI test is a complicated
biologic immunologic procedure requiring meticu-
lous care in its performance. It is susceptible to
technical difficulties which at times may interfere
with the validity of results of a given laboratory
over a period of weeks. It is time consuming and
expensive to perform and provides only qualitative
not quantitative results, since a satisfactory method
of quantitation has not yet been agreed upon.
Because of these defects, the TPI test is clearly
not utilizable on anything approaching a service
basis comparable to that of the standard serologic
test. Only a few laboratories in this country are
capable of its performance. In them the number
of specimens which can be accepted for diagnostic
purposes is sharply limited. None of this, how-
ever, impairs its value as an investigative tool.
In Michigan, TPI tests are being performed at
the Dermatological Research Laboratory, Univer-
sity Hospital, Ann Arbor, under the direction of
Doctor A. H. Wheeler. A charge of $25.00 is made
for the performance of these tests at this labora-
tory. The Michigan Department of Health Labo-
ratories have an agreement whereby the serum
from problem cases can be sent by the state labora-
tory to the Venereal Disease Research Laboratory,
U. S. Public Health Service, Atlanta, Georgia. No
charge is made for the service of this laboratory.
It is required that special history forms be made
out before sera are submitted. The laboratory
requests that only those sera be sent which involve
a diagnostic problem and in which the results of a
TPI examination would definitely be helpful in
coming to a diagnostic determination. Ordinarily
it takes from three to four weeks before the results
of the test are available, and at the laboratory in
Ann Arbor, Michigan, it requires from ten days
to two weeks to obtain the results.
Since the development of the TPI test by Nelson
and Mayer, other tests using specific treponema
antigen have been developed.3 These have been
stimulated, at least in part, in order to circumvent
the technical difficulties of the TPI test. These
tests include, (1) Treponema pallidum agglutina-
tion test,4 (2) Treponema pallidum immune-ad-
herence test, and (3) recently the Treponema
pallidum complement fixation test (TPCF). The
latter test has an antigen prepared from virulent
T. pallida by removing the lipid fractions and then
extracting the antigenic material. The resulting
antigen is used in a regular complement fixation
test. Preliminary results suggest that this test is
1014
JMSMS
SEROLOGIC TEST FOR SYPHILIS— COWAN
of value in the diagnosis of syphilis. The TPCF
test is being performed at the present time in a
number of laboratories throughout the United
States, and it is expected that more laboratories
will be making this test available in the near
future, provided preliminary results can be con-
firmed.
Incidence of the Biologic False Positive
Phenomenon
It is impossible to determine the incidence of
the biologic false positive phenomenon in relation
to the population of the United States as a whole
or of Michigan. We do know, however, that the
biologic false positive, acute or chronic, does occur
frequently. Moore’s estimate, that 40 per cent of
the patients in the high socio-economic levels and
high upper educational levels are biologic false
positive reactors, appears to us to be extremely
high. It is known that most of these cases would
be persons who have already been screened by
other physicians and were in all probability seen
by Moore in his special consultation practice.
Moore does state that from unpublished data in
an outpatient clinic of lower educational and
economic levels, only about 10 per cent of clini-
cally and serologically comparable patients are
biologic false positive reactors.
It has been brought out5 that in several of the
studies reported, including Moore’s, the high rate
of biologic false positive reactions was a result of
the fact that not a single test but a battery of tests,
such as the V.D.R.L., Mazzini, Kolmer, and Kline,
were used. If any one of this battery was positive,
even though the rest might have been negative,
this was called a biologic false positive. From this
it might be assumed that the high rate of biologic
false positives, in at least some of the reports from
the literature, is more apparent than real. Inci-
dentally, Curtis believes that the Kahn test picks
up collagenous disease less often than many of
the other serologic tests for syphilis.
In Michigan, we have been able to get some
indication of the relative frequency with which
practicing physicians believe biologic false positives
are occurring by the requests we receive for ap-
proval of special medical dispensations for mar-
riage under Michigan's premarital examination
law. During the three year period of 1953-1955
inclusive, seventy-six special dispensations for mar-
riage were approved on the basis of biologic false
positive serology. In 1954 and 1955, the sixty spe-
cial dispensations approved on the basis of biologic
false positive reactions approximated a little more
than 5 per cent of the total approvals. Because
the Michigan premarital examination law requires
that persons who have a positive or doubtful sero-
logy can get married in this state only after
approval of a special medical dispensation for
marriage, the biologic false positive phenomenon
becomes a matter of considerable practical im-
portance. The TPI test, valuable as it is, does
not seem to be a satisfactory answer to the prob-
lem of biologic false positives under the marriage
law for the reasons cited above, particularly
because of the difficulty in performance of the
test, the expense involved, and the length of time
before the results are known. The results, then,
are quite often only of academic interest. As this
problem is becoming of increasing importance,
not only in administration of the Michigan pre-
marital examination law, but also in other cases in
which the possibilities of biologic false positives
present diagnostic problems to the physician, the
development of other more adequate and more
practical tests, such as the TPCF test, is eagerly
awaited both by physicians and public health
people.
Relationship of the Biologic False Positive
to Certain Nonsyphilitic Diseases
The etiologic background of the chronic biologic
false positive phenomenon has been studied by a
number of investigators since 1948. Because evi-
dence suggests that these persons with chronic
biologic false positive reactions may have other
nonsyphilitic disease, particularly a disease of the
so-called collagen type, it has made the serologic
test for syphilis of greater importance than merely
determining the presence or absence of syphilitic
infection. Moore and Lutz state, “Indeed, the
physician is no longer justified when he has iden-
tified a chronic biologic false positive reactor, in
dismissing his patient with congratulations on the
absence of syphilis. Instead, he is faced with a
lengthy and detailed clinical investigation to
attempt to identify the cause of the biologic false
positive reaction, and this may and usually does
mean prolonged and periodic observation and re-
examination.” Harvey et al6 have pointed out that
when disease does develop in these patients “it
tends to follow a remarkably uniform pattern, the
clinical manifestations of which conform to a
series of events known to occur in verified collagen
August, 1957
1015
SEROLOGIC TEST FOR SYPHILIS— COWAN
vascular diseases, especially lupus erythematosus.”
The relationship of the biologic false positive to
some of the collagen diseases such as rheumatoid
arthritis, lupus erythematosus, periarteritis nodosa
and others, now appears to be more than sugges-
tive. This is particularly true of systemic lupus
erythematosus (SLE).
SEE used to be considered a relatively rare
disease. Its exact incidence is not known, but the
development of the LE cell test has led to the
detection of many cases previously regarded as
having other disorders. Dubois reported that at
the Los Angeles County General Hospital the
disease was diagnosed in only eleven patients
through 1948 and 1949; during the following two
years an active search for new cases was under
way utilizing the LE cell test, and a diagnosis was
made in forty-four cases. Although these figures
cannot be interpreted as indicating any change in
the incidence of the disease, they suggest that with
better diagnostic methods more cases of the dis-
ease will be discovered.
Because it is now possible with the TPI test in
practically all instances, to determine whether or
not a patient has a chronic biologic false positive,
or has a true syphilitic infection, a number of
studies are progressing in terms of this phenome-
non and the so-called collagen diseases. Clinical
and laboratory data of many of these studies
strongly suggest that the chronic biologic false
positive phenomenon is one manifestation of tissue
injury, probably chiefly of collagen and vascular
tissue due to an unknown agent or antigen. Ap-
parently, the first evidence of this is in an uniden-
tified alteration of serum globulin known as dys-
gammaglobulinemia. It is further suggested by
these observers that this clinical disturbance is re-
sponsible for a number of the observed laboratory
phenomena: the biologic false positive reaction it-
self, increased sedimentation rates, abnormalities of
protein flocculation tests, the quantitative increase
in serum globulin, the occasional alteration in the
electrophoretic pattern of the serum, and the
development of the LE cell phenomenon. Harvey
and his associates, in a study of 138 cases of SLE
found that in verified SLE patients the incidence
of the biologic false positive phenomenon was
about 20 per cent. It is important to note that
it has been pointed out that the discovery of the
chronic biologic false positive phenomenon may
precede any critical manifestation of SLE by a
number of years. In most instances these biologic
false positive reactors, which later turned out to
be verified cases of SLE, were discovered to have
an original positive serologic test for syphilis on
routine testing of apparently healthy individuals.
This was true in 62 per cent of the cases. It was
pointed out that routine serologic tests for syphilis,
although done primarily as a syphilis casefinding
measure, also have secondary7 value in terms of
differential diagnosis and also in the prognostica-
tion of other systemic diseases, principally of the
collagen variety. If one keeps these facts in mind,
the present tendency to discontinue routine sero-
logic tests for syphilis on general hospital admis-
sions is quite disturbing. As of recent date, the
Committee on Accreditation of Hospitals no longer
requires admission routine serologic tests for
syphilis for a hospital to become accredited. From
the conclusions made by investigators in this field
of the chronic biologic false positive reactors (prin-
cipally Mohr, Lutz, Harvey and others), it is
apparent that:
1. There is a probable margin of error of 2 per
cent or less in the results of the TPI test.
2. It frequently is first discovered as a result
of routine blood testing of persons in apparent
good health.
3. It is twice as frequent in women as in men,
and in both sexes more frequent in younger
persons.
4. It is frequently followed in a few years, espe-
cially in women, by the development of verified
systemic lupus erythematosus, or by an episodic
form of chronic illness, the manifestations of
which conform to those known to occur in SLE.
5. The chronic biologic false positive reaction is
frequently accompanied by hemotologic disorders;
it is also frequently associated with disorders of
serum globulin.
Finally, it should be pointed out again that the
biologic false positive reaction should not be an
end point, but it is recommended as the starting
point for further clinical investigation of the pa-
tient in terms of the possibility of other nonsyphi-
litic constitutional disease.
References
1. Moore, Joseph E., and Mohr, Charles F.: Biologi-
cally false positive serologic tests for syphilis.
J.A.M.A., 150:467 (Oct. 4) 1952.
2. Nelson, Robert A., Jr., and Mayer, Manfred M.:
Immobilization of T reponema pallidum in vitro by
antibody produced in syphilitic infection. J. Exper.
Med., 89:369, 1949.
(Continued on Pape 1070)
1016
JMSMS
Keeping the Medical Profession Oriented
on Public Opinion
The MSMS study of public wants and needs in medical-
surgical coverage by insurance and prepayment plans includes
the making of three surveys and the distribution by mail of
upwards of 60,000 questionnaires. In addition, the Detroit
Times will publish the public’s survey questionnaire. Thus,
an additional half million “ballots” will be circulated mainly
in the Detroit area.
The IBM tabulation of the returned questionnaires was
scheduled for completion by August 16. Analysis of the re-
sults is to be finalized by September 6, and the final report
made to the House of Delegates and the public on Sep-
tember 23.
The report will contain an analysis of : ( 1 ) the survey of
doctor opinion regarding Blue Shield policies and adminis-
tration, (2) the survey of the wants of both the lay public
and medical profession in medical-surgical coverage in rela-
tion to the costs of individual medical care services, and
(3) the collation of existing data on the medical insurance
needs of the public from a medical-scientific viewpoint.
That, in essence, is the story of the progress made since
April 27, 1957, when the MSMS House of Delegates initiated
the opinion survey.
D. Bruce Wiley, M.D., chairman of the Survey Committee,
said, “The MSMS study is the largest and most comprehensive
effort of its kind ever undertaken on a state-wide basis. Be-
cause of its scope, national attention has been focused on our
findings.”
This is a big, big study. It will cost money — the hard
earned cash of the medical profession paid in dues to the
State Society. But it’s worth it. For only by constant research
of this nature can we hope to continue in an organized fashion
to give the public what it wants as well as what it needs.
Predident
eMacj,
President, Michigan State Medical Society
August, 1957
1017
Editorial
UPPER PENINSULA MEDICAL SOCIETY
According to the custom established several
years ago of dedicating certain numbers of The
Journal to special interests of the members or
committees of the Michigan State Medical So-
ciety, we are happy to devote this number to the
Upper Peninsular Medical Society. In our north
country we have an essentially isolated small group
with long distances and many difficulties involved
in attending the Michigan State Medical Society
annual sessions. With devotion to our profession
stimulating the establishment of what could almost
have been a separate state medical society, they
have carried on a program for sixty-four years and
have developed a tradition of service and excell-
ence that rivals most any state medical meeting
with programs and exhibits.
The Editor remembers attending the Upper
Peninsula Society meeting in Menominee in 1912
and the enthusiastic welcome h^ was given for
having been the first state society officer to offi-
cially attend their meeting. The past many years
it has been customary for several of our officers,
the President, President-Elect, Secretary, and oth-
ers to attend. This year, their President being a
member of the MSMS Council, the Executive
Committee of the Council was invited to hold
its June meeting the day before the Upper Penin-
sula Meeting, and stay for that occasion. The
enthusiasm and satisfaction manifested attested to
the value of this meeting.
A token of the efforts of this isolated group is
illustrated by the members of their Society who
have been President of the Michigan State Medi-
cal Society: Beverly D. Harrison, Sault Ste.
Marie; A. F. Lawbaugh, Calumet; A. W. Horn-
bogen, Marquette; Henry E. Perry, Newberry:
and William S. Jones, Menominee.
We salute you, UPMS — keep up the good
work!
PROFESSION AT BAY
The medical profession again is faced with an
accumulation of circumstances which may well
lead to drastic economic and social changes. In
the 1930’s and the 1940’s the pressure of social-
ism, the determined effort of governmental and
other pressure groups and power-mad ambition-
driven forces, kept the medical societies and mem-
bers on the defensive — always opposing some leg-
islative move or threatening bill — until we earned
the reputation of “opposers.”
European nations before us had already passed
into and accepted state medicine. Bismarck and
Lloyd George used it as a stepping stone to power.
Beveridge published his famous report advocating
health and security “from womb to tomb.” The
facts of social security and government medicine
were all about us. Our own Senator Vanden'berg
told a group of MSMS officers that our prepay-
ment plans, by demonstrating the ability of private
medicine to solve both the health and economic
need of our patients, had stopped the government
move to establish state medicine, and so long as
these plans worked satisfactorily, we need not fear
government medicine.
New times, new ideals, new ideas, changed
trends, together with some modern concepts of
health needs and social security, another genera-
tion of do-gooders and dedicated leaders in and
out of government, have made other problems.
Another set of demands and requirements suffi-
ciently different to require great decisions, great
adjustments and an entirely modern approach, has
developed. The plans of a short generation ago
must be readjusted and extended to meet the vastly
expanded requirements of our patients and their
dominating advisors and organizers. We have
made periodic surveys during the years and have
expanded or changed plans, but now a major re-
newal and modernized readjustment of offerings
is imperative.
The profession has been blamed on every side
for the abuse and misapplications. To be sure
the doctor must sign the entrance papers for hos-
pitalization, but he has done that mostly under
pressure. The Blue Shield plan was established
primarily to care for the low-income patient with
a catastrophic illness. As it proved reliable and
successful, each group and each patient demanded
extensions of service and more help. Each illness
and each bed confinement suggested and ultimate-
ly demanded care. Hospitals wanted full beds;
1018
JMSMS
EDITORIAL
the patients wanted convenience of hospital care,
as modem houses are not equipped to care for the
bed patient. Someone must stay home from work
and readjustments in home layout must be made.
Since it is so much easier to use the hospital,
friends, families, and the sick themselves demand
that the doctor send the patient to the hospital.
Too many of our doctors gave in rather than see
their patients go to another doctor who would
comply.
Pressure groups in various forms made expensive
demands even to the extent of urging that as long
as there was “insurance” every mode of diagnosis
be employed so as not to miss anything. Each and
every extra unnecessary service costs someone (the
subscriber ultimately) more and more money.
The result is that the Plans are in temporary finan-
cial difficulty. Blue Cross has made four increases
in rates in the past five years. Blue Shield now
faces it first rate increase since 1949 when the
$5,000 policy was offered. Studies have been made
and rates are ready. We are now approaching
decisions which must be made within the next two
or three months. The doctors are compelled to
shoulder the responsibility and make the changes
even though four parties are blameworthy: pa-
tients, hospitals, pressure groups, and doctors.
The doctors are the ones who will suffer most
if government medicine comes, as it surely will
unless right answers are given now. Every one of
us must help decide. This is past the realm of our
medical pioneers who met the issue twenty years
ago. Each and every one MUST accept his share
of responsibility.
The Threat
Many do not believe the issue is as urgent as
pictured. Remember however, that government is
ready to administer its kind of medicine. It is
now reaching many millions and is increasing every
year. Labor is ready to compete with us and
undersell, if possible, and promise more and com-
pletely-paid care by salaried doctors. Labor has
hired a doctor director of its plan for (reputedly)
$50,000 a year. Labor knows they cannot offer
more than the medical plans, except as salaries
instead of fees will allow, but labor has announced
repeatedly that its goal is to demonstrate that full
coverage cannot be given at prices their people
can pay, so the government must establish medi-
cal care — meaning government medicine.
Some doctors may want to work for the gov-
ernment or for some of the labor leaders — we do
not. Only one action will forstall that eventuality,
and that is complete co-operation with some plan
to be evolved by all of our doctors. The decision
is up to YOU and it must come before the present
Blue plans have exhausted their reserves. Either
we make satisfactory plans, adopt controls, accept
pro-rating, or surrender.
Government and labor, especially labor, would
enjoy administering medical service at no expense
to themselves.
THE VANISHED “PHYSICIAN”
The profession now faces a new trend and at
a very great disadvantage. In the memory of our
older men, doctors were in general family physi-
cians but also the best and closest friend, the
first resource in trouble — all types of trouble in-
cluding the intimate family problems. We loved
it and our families loved us for the long and un-
selfish devotion which was always available and
always immediately responsive.
Then came the war and its effect on men —
medical and others — resulting in specialization,
duty hours, better transportation and training, but
less time for our individual patient and troubled
family. For too many doctors, that devoted and
intimately satisfying period has passed.
An era of attack, misunderstanding, planned de-
liberate misinformation, biased propaganda from
selfish interests, and ambitious social planners, to-
gether with some of our own selfish members who
showed an unwillingness to work together for the
common good of the entire profession, has brought
about an entirely different but still soluble eco-
nomic stress.
MEDICINE AND SOCIALISM
The Conference of Presidents and other officers
of State Medical Societies in New York City, June
30, 1957, was the unexpected scene of a most sig-
nificant discussion of vital interest to the medical
profession and their leaders. Three laymen speak-
ers : Oren Harris ( Arkansas) , Chairman of the
House Foreign and International Commerce Com-
mittee; Charles B. Shumann (Chicago), President
of the American Farm Bureaus; and Oswald D.
Heck of New York, Speaker of the Assembly at
Albany, all talked of premeditatedly deferred
socialism as an established and creeping fact in
America for the past generation, and the remark-
able preservation of the private practice of medi-
August, 1957
1019
EDITORIAL
cine in America by the ingenious and effective
development of an answer to socialism — the bud-
geting and prepayment system of medical care.
They said that it is most discouraging and unfor-
tunate that the medical profession has been de-
signedly or neglectfully placed in a position of
defense or opposition, always appearing as dissent-
ers when apparently desirable proposals are made.
The profession must and does see through the
trap. It should never have allowed itself to be
led by designing social planners who always see
the second or third step before making the first.
The profession should and really does know the
socio-medico-economic need and is censorable for
its present role of defense. It must reform, re-
align, propose and aggressively assume leadership.
It can, or someone else will.
In other countries, socialism under many names
has taken over 40 per cent, 50 per cent, 80 per
cent or even 100 per cent of medical services. In
this country it is steadily advancing and now has
from 25 per cent to 33 per cent of medical care
administered in the land, as witness the Veterans
Administration and its constantly increasing num-
ber of hospital beds far in excess of the service-
connected disabilities which are a just charge to
the nation.
Socialism is what the nation or the public does
for or to the individual or the group. Naturally,
that is nothing, unless by consent, grant or usur-
pation of materials, for the public is not in itself
a producer. Socialism can only be likened to preg-
nancy. There can never be only a little of it. It
takes many forms and many names, it is seduc-
tively enticing and unfortunately has been gladly
and happily embraced in small idealistic forms. A
very much desired favor or help here or there,
when help from government or pressure groups
seemed the sole method of benefiting, has been
the opening wedge.
To continue the advice: the medical societies
and their economists, the same men, with some
additions, who served before MUST again devise
modifications and new programs, must write them
into laws or rules and regulations and present
them with a demand for acceptance. Otherwise,
unfriendly bureaucrats still in government and in
dictatorial positions will write the rules not to
our liking.
When socialism is basically established it must
be progressively accepted or eliminated. There
are no evidences of elimination yet. The remedy
1020
is drastic, cohesive action, or submission. Denials
by some dissenting members could only spell de-
feat.
PROMISING FORWARD STEPS
The grass roots, the state and local medical so-
cieties, for two decades have tried to start move-
ments of advocating and suggesting new ideals
and goals on the national level. Too many times
they met the reply that they should start at the
grass roots — it is a local matter, not national.
The saving grace of the passing era has been the
almost universal, but always local or statewide,
designing and acceptance of the budgeting and
prepaid concept of distributing medical services.
The county and state doctors begged for leader-
ship, for information, for materials of national sig-
nificance. They were only obtainable locally
through laborious, desperate and persistent scat-
tered research studies, or discouraging establish-
ment of principles of procedure complicated by er-
ror and disappointment, and leading ultimately to
the truth as shown by the saving of private medi-
cine in the trial years. Many of our workers,
many of our dreamers, without whom we would
have failed, have been ostentatiously listened to
but ultimately rebuffed.
Every so often someone has broken through the
“dread-to-change” and received unwilling approv-
al and acceptance on the national level, and the
establishment of a committee or a board or a
council to “determine and outline principles.”
For many years dreamers from Michigan offered
leadership at the national level — Andy Brunk.
Ralph Pino, and others. They were heard, re-
buffed, but their ideas, later — sometimes years later
— were accepted. This present year the Michigan
delegation offered another resolution which was
refused by the reference committee after lengthy
hearings but whose ideas are now being promul-
gated nationally under a far different heading.
Another forward movement is now beins taken
by the AMA. A study group has been reviewing
the whole basic structure and organization of the
parent body and has made an as yet unpublished
report (The Heller Report) which has been seen
only by a select few in addition to the Board of
Trustees. The House of Delegates has authorized
the appointment of a special committee to review
and bring in a working model at Philadelphia in
December. We believe this is the most important
committee ever appointed by the American Medi-
JMSMS
EDITORIAL
cal Association. The membership of this AMA
House of Delegates Committee to Study the Heller
Report is as follows:
William A. Hyland, M.D., Chairman, Michigan
Lewis A. Alesen, M.D., California
Harlan English, M.D., Illinois
Norman A. Welch, M.D., Massachusetts
Charles T. Stone, M.D., Texas
The membership are men of vision, men meas-
uring far beyond the traditions of the past, with
the valor and persistence to do a job. This could
be the most important year the medical profession
has ever had, and it has had many great and sig-
nificant accomplishments. We are happy and
proud that Michigan has the chairmanship through
such a fine leader as William Hyland.
THE ROLE OF THE DOCTOR IN
BLUE SHIELD
Dr. Fred Sternagel, President of the Iowa State
Medical Society, and Dr. James W. Colbert, Jr.,
St. Louis University’s Dean of Medicine, have of-
fered sound counsel on shaping the course of Blue
Shield. Both agree that the future of these Plans
depends upon the guidance the profession gives
to their development.
On the President’s Page in the Iowa Journal
for June, Dr. Sternagel reminded his colleagues
that Blue Shield must continue to shape its course
in accordance with changing conditions and public
demand so that the program would continue to
serve as an effective means of budgeting the cost
of medical care.
“Blue Shield’s job,” wrote Dr. Sternagel, “is
not yet finished for the spectre of ‘socialized med-
icine’ still haunts us. We shall have to co-operate
intelligently and unselfishly, if our Plan is to pro-
tect the dignity of individual enterprise. It is clear
that this program cannot continue to maintain
leadership in a competitive field unless we work
more closely (with it) than ever before.”
Meanwhile, in San Francisco, Dr. Colbert told
an annual staff day audience at St. Mary’s Hospital
that “it is absolutely essential that the plans do
not get out of the control of the medical profession ;
if they do, the profession and the welfare of the
patient will both suffer.”
The thoughts expressed by Drs. Sternagel and
Colbert are to the point. They place in sharp
perspective the fundamental principle on which
Blue Shield Plans were organized and must con-
tinue to operate. And today, perhaps more than
ever before, developments in the health prepay-
ment field necessitate a dedication to the prin-
ciple of physician control with renewed vigor.
What Dr. Sternagel and Dr. Colbert were saying
is clearly and concisely the clue to Blue Shield
progress. Their ideas are basic . . . for it is in
fact the physician’s leadership, guidance, and ac-
tive participation that are fundamental to the prin-
ciples and objectives Blue Shield Plans were organ-
ized to serve. It is obvious, therefore, that the
degree to which the profession contributes to the
development of Blue Shield is alone the factor
determining the extent to which Blue Shield will
serve the profession and the public best.
With its strong ties to the profession through
local medical society sponsorship, Blue Shield Plans
can fully serve both professional interests and the
public’s need for a satisfactory means to budget
medical care costs. And over the years, active
physician participation in the affairs of Blue Shield
has been encouraged and earnestly sought for the
reason that those who administer the Plans recog-
nize that in matters of providing health care cov-
erage, it is the physician’s judgment, leadership,
and counsel that must prevail. It is only under
these conditions that health care coverage consist-
ent with the values and traditions of American
medicine can continue to flourish and serve the
public fully.
CONFERENCE OF PRESIDENTS
The three very vocal speakers at the thirteenth
Annual Conference of Presidents all stressed social-
ism in some form, and all recommended that the
medical profession must meet certain persistent
and growing demands of our patients and public
— demands that must have an answer or become
overwhelming. The facts of social progress are
with us in government or in dictatorial forces
which are constantly demanding and securing more
“security” in many fields such as old age, job
assurance, and medical attention.
The medical program is especially important to
us. The medical profession has established a com-
peting, but not entirely adjusted, prepayment
scheme, not even accepted by some of our own
members, but which is covering 50 per cent more
or less of all medical costs. The working person
(or his representative) is demanding, and in other
countries is receiving, “complete protection” as
August, 1957
1021
EDITORIAL
they understand it. The profession must find
an answer, more and more comprehensive pro-
grams must be made available. We hope most of
our subscribers will be willing to buy if they are
assured the service will be given as scheduled. No
matter what their income level they are geared to
monthly payments for almost everything: their
car and household equipment, their home, their
income tax. They are willing to pay fixed pay-
ments on a set monthly basis, including medical
costs.
Michigan Medical Service in its first years ini-
iated and was markedly successful in such a pro-
gram. For the past ten years or more some of
our farsighted officers and advisors have suggested
that a policy be written and made available on
request, giving complete coverage, home, office
and hospital, so that no one could claim he could
not get “complete coverage.” For well over three
years, management has been working on an ex-
tended service to include office surgery, outpatient
surgery, therapeutic and diagnostic x-ray, radium,
diagnosis to include EKG, BMR, and EEK, blood,
and consultation, to be sold as an extra rider to
this basic contract. What held up this extended
service was the unwillingness of the medical so-
ciety to give a “go ahead” because of difficulties
in administering.
The speakers in New York City all pointed to
a lack of foresight in not making the extensions
available before the demand came from organized
pressure groups, including the Governor’s Com-
mission. It is possible to offer the full program
outlined and suggested, but it may be embarrass-
ingly late. The counter efforts of our critics have
been announced. We can and must compete
and as private individuals give better service than
can be done by salaried doctors working by the
clock.
For Michigan, this year is fraught with dangers
and disfavor from outside, and with inner hesita-
tion and selfishness. The leaders, the House of
Delegates, The Council — every available source
of plans or advice is being tapped, and that mass
of material is being made freely available to every
member who will listen or read. Time is now
of the essence. We must decide right and now —
not next year — which will surely be too late. The
small bit of pregnancy is growing — pressure groups,
labor, and government have already taken big bites
into our work and privileges and they stand not
only ready but willing and anvious to increase
their “bite” if we falter in our own plans of
offense. This is not a problem solely for the offi-
cers and committees, including Michigan Medical
Service. IT IS THE PROBLEM OF EVERY
MEMBER. Whether he agrees or not, he is in-
volved. His personal decision could be the deci-
sive blow if it leads to disunion and dispersed ef-
forts, to “abuse or waste of our talents.”
CURRENT TRENDS IN
OCCUPATIONAL HEALTH
(Continued from Page 1012)
and competent in developing an effective indus-
trial health program. The plant physician and
nurse must concern themselves with improving
and maintaining the health of the worker. They
must be able to bring the services of the local
health department and the voluntary health agen-
cies into the plant and to refer the worker to
appropriate medical and social facilities and serv-
ices available in the community. Moreover, to
operate efficiently, the plant physician must have
the confidence of, and free exchange of medical
information with hospitals, clinics, the local health
department and his fellow practitioners in the
community.
4. The medical service must come into the
plant. Just as the industrial hygienist must regu-
larly visit and check all possible hazards in the
plant he serves, the physician and nurse must
visit the plant at regular intervals so as to be-
come familiar with the working environment and
the physical and emotional requirement of the
various jobs. Such visits also provide the medi-
cal and nursing personnel with an opportunity
to learn about particular situations affecting em-
ploye health and enable employes to have free
access to them and to gain a feeling of confidence
in them.
These services and factors, as outlined, are the
elements providing guide lines for the design and
development of successful in-plant health pro-
grams of today and tomorrow.
* * *
Girl babies seem to be healthier than boy babies: In
1954, says Health Information Foundation, the mortality
rate for male infants was 28 per cent higher than for
female infants.
1022
JMSMS
DOCTOR, YOU AND YOUR LADY
Are Cordially Invited to Attend the
Officers Night Dinner Dance
Sponsored by
Michigan State Medical Society
and Woman's Auxiliary
During MSMS Annual Session
PANTLIND HOTEL, GRAND RAPIDS
Wednesday, September 25, 1957
GOVERNOR G. MENNEN WILLIAMS
Guest Speaker
Reception 7:00 p.m. — Continental Room
Dinner 8:00 p.m. — Ballroom
Informal Limit of 250
MSMS 92nd ANNUAL SESSION
STATE SOCIETY NIGHT
PANTLIND HOTEL, GRAND RAPIDS SEPTEMBER 26, 1957
Ken Whitmer, the jack of all instru-
ments and master of many, is one of
the bright lights of any show with a
mess of heady foolishness involving
erratic violins, an umbrella, sax, trum-
pet and other instrumental odds and
ends. Whitmer has a sure-fire routine
combining comedy with fine muscian-
ship.
George Johnstone and Betty. An Ed
Sullivan show hit, George Johnstone
is a screamingly funny magician who
doesn’t do a trick, but has a way with
audiences.
You may call it madness, but we call it Curry, Byrd and
Leroy! And they come direct from the Roosevelt Hotel
in New Orleans, with their own special brand of in-
sanity. They are reported to dance. They really do, but
that’s not all. Tagging themselves “Bedlam in the
Ballroom,” they have hit the nail squarely on the head.
Patricia Melville — a tal-
ented and attractive girl
who will entertain the
guests with her accordion
while strolling through
the audience.
1024
JMSMS
MSMS Annual Session — 1957
MEETINGS OF ANCILLARY GROUPS
Increasing numbers of specialty societies, alumni as-
sociations and other ancillary groups are planning to
fold their meetings coincident with the 1957 MSMS
\nnual Session. Arranged chronologically, these meet-
ngs are:
Tuesday, September 24, 1957
Vlichigan Branch, American Academy of Pediatrics will
hold a meeting from 1:30 to 5 : 00 p.m., reception at
5:30 p.m., followed by dinner at 7:30 p.m., in the
Continental Room, Pantlind Hotel.
Thursday, September 26, 1957
Michigan Association of Alpha Kappa Kappa will hold
a breakfast-meeting in the Sadler Lounge of the Pant-
lind Hotel, 8:00 a.m. All Michigan A.K.K.’s are re-
quested to be present.
ilSMS Section on Public Health and Preventive Medi-
cine will meet at 5:00 p.m., followed by reception
and dinner beginning at 6:30 p.m., in Room 222 of
the Pantlind Hotel.
tfSMS Section on General Practice will hold its Sec-
tion Meeting from 5:00 to 6:00 p.m. in the Con-
tinental Room of the Pantlind Hotel. Benjamin Jef-
fries, M.D., of Detroit will deliver a paper on “Psy-
chiatric Techniques for the Generalist.” Following
this paper an election of Section officers for the
following year will be held. F. P. Rhoades, M.D.,
Chairman, has also arranged for a preprandial at
6:30 p.m., through the courtesy of The Upjohn Com-
pany, in the Continental Room preceding the Annual
Section Banquet. G. F. Cartland, M.D., will be the
banquet speaker. His address, “Romance and Realism
in Research,” should prove interesting to both physi-
cians and their wives.
Michigan Academy of General Practice, Board of Di-
rectors, will hold a luncheon-meeting beginning at
12:00 noon in Room 328 of the Pantlind Hotel.
ISMS Past Presidents Committee will hold a luncheon-
meeting at 12:30 p.m. in Room 327 of the Pantlind
Hotel.
Michigan Regional Committee on Trauma will meet
for cocktails and dinner at 6:30 p.m. in the Sadler
Lounge, Pantlind Hotel. The Grand Rapids Com-
mittee will be host. Emil M. Roth, M.D., Grand
Rapids, will serve as chairman of the meeting. Speak-
er is Albert Van’t Hof, M.D., Grand Rapids, on
‘‘Repair of Tendon Injuries.”
Jnivers'ty of Michigan Alumni will have a reception
at 7:00 p.m. on the Mezzanine Floor of the Pantlind
Hotel, followed by dinner at 8:00 p.m. in the Kent
State Room.
'he MSMS Section on Gastroenterology and Proctology
will hold its Section Meeting in Rooms D and E,
Civic Auditorium, at 5:00 p.m., followed by cocktails
and dinner at the Peninsular Club at 6:30 p.m.
lichigan Diabetes Association will meet for cocktail's
and dinner beginning at 6:30 p.m. in Room 323 of
the Pantlind Hotel.
ISMS Section on Otolaryngology will hold its Section
Meeting at 5:00 p.m., followed by a reception and
dinner at 6:30 p.m. in Rooms 322-324 of the Pant-
lind Hotel. There will be a speaker after the dinner,
^ayne State University College of Medicine Alumni
Association will hold an Alumni Banquet on Thurs-
day, September 26, in the Schubert Room of the
Pantlind Hotel. Reception and cocktails at 6:00 p.m.,
dinner at 7:00 p.m. All alumni, faculty and friends
of Wayne State University are cordially invited to
attend. Dean Gordon H. Scott of the College of
Medicine will be the principal speaker. The banquet
luoust, 1957
program will be dismissed in time for alumni to at-
tend the State Society Night program. The College
of Medicine Alumni Association will also maintain a
headquarters suite in the Pantlind Hotel during the
annual session.
Friday, September 27, 1957
Michigan Society of Neurology and Psychiatry and the
Michigan District Branch of American Psychiatric
Association will hold a dinner meeting in the Kent
State Room, Pantlind Hotel, beginning with pre-
prandial at 6:30 p.m.
MSMS Section on Pathology and Michigan Pathological
Society will hold a meeting in the Continental Room
of the Pantlind Hotel beginning at 3:00 p.m. with
cocktails at 6:30 p.m. and dinner at 7:30 p.m. There
will be a slide seminar on some aspects of bone
pathology, which will be moderated by D. C. Dahlin,
M. D., of the Section of Pathology, Mayo Clinic,
Rochester, Minnesota. All members of the Michigan
State Medical Society are most welcome.
Michigan Chapter, American College of Chest Physi-
cians will hold a reception-dinner-meeting at 6:30
p.m. in Room 222 of the Pantlind Hotel. Winthrop
N. Davey, M.D., Associate Professor of Internal Med-
icine, University of Michigan, will speak on “Pul-
monary Aspects of Histoplasmosis.”
MSMS Section on Nervous and Mental Diseases will
hold its Section Meeting at 5:00 p.m., followed by
reception and dinner at 6:30 p.m., in the Schubert
Room of the Pantlind Hotel.
Women’s Organizations
WOMAN’S AUXILIARY, MICHIGAN STATE
MEDICAL SOCIETY
Thirty-first Annual Meeting
September 23-24-25-26-27, 1957
Pantlind Hotel, Grand Rapids
Monday, September 23, 1957
10:30 A.M. Report of the Auxiliary President (Mrs.
A. C. Stander) to the House of Dele-
gates of the Michigan State Medical So-
ciety.
Tuesday, September 24, 1957
12:00 noon
12:30 P.M.
3:00 P.M.
6:00 P.M.
Registration opens, Mezzanine floor, Pant-
lind Hotel.
Hospitality Room opens, Parlor D, Pant-
lind Hotel.
Organizational luncheon and meeting of
District Directors — Mrs. Robert Reagan,
presiding. Sadler Lounge, Pantlind Ho-
tel.
Meeting of 1956-57 and 1957-58 State
Committee Chairmen — President’s Suite.
Mrs. C. Allen Pavne, presiding. Pantlind
Hotel.
Past Presidents’ and Secretaries’ Dinner
Wednesday, September 25, 1957
8:00 A.M. Continental Breakfast — Pantlind Hotel —
District Directors and County Presidents.
9:00 A.M. Pre-convention Board Meeting (for 1956-
57 State Officers, Directors, Chairmen
and County Presidents).
Red Room, Civic Auditorium.
10:30 A.M. Formal opening of the 31st Annual Meet-
ing of the Woman’s Auxiliary to the
1025
MSMS ANNUAL SESSION— 1957
Michigan State Medical Society, Mrs. A.
C. Stander, President, presiding.
(Delegates and Board Members will
please register with the Roll Call Chair-
man at the door before the opening of
each session, thus eliminating the need
of an oral roll call.)
Invocation.
Pledge of Allegiance to the Flag.
Woman’s Auxiliary Pledge.
Address of Welcome — Mrs. Garrett E.
Winter, Immediate Past President, Kent
County Auxiliary.
Response — Mrs. Robert Reagan, First
Vice-president, Woman's Auxiliary to
MSMS.
Introduction of Convention Chairmen —
Mrs. Kenneth Fellows and Mrs. Henry P.
Kooistra.
Report of Roll Call Chairman.
Convention Rules of Order
Presentation of Program.
Announcements.
Address of the President — Mrs. A. C.
Stander.
Reports of the Officers:
President-elect — Mrs. C. Allen Payee
First Vice-president — Mrs. Robert Rea-
gan
Second Vice-president — Mrs. George
Cook
Recording Secretary — Mrs. Harold
Machin
Corresponding Secretary — Mrs. F. J.
Busch
Financial Secretary — Mrs. Milton R.
Weed
Treasurer — Mrs. Francis Krynicki
(including report of the auditor)
Report of Finance Committee (and pres-
entation of the budget for 1957-58) —
Mrs. Walter S. Stinson, chairman.
Address of National President — Mrs. Paul
C. Craig
12:30 P.M. Past Presidents’ Luncheon, Ballroom,
Pantlind Hotel — Honoring Mrs. William
Mackersie, retiring Director, Woman’s
Auxiliary to the American Medical As-
sociation; Past Presidents of the Woman’s
Auxiliary to the MSMS and representa-
tives of the MSMS.
Greetings — D. B. Hagerman, M.D., Presi-
dent, Kent County Medical Society.
Luncheon Program (to be announced
later)
2:30 P.M. General Session- Red Room, Civic Audi-
torium
Report of Metnbers-at-large Chairman —
Mrs. C. O. Willits
Reports of District Directors
Reports of County Presidents — AUXILI-
ARY HIGHLIGHTS
Mrs. Dwight F. Scott, District IX, pre-
siding, Chippewa, Mackinaw, Luce-Delta,
Schoolcraft-Menominee
Mrs. R. H. Reitzel, District I, presiding,
Huron, Sanilac, Lapeer, St. Clair, Oak-
land, Macomb, Wayne, Wayne Southern
Mrs. J. J. Burke, District VIII, presiding,
Houghton, Baraga, Keweenaw-Marquette,
Alger-Dickinson, Iron-Gogebic.
Mrs. John W. Freud, District II, presid-
ing, Eaton, Ingham, Livingston, Jack-
son, Washtenaw, Lenawee, Monroe.
Mrs. B. B. Bushong, District VII, presid-
ing, Grand Traverse, Leelanau, Benzie,
Kalkaska-Northern Michigan.
Mrs. J. Norris Asline, District VI, pre-
siding, Bay, Arenac, Iosco-North Central.
OFFICERS NIGHT DINNER-DANCE
6:30 P.M. Reception, Continental Room, Pantlind
Hotel.
7:15 P.M. Dinner, Ball Room.
Thursday, September 26, 1957
9:00 A M. General Meeting of the Woman's Auxili-
ary to the Michigan State Medical So-
ciety, Red Room, Civic Auditorium.
Mrs. A. C. Stander, President, presiding.
In Memoriam — Mrs. Martin Patmos
Report of Roll Call Chairman
Reports of County Presidents — con’t
Mrs. Robert Leitch, District III, pre-
siding, Allegan-Van Buren-Kalamazoo-
Calhoun-Berrien-St. Joseph, Branch
Mrs. Harold Gay, District V, presiding,
Gratiot, Isabella, Clare-Midland-Saginaw-
Tuscola-Clinton-Shiawassee. Genesee
Mrs. Edward Heneveld, District IV,
presiding, Mason-Mecosta, Osceola,
Lake - Newaygo - Muskegon - Kent - Ionia ,
Montcalm-Ottawa
Announcements of the Top Ten Coun-
ties in A.M.E.F. Contributions, Mrs.
Victor Zerbi
Announcements of Counties reaching
100% in Today’s Health Subscrip-
tions contest for 1956-57 — Mrs. D. Bruce
Wiley
Unfinished Business
New Business
Report of Resolutions Committee
Report of Nominating Committee — Mrs.
Delbert MacGregor
Election of Officers
Final report of Registration and Cre-
dentials Committee — Mrs. John Ten-
Have
Meeting of Executive Committee for
1957-1958 — Mrs. C. Allen Payne, pre-
siding
12:00 P.M. Inaugural Luncheon, Kent State Room,
Pantlind Hotel
Mrs. A. C. Stander, presiding
Installation of Officers — Mrs. J. Earl Mc-
Intyre, Past State President
Presentation of Past President’s Pin
Presentation of President’s Pin and Gavel
Inaugural Address — Mrs. C. Allen Payne
Adjournment
2:30-4:00 P.M. Post Convention Board Meeting (For
all 1957-58 Officers, Chairman and
County Presidents) Mrs. C. Allen Payne,
Presiding
State Society Night
1026
JMSMS
MSMS ANNUAL SESSION — 1957
MICHIGAN STATE MEDICAL ASSISTANTS
SOCIETY
September 25-26, 1957
Manger Rowe Hotel, Grand Rapids
Tuesday, September 24, 1957
8:00 P.M. Hospitality Room — Welcoming Commit-
tee— Mezzanine
Hostess: Mrs. Marion Horning assisted
by the Presidents of each component so-
ciety.
Wednesday, September 25, 1957
9:00 A.M.
10:00 A.M.
11:00 A.M.
12:30 P.M.
2:00 P.M.
4:00 P.M.
6:30 P.M.
7:30 P.M.
Registration — Chairman: Miss Matilda
Brechting — Mezzanine
Welcome — Miss Doris Jarrad, President
Harold Mikelson, Ph.D., N. E. Missouri
State Teachers Gollege
“Division of Duties in Doctors’ Offices”
— English Room
Coffee Break — Mezzanine
Michigan Medical Service
Mr. Thomas Paton, Moderator
“Medicare” — English Room
Luncheon — Hostess: Mrs. Marion Horn-
ing
Courtesy of the Michigan State Medical
Service— Louis XV Room
Business Meeting — English Room
View Exhibits at Civic Auditorium
Social Hour — Hostess: Mrs. Eileen De-
Went
Host: Mr. Kenneth Cook
Music for your listening pleasure — Mez-
zanine and English Room
Banquet — Hostess: Mrs. Vivian Branyan
— Louis XV Room
W. O. Badgley, M.D., Lansing, Master
of' Ceremonies
Thursday, September 26, 1957
9:00 A.M.
10:00 A.M.
11:00 A.M.
12:30 P.M.
2:30 P.M.
4:00 P.M.
Registration — Mezzanine
Mr. Gerrit Weigerink, Director, Grand
Rapids Rehabilitation Center
“Rehabilitation of the Physically Dis-
abled”— English Room
Coffee Break
Mr. Don Blanchard, Physicist, Grand
Rapids, Butterworth Hospital
“X-Ray Uses of Radio Active Cobalt;
Physical and Clinical Aspects” — English
Room
Presidents’ Luncheon — Hostess: Mrs. Ei-
leen DeWent — Louis XV Room
Arthur Murray Dance Studios
“American and Latin American Ballroom
Dancing”
View Exhibits at Civic Auditorium
*
* *
Anyone actively employed in a technical or in an ad-
ministrative capacity in the office or laboratory of a
member of the Michigan State Medical Society, also, ad-
ministrative employes in the offices of medical hospitals
or medical laboratories of the State of Michigan, is wel-
come to attend all activities of the Michigan State
Medical Assistants Society meetings. All activities will
be held at the Manger Rowe Hotel in Grand Rapids.
Registration fee for non-members is $2.00, no registra-
tion fee for paid members. Deadline for all registrations
is September 1, 1957.
August, 1957
Scientific Exhibits
American Cancer Society Booth No. S-IX
Detroit, Mich.
Benjamin Franklin Clinic Booth No. S-I
Philadelphia, Pa.
“Technique for Extra-Articular Injection”
Tabular results of injections of hexylcaine and pred-
nisolone tertiary butylacetate into various rheumatic
and orthopedic soft tissue lesions will be presented.
These will include both acute and chronic conditions.
Comparisons of time required for recovery by injec-
tion techniques vs. other accepted methods of treat-
ment will be presented. Injection technique will be
demonstrated indicating sight by surface anatomy
and placement of needle by cutaway art.
Henry Ford Hospital Booth No. S-V
Detroit, Mich.
Mary Free Bed Guild Children’s Booth Nos. S-X, S-XI
Hospital and Orthopedic Center
Grand Rapids, Mich.
An exhibit showing types of patients treated at Mary
Free Bed Guild Children’s Hospital and Orthopedic
Center with special emphasis on treatment of the
child amputee. Pictures are used to show different
phases of physical therapy, occupational therapy,
nursing and follow-up care in out-patient clinic.
Latest prosthetic components will be displayed.
Michigan Cancer Coordinating Booth No. S-VII
Committee
Lansing, Mich.
An exhibit dealing with the problem of Cancer Quack-
ery. Something beneficial can always be done for the
terminal cancer patient by the reputable M.D. This
display will prove this statement.
Colored slides, photographs and X-rays plus litera-
ture dealing with the problem, and gadgets which
have been used to treat cancer, all help to emphasize
the fact, that the medical profession has much more
to offer these patients then does the “quack.”
Michigan Heart Association Booth No. S-XII
Detroit, Mich.
Michigan Pathological Society Booth No. S-III
Detroit, Mich.
Michigan State Medical Society Booth No. S-VIII
Lansing, Mich.
This exhibit features Ideas for MSMS Headquarters.
Other state medical societies have built adequate
“homes” for their executive offices. MSMS is com-
mitted to do so also, and constantly rising construc-
tion costs demand immediate action. This display says
“Look at what others have done? What shall we do?”
Michigan State Pharmaceutical Assn. Booth No. S-VI
Lansing, Mich.
Pharmacy, as one of the members of the Michigan
Health Team, displays methods of introducing the
many new drugs that are playing so large a part in
combatting disease. Figures and examples graphically
illustrate the volume of new items that are introduced
each year in the field of medicine to serve our first
concern, the patient.
The Straith Clinic Booth No. S-II
Detroit, Mich.
Numerous Kodachrome enlargements, showing methods
of treating deformities as harelips, cleft palates, pro-
truding ears, nasal deformities, birthmarks, breast
hyperplasias, et cetera. Slides showing plastic closure
of traumatic wounds, facial fractures, hand and tendon
repairs, treatment of malignancy and plastic repair.
Wayne State University Medical Booth No. S-IV
Alumni Association
Detroit, Mich.
A pictorial progress report of recent developments
in the Wayne State University Medical College area.
1027
Annual Reports
ANNUAL REPORT OF THE COUNCIL
1956-1957
The Council held three sessions totalling six days, and
the Executive Committee of The Council convened eight
days (to September 21, 1957), a total of eleven meetings
up to the date of the 1957 Annual Session of the
Michigan State Medical Society. This represented a
total of 102 hours of deliberations, equivalent to thirteen
days on an eight-hour working day basis, but, as in the
past, this total does not include additional time neces-
sarily spent by the twenty-six members of The Council
going to and returning from meetings held in various
Councilor Districts throughout the state. All matters
studied (899 items) and recommendations made by
The Council’s thirty-nine committees, as well as by the
Society’s twenty-two committees, and all business of the
Society, were referred routinely to The Council or to its
Executive Committee for consideration and action.
Membership
Membership as of June 30, and as of December 31,
from 1935 to 1957, is indicated in the following chart:
1935 1945 1950 1954 1955 1956 1957
June 30 3410 4425 4881 5111 5503 5794 6104
December 31 ....3653 4686 5114 5787 6109 6360
The figures for 1957 include 5,291 Active Members,
286 Emeritus and Life Members, 74 Retired Members,
453 Associate and Military Members.
Finance
As in the past, the first item of new business on
the monthly agenda of The Council or its Executive
Committee is “Study of Monthly Financial Reports.”
Every thirty days, therefore, the Society’s financial pic-
ture is reviewed and governing policies established. In
addition, the Finance Committee meets periodically to
study and to advise The Council on particular fiscal
questions.
The auditor’s report for 1956 was published on page
634 of the May issue of The Journal, and the budgets
of the Society for 1957 were published in the March
number, beginning on page 375. Members are invited
to acquaint themselves with the financial status of their
State Medical Society and to offer suggestions; these
always are truly appreciated. As of June 30, 1957, 5,434
members paid Society dues amounting to $154,869.00.
This was on the basis of $28.50 per member allocated
to the General Fund as established by The Council in
January, 1957, and includes some payments by new
members of portions of a year. Also, $16,303.50 accrued
to the Public Education Reserve, $34,632.89 accrued
to the Public Education Account, $19,315.57 accrued
to the Public Service Account, and $29,035.27 accrued
to the Professional Relations Account, for current ac-
tivities as directed by The Council in January, 1957.
The sum of $11,053.22 was set aside in a present Build-
ing Maintenance Fund, as well as $27,172.50 to a new
MSMS headquarters fund. A brief financial resume of
each of the MSMS activities as of June 30, 1957 is
presented in the accompanying table.
The AMA dues collected by county medical societies,
forwarded to MSMS, and then mailed to the American
Medical Association during the six months to June 30,
1957, totalled $133,487.50. The very high percentage
of AMA dues being paid by MSMS members (98.3 per
cent) is to be noted; The Council feels that the mem-
bers of our State Society are to be congratulated on
1028
their tangible co-operation with and support of the
American Medical Association. A resume of the finan-
cial condition of the Michigan State Medical Society
as of August 31, 1957, will be presented to the House of
Delegates at its opening session of September 23, 1957,
as a part of The Council’s Supplemental Report.
Financial Report for Period Ending June 30, 1957
Account
On Hand
1/1/57
Income to
7/1/57
Expenses to Balance on
7/1/57 Hand 7/1/57
General Fund
.$ 89,870.56
$159,371.71
$ 92,466.36
$156,775.91
Annual Session
Michigan Clinical
0
28,430.00
7,177.64
21,252.36
Institute
0
13,650.00
13.302.75
347.25
The Journal
0
68.919.49
54,123.51
14,795.98
Public Education.
. 73,891.87
34,632.89
31,871.19
76,653.57
Public Service
Professional Rela-
3,675.16
19,315.57
10,492.72
12,498.01
tions
Public Education
4,897.50
29,035.27
17,610.47
16,322.30
Reserve
Rheumatic Fever
. 57,245.00
16,303.50
0
73,548.50
Control
7,675.56
8,437.01
7,491.11
8,621.46
Contingent Fund.. 53,614.34
Building Maintenance
0
0
53,614.34
Fund 14,124.94
MSMS Headquarters
11.053.22
2,792.93
22,385.23
Fund
0
27,172.50
0
27,172.50
Totals:
$304,994.93
$416,321.16
$237,328.68
$483,987.41
Thus far in 1957, $50,000.00 of the funds of the
Michigan State Medical Society have been invested in
short-term securities. These funds are invested during
the early part of the year when income resulting from
dues payments is high and thus earn interest for the
commercial account. These securities mature later in the
year when income is low and expenses continue at the
regular rate. Any securities maturing, the funds from
which are not immediately required, will be reinvested
upon the advice of the Finance Committee.
The Journal
The Journal of the Michigan State Medical
Society was established fifty-six years ago to carry out
the projected “modernization” of the Medical Society,
changing it from a group of a few hundred members
with one annual meeting and one annual publication,
to a fully democratic body, with branches in the coun-
ties and with representatives in a central governing body.
Some method of frequent communication had to be
established, and the Secretary, Andrew P. Biddle, M.D.,
established The Journal, to be published monthly.
For fifty-six years there has not been an interruption.
The Journal has brought to the membership, medical
and scientific papers of the highest quality prepared
mostly by our own members, but including some each
year by the foremost authorities of our profession who
have been glad to come to our Annual Sessions and
give their best. The Journal has also brought to our
members news items and official communications, and
has carried the messages of our officers and administra-
tive groups, in addition to the official reports of legislative
action.
During the past ten or more years the Publication
Committee and the editorial staff have been happy and
proud to dedicate almost every number to a special
interest: an outstanding local county or district organiza-
tion, committee, clinic, or activity in the public interest.
Each year we have listed some of these interests and
have set them apart with specially designed and unique
covers, mostly in two colors. We are glad to report
JMSMS
ANNUAL reports
that acceptance has been favorable and many of the
other state medical journals are following suit.
July, 1956, was, as always, devoted to the Annual
Session and pictured a doctor pointing and all roads
from the far corners of the United States leading to
Detroit. The August issue on trauma featured the ap-
plication of a plaster dressing; this issue also contained
a Directory Supplement. The 28th Annual Ingham
County Clinic was the subject of the September number,
spotted on a Michigan map, with stethescope, hypo,
et cetera, to add color. October was devoted to Diabetes
Detection, with the cover carrying pictures of five great
leaders in this field. Michigan’s Public Service was the
subject of the November issue with reports from twenty-
eight service groups, presented primarily for indoctrina-
tion of new members. December was devoted to the
Michigan Clinical Institute with the cover showing a
doctor on call. The January number was devoted to
Heart with a segment of heart surgery gracing the
cover. A symbolic large crab on the cover of the
February issue called attention to the Genesee County
Cancer Day, and a healthy little girl illustrated the
cover of the March Journal devoted to Child Health.
April featured Cancer: “Medicine” fighting the many-
headed dragon, while May with Geriatrics as its interest
was illustrated with a sylvan scene. June, Michigan
Medical Service, showed crossroads signs and directions.
Medico socio-economic problems again have occupied
most of our editorial effort. Due to the pressure on
our Blue Shield Service Plan and the necessity of calling
an extra session of the House of Delegates, we have
devoted increasingly great space in text, news, reports
and editorials to that vital part of the Society.
We have again been very thankful to certain chair-
men and others designated to assist in gathering material,
writing editorials, and doing general supervision when
we have been preparing a special number. The Editor’s
work with the Publication Committee, the Executive
Committee and the official staff has been a pleasure
and a stimulus to continued service. This year we are
pleased that an Assistant Editor has been selected, a
man of editorial experience, and that the continuity of
The Journal is assured.
Organization
1. The Annual County Secretaries — Public Relations
Seminar — a three-day indoctrinational course — was held
in Detroit on January 25, 26. 27, 1957, with 150 at-
tending. The theme was “Protecting our Heritage”
with the first two days devoted to discussion of problems
facing prepaid medical care plans. This was in accord
with the oft-expressed feeling that more information
on Michigan Medical Service should be funnelled to
the medical profession of Michigan, particularly to its
leaders on the local level.
2. The Eleventh Michigan Clinical Institute was held
in Detroit, March 13, 14, 15, 1957, with an attendance
of 3,243, including 1,654 M.D.'s. The popularity of
the MCI, as a purely scientific “refresher course,” im-
proves year after year.
3. Our AMA Delegates and Alternates are doing
efficient work and are gaining well-merited recognition
in the AMA House of Delegates. Proof is that the Chair-
man of the group, Wm. A. Hyland, M.D., of Grand
Rapids, was appointed in July as Chairman of the all-
important AMA Study Committee on the Heller Report,
calling for extensive revisions of the AMA organizational
set-up. R. L. Novy, M.D., Detroit, was re-elected a
member of the Council on Medical Service.
4. The Residents-Interns-Senior Medical Students
Conference was held in Detroit, March 15, 1957, co-
incident with the Michigan Clinical Institute. MSMS
again sponsored the sending of Delegates from Michi-
gan’s two medical schools to the Student AMA Con-
vention in Philadelphia in May, 1957.
5. The 91st MSMS Annual Session in Detroit, Sep-
August, 1957
tember 26, 27, 28, 1956, attracted a record registration
of 4,300, including 2,464 M.D.’s. This meeting has
gained the reputation as one of the three best state
medical conventions in the country.
6. More national medical leaders from Michigan
are gaining recognition: during the 1957 Michigan
Clinical Institute, eight Michigan doctors of medicine
were honored for currently achieving the presidency of
national medical associations:
J. S. DeTar, M.D., Milan — American Academy of
General Practice
Cameron Haight, M.D., Ann Arbor — American As-
sociation for Thoracic Surgery
Charles G. Johnston, M.D., Detroit — American As-
sociation for the Surgery of Trauma
Rupert C. L. Markoe, M.D., Detroit — American
Academy of Tuberculosis Physicians
Edgar E. Martmer, M.D., Detroit — American Academy
of Pediatrics
Norman F. Miller, M.D., Ann Arbor — American Gy-
necological Society
Robert L. Novy, M.D., Detroit — National Association
of Blue Shield Medical Care Plans
William D. Robinson, M.D., Ann Arbor — American
Rheumatism Association
7. Leon DeVel, M.D., of Grand Rapids, for eight
years Medical Co-ordinator of the MSMS Rheumatic
Fever Program, resigned as of February 1, 1957, after
performing an outstanding job in the pioneering work
of rheumatic fever organization. The Council feels that
a new position of “Director of Scientific Activities” of
the Michigan State Medical Society should be created;
all preventive medicine activities of the Society, such as
rheumatic fever control, geriatrics, child welfare, mater-
nal health, cancer control, et cetera, could be co-ordin-
ated by such a full-time M.D. employe of the Society. A
special committee is investigating possibilities in this
direction.
8. The American Medical Education Foundation work
in Michigan is being vigorously spearheaded by C. E.
Umphrey, M.D. of Detroit, Chairman for Michigan.
The tangible co-operation of all members is urged.
9. In July, The Council appointed Louis J. Bailey,
M.D., of Detroit, as Assistant Editor of The Journal,
MSMS.
10. A Special Session of the House of Delegates (the
first since 1939) was held April 27, 1957, in Detroit to
inform the Delegates and the profession in general on
the condition of prepaid medical insurance programs of
this state. The Delegates were faced with the bare fact
that Blue Cross-Blue Shield and the commercial insur-
ance companies are facing heavy losses due to increased
costs of health care and accelerated utilization. Valuable
information on the status of plans in and outside Michi-
gan was presented and discussed. A market-opinion
survey of the public and the medical profession was
authorized.
The MSMS Market-Opinion study began with inter-
views on July 8. Some 61,000 questionnaires to the
public will be sent and the returns will be analyzed in
connection with the returns from an additional survey
to the 6,100 members of MSMS. The Director of the
Business Research Institute of Michigan State University,
Mr. David Luck, has been retained as consultant; the
Market-Opinion Research Company of Detroit is con-
ducting the interview survey portion of the study under
the supervision of Mr. Richard Oudersluys, Managing
Director. Lansing is used as the “control” with 10,000
questionnaires saturating this city. The Detroit News
and the Detroit Times (total circulation is 1,100,000)
have volunteered assistance by running the mail survey
questionnaire in their newspapers — which generous co-
operation will greatly expand and make more valuable
this survey. IBM services are being used to tabulate
1029
annual reports
and analyze the returns. The whole report will be
ready for presentation to the House of Delegates on
September 23.
11. The groundbreaking of the Wayne County Medi-
cal Society’s new building was an historic event of De-
cember 19, 1956; MSMS is supplying a documentary
film on the erection of the WCMS edifice.
12. Organization among the fifty-five component so-
cieties, covering all of Michigan’s eighty-three counties,
was well maintained during the past year. The scientific
side of medicine in this state continues at an all time
high. MSMS is gratified at the increased interest in
socio-economic matters on the part of its component
societies, evidenced by many more requests to the State
Society for speakers, assistance, and information.
Public Relations
It is one thing to look back on a score of years of
effort in public relations with some degree of satisfac-
tion. It is quite another to be able to look ahead.
The public relations program of the individual doctor
of medicine, as well as of his 6,100-member state-wide
Society, has been a continuous, everyday effort. It must
continue to be, as the profession adapts its service to
the changing needs of our people and our economy.
Today, the greatest single danger to the good name
of the medical profession can be designated with one
word — “money.”
Our strenuous efforts to tell the story of advances
in medical service and science, the successes in establish-
ing public service and educational programs, the sincere
and devoted work of men in medical organization to
meet the public medical needs, will fail of their intended
objective unless the financial problems surrounding the
provision of medical care are solved to the satisfaction
of the public.
A tremendous effort is being made by way of the
greatest survey ever attempted by a state medical society
to assist the voluntary health insurance and prepaid
medical care plans to meet the need of a satisfactory
mechanism to satisfy the financial obligations of the
public to the profession.
In addition to this, however, is the very real problem
which also requires the help of every M.D. if it is to be
solved satisfactorily. Namely, for every doctor to “sell”
every member of the public on the idea that the “price is
right” for his services. The techniques for doing this
job are known, the qualified personnel for assisting the
profession are with us, but the will to do this and the
continued effort to succeed must come from a dedicated
profession.
Methods of mass communication have been utilized
this year in the same effective fashion as in the past.
A full recounting of them in this report is impractical.
Suffice it to say that voluntary medicine must continue
to amplify as never before its communication, by every
possible means, with others in the health field and with
the public.
However, just a few highlights of Public Relations
activity bear special mention.
Every year an increasing number of the bills intro-
duced into the House and Senate in Lansing affect the
doctor’s practice of medicine and the provision of health
care to his patients. This is caused by the new public
health problems inherent in the growing complexity of
medical science: e.g., atomic energy and radiation. It
is a tribute to the public stature of Michigan M.D.’s
and the high esteem in which they are held by the law-
makers (maintained and enhanced by a strong P.R.
awareness on the part of the individual physician) that
this interdependence between legislator and doctor of
medicine continually provides Michigan citizens with the
best health care legislation.
Medical Education Week, the second annual salute,
was once again a successful educational drive in Michi-
gan. MSMS acted as statewide co-ordinator for the
group effort by county medical societies and medical
schools.
The Publicity and news coverage of MSMS activities
during the year hit an all-time high. Radio and television
public service programs continued as a valuable asset
to medicine. The 91st Annual Session in Detroit was
noted for its utilization of on-the-spot radio and television
coverage, marking a heightened interest in the scientific
and policy aspects of organized medicine.
The MSMS co-sponsorship of the live heart operation
telecast in color from Detroit’s Grace Hospital during
the Michigan Clinical Institute provided an unprece-
dented opportunity for MSMS in the public service
field. And for those areas in Michigan which were
unable to carry the actual telecast, MSMS shared the
cost of making a kinescope and supplied it for rebroad-
cast at later dates throughout the state. More than
2,000 letters commending this telecast were received.
Another successful publicity campaign was Operation
Armor, the doctors’ own effort to urge public acceptance
of all immunization procedures. Special emphasis was
placed on having these done in the doctor’s office. More
than 150 Michigan newspapers carried one or more of
MSMS’s press releases on this subject and national
recognition of our program was received.
The MSMS Public Relations Library is rapidly near-
ing completion. Permanent metal shelving, film cabinets,
record cabinets, files and card catalogs have been in-
stalled in the MSMS headquarters, and most of the
material for the library has been cataloged and shelved
under the direction of professional library consultants.
Among available items from the library are films, radio
transcriptions and tapes, kinescopes, speeches, books,
and brochures on various medical public relations and
medico-socio-economic subjects. In addition, items of
historical value, such as the permanently bound volumes
of the State Medical Society beginning with the year
1859, are maintained. Added to the P. R. Library this
year was a new MSMS production, “Something Called
Epilepsy.” This fifteen-minute sound, color, motion pic-
ture dispels the mystery and misunderstanding which
can surround this disease. Special emphasis is given to
the control and curative advances of modern medicine.
Resource material from the library is available on free
loan to all members of the MSMS, its auxiliary and
ancillary groups. This is proving to be a valuable tool
in the public relations work of the Society.
Among its other advisory services in public relations,
the MSMS is assisting the Michigan State Medical As-
sistants Society in setting up an educational training
program through college and university extension and
short course facilities. The ultimate objectives are to
broaden the existing knowledge of physicians’ assistants
and to aid in the training of new assistants.
The public relations effort of the medical profession
has borne fruit. This is well, for there are those who
would cast aside the traditional scientific methods and
substitute new and unproven ways of dispensing and
paying for medical care. To combat this cavalier ap-
proach to a recognized problem, the doctors will need
every ounce of public understanding they have managed
to produce over the years.
Woman’s Auxiliary
The fine work being accomplished by our Medical
Auxiliaries throughout Michigan reminds one of a
symphony. The many fields in which we work is like
an elaborate piece of music written for a full orchestra.
And, as a symphony, which is written in four movements,
we feel that we have successfully played the passages
written for us. In the first movement of a symphony the
theme is developed, and is played throughout the score.
Our theme for the year was “Full Time Citizenship.”
This theme led us right into the national election. At
this time the auxiliary set up dozens of “Get Out The
Vote” telephone centers, which were under the direction
1030
JMSMS
ANNUAL REPORTS
of the Michigan State Medical Society. At this time
we realized the importance of medical auxiliaries, as our
work was quickly accomplished among the organized
groups. There were several spots, however, that we were
unable to touch because of no organization. In the “Year
of Decision,” a national election year, it is important
for us to do a complete job, but only until we are
completely organized will this be possible. Also, in
legislation, our auxiliaries were informed on all major
medical issues.
In Civil Defense 50 per cent of our auxiliaries par-
ticipated in some form or another. The First Aid Course
given by Red Cross found at least 25 per cent of our
members enrolled.
In T oday’s Health, a struggling activity of the Aux-
iliary, we reached a state total of 61 per cent, after much
hard work. Mason County topped the list with 633 per
cent, followed by St. Joseph, Newaygo, Sanilac, Huron,
Wayne Southern, Monroe, Eaton, Midland, Gogebic, Ma-
comb, Berrien, Muskegon and Washtenaw having 100
per cent or over. We are grateful to all counties for
their great effort.
Our Public Relations project has been in the realm
of Science Fair. This we felt was important, as the
next National Science Fair will be held in Flint in 1958.
Our Tuberculosis Speaking Project, which is co-spon-
sored annually with the Michigan Tuberculosis Associa-
tion, again had an exciting year. Two thousand nine
hundred and ten students entered from eighty-eight
schools throughout twenty-eight counties. These students
spoke to audiences totaling over 14,000 people. An un-
determined number of persons were reached when
twenty-four of the schools presented scripts over local
radio stations.
In American Medical Education Foundation, we are
happy to report a grand total of $3,866.47 was raised
for our medical schools, most of this sum going to the
two schools in Michigan. We feel that now our auxili-
aries are aware of the Foundation and for what it
stands.
Many varied programs in mental health and safety
were given in nearly all auxiliaries.
Michigan is outstanding in “Health Careers.” We
now have 357 Future Nurse Clubs fully organized in
Michigan with a membership of over 5,000 students.
We are working toward one goal^to interest our young
people in a Health Career. Our financial assistance this
year comes to a grand total of $10,410.00:
Professional nurses graduated
(with our assistance) 32
Postgraduates graduated.... (with our assistance).... 3
Medical students graduated (with our assistance).... 5
Practical nurses graduated.... (with our assistance).... 8
These are only a few of medical activities mentioned.
The greatest public relations potential that we have is
working as a Full Time Citizen in our own community
according to its needs. Wherever the Woman’s Auxiliary
President’s travels took her this year in the State of
Michigan, she found the same picture: the doctor’s wife
is a backbone of her community.
And now the fourth movement of our symphony is
almost over — the Allegro. We, in our medical auxiliary
work, also hope we have a triumphant ending. But
like Shubert, our ending is unfinished.
Contact with Governmental Agencies
The necessary contacts with federal, state and local
governmental agencies continues to be an important
activity of the Michigan State Medical Society. The
most significant contacts made during the past year
were:
1. Michigan Day in Washington, D. C. Again, on
April 30, the MSMS representatives visited Washington
and made personal contacts with our friends in the
Capitol and in the administrative offices of the federal
August, 1957
government. The resulting good will is on an ever-
increasing plane.
2. The Veterans Administration “Home Town Medi-
cal Care Program” was a subject that faced The
Council and its Executive Committee at all of its
meetings during 1956. The crisis came in January
when the Veterans Administration submitted a new
contract to replace the contract in operation at the
time. This contract was declared to be objectionable
to representatives of the eight states and Hawaii which
have utilized intermediaries successfully in the opera-
tion of the program. A new contract was developed by
this group, and the Chairman (Wm. Bromme, M.D.,
Detroit) was named spokesman to procure an audience
with Dr. W. S. Middleton, Chief of the Bureau of
Medicine of the Veterans Administration and to re-
concile basic differences in the contracts. At this meet-
ing, most of the major items in our proposed contract
were agreed to by Dr. Middleton and he subsequently
released a press statement endorsing the Home Town
Care Programs, and indicating that the Michigan Pro-
gram, with its simplified reporting forms, was to be
considered a model. Following this, the Veterans Ad-
ministration submitted a new contract which was in
most respects less satisfactory than the one presented in
January, 1957. Officers of MSMS made strong direct
protests to Mr. Harvey C. Higley and Dr. Middleton
on May 6, 1957. MSMS Executive Committee on May
15, 1957, reiterated its opposition to supplying to the
Veterans Administration lists of physicians with designa-
tion of specialists. By telegram on June 4, 1957, Veter-
ans Administration produced a reinterpretation of its de-
mand for these lists which was not inconsistent with the
position of MSMS; other areas of variation in contract
have been amended by the Veterans Administration, and
a new working contract was approved by The Council
on June 20, 1957. This contract insures that veterans in
Michigan — for the time being — will be given the best
of medical care in their own localities. This boon was
won exclusively through the efforts of the Michigan
State Medical Society — without stirring the veterans
and their organizations to militant action.
3. Medicare, in like manner, was a new program
that demanded attention of The Council and its Execu-
tive Committee at numerous meetings. The Dependents
Medical Care Act — Public Law 569 — of the 84th Con-
gress went into effect December 7, 1956. The contract
was executed by Michigan State Medical Society and
Michigan Medical Service (as its fiscal agent). The fee
schedule for Medicare, submitted on a deadline date
requiring immediate action, was that of the already-
approved $5,000.00 income contract of Michigan Medi-
cal Service. This action was indicated since, for the
most part. Medicare clients fell within that income
limit. The Fee schedule was printed and mailed to
all MSMS members, as were information and provisions
of the Directives prepared by the Department of De-
fense, included in the Michigan Medical Service “Physi-
cian’s Manual.” Additional explanations were presented
at the County Secretaries Seminar last January and
special material was mailed to county society officers.
Medicare is government medicine which is never
satisfactory to the practicing physician. Its imperfections,
soon recognized by some of our specialty groups, are
being catalogued by the State Society for correction
when the contract is renegotiated, which, according to
priority among the states, will be March 31, 1958. All
members of the Michigan State Medical Society are
invited to send suggestions to MSMS to improve the
Medicare program — for inclusion in the rc-negotiation
document.
4. Contacts with the State Executive Office in Lan-
sing continued to be frequent and pleasant. Matters
discussed were: (a) nominations for the Michigan State
Board of Registration in Medicine and for the Michigan
1031
ANNUAL REPORTS
Board of Nursing Advisory Council; (b) MSMS repre-
sentation on the Governor’s Study Commission on Public
Health — with the MSMS statement on health and medi-
cal matters being presented to this Commission by Presi-
dent Arch Walls, M.D.; (c) MSMS representation on
the Governor’s Study Commission on Prepaid Hospital
Care Plans, which in July, 1957, completed arrange-
ments with the University of Michigan to carry on a
factual, unbiased, and unprejudiced survey of prepaid
medical care and insurance programs extant in Michi-
gan; (d) MSMS opinion on health proposals which the
Governor placed before the 1957 Legislature; (e) the
Governor was invited to be guest speaker at the Officers’
Night Dinner, during the 1957 MSMS Annual Session
in Grand Rapids.
5. Liaison with the Michigan Commissioner of Health
continues, with A. E. Heustis, M.D., being invited to
all meetings of The Council and of its Executive Com-
mittee to report on matters of mutual interest in the
field of preventive medicine. During the year The Coun-
cil reiterated its policy on immunization programs: that
they be continuing programs to include all procedures.
In 1957, MSMS opinion on health proposals to be
placed before the legislature was invited by the State
Health Commissioner. In this connection. The Council
decided that “as a matter of policy, MSMS is opposed
to increased state expenditures, caused by the inaugura-
tion of new programs on the part of state agencies, at
this time.” The Council recommended that present ap-
propriations be carefully scrutinized to avoid forcing
upon future legislatures programs that will require ex-
penditures to exceed the income to be expected from the
state tax structure as presently enacted.
6. Liaison with the University of Michigan was
concentrated, during the past year, on the subject of
hospital admissions. The policy of the University of
Michigan Hospital, as presented in the November 20,
1956 letter from the Hospital Director is:
“All patients who are cared for by the University
Hospital are referred to it by practicing physicians
of the State and a complete case summary is sent
to them at the time of discharge. Reports are not
sent to anyone other than the referring physician
unless so requested by the patient.
“There will be no further action on the part of
the University Hospital to develop an ‘interagency
referral program’ until we are requested to do so
by the Michigan State Medical Society.”
Additional suggestions, to aid relations between Michi-
gan's practicing doctors and those in our medical centers
— in referral of medically-indigent patients back to their
private physicians — were made by the Liaison Com-
mittee. Two members of this Liaison Committee ad-
dressed the University Hospital residents and interns
during their orientation period in July, 1957, stressing
these suggestions. The Council is gratified at the co-
operation it has received from the University Hospital
authorities, and feels that real progress has been gained
from mutual understanding.
Another progressive step with the University Hospital
was the MSMS approval of the Home Visit Program
of the University of Michigan Pediatrics Department,
subject to approval by the county medical societies in
the areas used.
7. The usual number of beneficial contacts were
maintained during the past year with the Michigan Em-
ployment Security Commission, the Michigan Crippled
Children Commission, Michigan State Board of Regis-
tration in Medicine, Michigan State University, Wayne
State LTniversity College of Medicine, Michigan Social
Welfare Commission, Michigan Department of Insurance,
Michigan Fire Marshall, members of the Michigan
Legislature (see paragraph on Public Relations and
Legislation), and with members of the United States
Congress.
Contacts with Voluntary Agencies and
Organizations
1. Michigan Medical Service elected L. Fernald Fos-
ter, M.D., long-time Secretary of the Michigan State
Medical Society, as its President and Medical Executive
Administrator during the past year.
Michigan Medical Service is faced with most critical
problems which, unless solved by the medical profession
promptly, may cause this medically-sponsored social
experiment to founder. If the medical profession allows
Blue Shield to fall, the void will be quickly filled either
by government (socialized) medicine or by union-con-
trolled medical programs.
Increased utilization ( but no increase in medical
fees) caused Michigan Medical Service to seek an in-
crease in rates from the Insurance Commissioner in
July (the first request since 1950). This was granted.
The Council prophesies vicious blasts against Medi-
cine, leveled primarily against the private practice of
medicine, and favoring a drastic and immediate change
to closed panel (salaried) practice or some variation of
it under nonmedical auspices and control. The Council
warns that this is a time for unselfish medical leadership
— that only wise statesmanship on a high altruistic level
will save the private practice of medicine as we know
it. The Council begs the entire medical profession to
lend its hand and heart in this crossroads crisis. No
recommendation on this matter will be made by The
Council until the findings of the Market Opinion Survey
are available.
2. The Joint Committee with the State Bar of Michi-
gan drafted during the last year a “Statement of Prin-
ciples Governing Physicians and Lawyers” which was ap-
proved by The Council in July, 1957. Subtitles of the
statement include “Medical Reports Requested by At-
torneys,” “Co-operation Between Physician and Attorney
in Cases Expected to be Tried and Where Attorney
Proposes to Present Physician as a Witness, Before Ap-
pearance in Court,” “The Physician as a Witness on
the Trial of the Case,” “Compensation for Services of
Physicians,” and “Interprofessional Courtesy and Under-
standing.” This statement will be distributed to all
MSMS members and also printed in The Journal;
it is a long step forward in better relations between
lawyers and those physicians whose work brings them in
frequent or occasional contact with the courts. Many
productive meetings have been held at the county level
between these two learned professions.
3. Favorable liaison continues to exist between MSMS
and the Michigan State Nurses Association; Michigan
League for Nurses; Michigan Health Council; Michigan
State Pharmacetuical Association; Michigan State Medi-
cal Assistants Society; Michigan Cancer Co-ordinating
Committee, including both Divisions in Michigan of the
American Cancer Society; Health Insurance Counsel;
World Medical Association; United Health and Welfare
Fund; Michigan Farm Bureau; Citizens Public Health
Advisory Committee; Michigan Hospital Association;
Michigan Health Officers Association; Michigan State
Veterinary Association; Michigan Heart Association;
Michigan Multiple Sclerosis Center (which invited
MSMS to appoint a medical advisory committee for its
guidance); Michigan Hospital Service (which invited
MSMS to nominate the personnel of a medical advisory
committee) ; Michigan Psychological Association; Michi-
gan Conference on Aging, and Cornell University Medi-
cal School (with which MSMS is co-operating in a high-
way accident crash survey) .
4. Again The Council expresses high thanks to all
MSMS members who have sacrificed valuable time and
effort to act as official MSMS representatives to the
many governmental and voluntary organizations which
invited MSMS to name delegates to their boards and
committees.
1032
JMSMS
ANNUAL REPORTS
Beaumont Memorial Restoration
The Council was gratified at the quick response to
its appeal that the MSMS members liquidate the in-
debtedness of $9,099.29 on the Beaumont Memorial. A
flood of checks was the answer — totaling $8,544.
Negotiations are going forward with the Michigan
Mackinac Island State Park Commission to place owner-
ship of the Beaumont Memorial furnishings (personal
property) in the name of the Michigan State Medical
Society, in order that the different displays of Beaumon-
tabilia, to be featured from summer to summer, are kept
authentic, mobile and interesting.
Committees
A total of ninety-six meetings of committees of MSMS
and of The Council were held during the past year (up
to September 1, 1957).
The background of MSMS progress is the activity of
our committees. Their annual reports deserve your care-
ful perusal. The Council again expresses true gratitude
to the chairmen and members of all these active com-
mittees for their great and unheralded contributions
and effort given on behalf of all MSMS members — for
the benefit of Michigan Medicine and the public of this
State.
Annual Reports of Committees of the Council
Again to save the time of House of Delegates’ Refer-
ence Committees, the Annual Reports of Committees of
The Council are being integrated into the Annual Report
of The Council —a pattern that proved successful during
the past two years:
Committee on Arbitration. — The Committee on Arbi-
tration attempts to advise fair, equitable and uniform
fees for certain medical services rendered to patients
who are being subsidized by governmental agencies. As
of the present date, the Committee has had six meetings
and reviewed twenty-one cases. Based on past experience,
it is anticipated that about two more formal meetings
will be held before the close of the current year.
Committee on Awards. — During the past year, the
Committee on Awards has carefully reviewed possibilities
for public recognition by the Michigan State Medical
Society of outstanding work done in behalf of the health
of the people of Michigan and the medical profession.
As a result, we have during the past year recommended
the citations noted below. The recommendations were
formally approved by The Council and the awards were
publicly presented.
At the Michigan Clinical Institute:
1. Eight MSMS members serving as presidents of
national medical organizations: J. S. DeTar, M.D.,
Milan, president, American Academy of General Prac-
tice; Cameron Haight, M.D., Ann Arbor, president,
American Association for Thoracic Surgery; Charles
G. Johnston, M.D., Detroit, president, American As-
sociation for the Surgery of Trauma; Rupert C. I,.
Markoe, M.D., Detroit, president, American Academy
of Tuberculosis Physicians; Edgar E. Martmer, M.D..
Detroit, president, American Academy of Pediatrics;
Norman F. Miller, M.D., Ann Arbor, president, Ameri-
can Gynecological Society; Robert L. Novy, M.D.,
Detroit, president, National Association of Blue Shield
Medical Care Plans; and William D. Robinson, M.D.,
Ann Arbor, president, American Rheumatism Associa-
tion.
2. Distinguished Health Service Awards were pre-
sented to four Michigan legislators: Representative
Arnell Engstrom, Traverse City; Senator Clarence F.
Graebner, Saginaw; Senator Perry W. Greene, Grand
Rapids; and Senator Elmer R. Porter, Blissfield; also
to Mr. Jay C. Ketchum, Executive Vice President and
General Manager of Michigan Medical Service; Mr.
John Reid, Director of Michigan Medical Service and
Michigan Commissioner of Labor; and Radio Station
WHAK, Rogers City.
August, 1957
Although not within the scope of this Committee’s
responsibility, the Committee nonetheless recognized with
pleasure the election of Ralph C. Cook, M.D., Kalama-
zoo, and Joseph H. Sherk, M.D., Midland, as Michigan’s
Foremost Family Physicians of 1956. (Dr. Sherk was
awarded the honor posthumously.) The Committee was
also pleased to note the fifteen MSMS members repre-
senting 750 years of medical service who were presented
with the Fifty-Year Award this year; the Biddle Lecturer,
Dr. Lawrence R. Hafstad, General Motors Vice President
in charge of research staff, and the Annual Beaumont
Lecturer, Leon Schiff, M.D., Cincinnati, Ohio.
Committee on Study of Basic Science Act. — No changes
in the Basic Science Act were made in the 1957 legisla-
ture. It remains the same as amended in 1955.
Prior to 1954 the figures issued by the Basic Science
Board indicated the number of physicians, dentists and
medical students in one category, osteopaths in another,
chiropractors in a third, and one category was reported
as unclassified. Reports of the Basic Science Board are no
longer released in this manner, so that for the past
three years the only figures available are the total
number of applicants taking the examinations, the num-
bers of applicants passed and the total number of candi-
dates certified by waiver, endorsement, reciprocity or
exemption.
The Committee has been informed that the figures
reported annually through the Journal of the American
Medical Association have not been complete, so that all
previous figures released by the Committee on Study
of the Basic Science Act are to be disregarded.
The most accurate figures on the numbers of candi-
dates examined, passed and certified by reciprocity,
waiver, exemption or endorsement which this Commit-
tee can obtain are presented in the following table:
Year
Total Taking
Examination
Total Passing
(Approximate)
*Total Candidates
Certified by Waiver,
Reciprocity, Endorse-
ment and Exemption
1953
600
450
—
1954
657
493
129
1955
640
480
209
1956
596
398
240
1957
361
271
100
(Feb. -March (all incomplete)
examinations
only )
[Total 678
*Figures are approximate in any single year but the
total certified without examination is accurate.
From the above table it is noted that a total of 678
candidates have been certified by endorsement, waiver,
reciprocity or exemption from December 1, 1954 to
June 1 1, 1957. The candidates thus certified are classi-
fied as follows:
7 chiropractors 7%
164 osteopaths 25%
507 M.D.’s 74%
This Committee has endeavored to maintain a close
working relationship with the Basic Science Board and
found them quite co-operative. We are hopeful of
obtaining more accurate and complete figures in the
future.
From the figures presented these observations seem
reasonable: First: the numbers applying for examination
changed relatively little in the last few years. Second:
the number of candidates certified without examination
has increased somewhat following the liberalization of
the Basic Science Law in 1955. This was to be expected.
1032
ANNUAL REPORTS
Third : the Basic Science Law apparently continues to be
a barrier that prevents the entrance into Michigan of
substandard practitioners of the healing arts.
Committees on “Big Look ” and Site. — The “Big Look”
Committee met on December 11, 1956, and discussed two
problems.
1. The question of maintaining a well-balanced per-
sonnel at the executive office. The Committee recom-
mended to The Council a formula for the increase of
base salaries of the key personnel at 606 Townsend to
be on equal footing with other state societies.
2. This Committee also looked into the possible sites
for a location of our new home. To date, the Committee
has not found such a site.
Committee on Blood Banks. — There have been no
specific meetings of the entire Committee on Blood
Banks of the Michigan State Medical Society; however,
meetings have been held from time to time by several
of the members pertaining to problems which arose
suddenly.
The Michigan Association of Blood Banks, which
was founded under the auspices of the Michigan State
Medical Society and the Michigan Pathological Society,
held its annual meeting in November, 1956, and a
capacity crowd attended. Associated with the scientific
meeting was a workshop for technicians which was held
for one day. The Association is now in the process of
planning a two-day workshop and scientific meeting for
November of this year.
Participation in the North Central District Blood Bank
Clearing House has been gratifying and the use of its
facilities has tripled since last year. We feel that this
is a real service to the people of the State of Michigan.
Committee on Use of the Word “Clinic.” — The word
“clinic” in the mind of the layman means a place for
medical teaching, a place for free examination and treat-
ment of indigents, or a place where special tests or
special procedures are done because of the availability
of unusual equipment or because of the banding to-
gether of a special staff of highly trained specialist
physicians.
The 1956 House of Delegates Resolution No. 19 de-
plores the use of the word “clinic” by one and two
physicians and further alleges unethical conduct by such
“clinics.” This Committee hastens to point out that the
rules of ethics apply equally to physicians practicing in
groups and if unethical practice is being done it is the
job of the county medical society to take action.
However, this Committee feels that the resolution
was not primarily drawn to charge unethical conduct,
but rather to point up the increasing exploitation of
the word “clinic” as the public has come to define it.
We deplore the use of the word “clinic” when used
by a doctor or doctors to describe what is actually an
ordinary doctor’s office. There is the implication to the
public that a “clinic” practices medicine rather than
the doctors who work there, and there is the added im-
plication that broader and more specialized care is to be
secured than in a doctor’s office.
We have received an opinion from legal counsel stat-
ing that there is no statute in Michigan defining the
use of the word “clinic” either as to size, equipment,
personnel or in any other way. We must conclude,
therefore, that the use of the word “clinic” by one or
two physicians is neither illegal nor in itself unethical.
We believe that the use of the word “clinic” when
done quite obviously to exploit a concept held by the
public for business reasons should be strongly con-
demned by physicians. Further, we feel this fact should
be publicized to the doctors of Michigan.
If the House of Delegates deems this of sufficient
importance to medicine, we would recommend that they
authorize the MSMS to sponsor legislation designed to
define what a clinic is and what places may properly
use the word in describing themselves to the public.
1034
Committee on Courses on Medical Economics and
Ethics. — The Committee met on August 10, 1956, in
Ann Arbor. The minutes of this meeting were approved
by the Executive Committee of The Council on August
22, 1956. The plans made at that meeting have been
partly carried out, and fifteen lectures have been pre-
sented so far. Possibly one or two more will be added
before the end of the year.
August 29, 1956: Mr. Eugene Wiard, Executive Secre-
tary of the Michigan Health Council, spoke on “Physi-
cian Placement in Michigan” and pointed out the facili-
ties which are available in bringing together a physician
seeking a location and a community seeking a physician.
October 3, 1956: Dr. Milton R. Weed of Detroit
again spoke on “The Relation of the Physician to Other
Practitioners” in which he pointed out methods of
avoiding pitfalls in intraprofessional and interprofession-
al relationships.
October 24, 1956: Dr. R. W. Teed filled in for Dr.
Foster who was unable to be present, and discussed the
subject of “Office Records.”
November 14, 1956 : Dr. Jackson Livesay of Flint gave
a lecture on “Provincialism and Economic Royalism in
Medicine.”
December 5, 1956: Dr. C. Howard Ross of Ann
Arbor presented a very practical discussion on the sub-
ject of “The Development of a Fee Schedule.”
December 19, 1956: Dr. James Blodgett of Detroit
spoke on “Self Policing of the Medical Profession,” de-
scribing the measures which have been taken within
the profession to improve the standards of medical prac-
tice.
January 16, 1957 : Dr. V. M. Zerbi, Chairman of the
Ethics Committee of the Washtenaw County Medical
Society, and his entire committee held an open session
of the Ethics Committee before the class. This gave the
class an opportunity to see the Committee actually
working.
February 20, 1957: Mr. William Burns and Mr.
Hugh Brenneman discussed the public relations activities
of both the Michigan State Medical Society and the
AMA.
March 6, 1957: Dr. Warren Mullen of Pentwater
spoke on “Starting a Medical Practice.”
March 13, 1957 : Dr. Lawrence A. Drolett of Lansing,
Chairman of the Legislative Committee of MSMS, spoke
on “The Relation of the Physician to the Legislator.”
March 27, 1957: Dr. Hugh Robins spoke on “The
Physician and the County Health Department.” Dr.
Robins is Director of the Calhoun County Health De-
partment at Battle Creek.
April 10, 1957: Dr. William Bromme of Detroit spoke
on “Medical Problems of Veterans.”
April 17, 1957: Dr. Ralph Johnson of Detroit spoke
on “The Art of Medicine.”
May 8, 1957: Dr. L. Fernald Foster of Bay City
spoke on “History, Philosophy, and Proper Utilization of
Voluntary Health Insurance.”
The Committee recognizes that its work has been
somewhat less effective than it could have been, but
there have been a number of limiting factors. The
Committee has also attempted to make contact with
the medical school at Wayne University, but so far
these contacts have not been effective. We feel that
we have made some contribution in bringing to the
medical students facts in the realm of medical economics
and ethics which they probably would not have secured
otherwise and trust that our performance will improve
in future years.
The Chairman would like also to thank all mem-
bers of the Committee for their cooperation and to
commend them for their aid in carrying out the pro-
gram. He would like also to express gratitude to all
JMSMS
ANNUAL REPORTS
of the members of the MSMS and others who have
cooperated in presenting the lectures.
Committee on Health and Accident Insurance Policy
Control — There has been no meeting of the Insurance
Committee, Michigan State Medical Society, during
the past year. All pending questions have been ad-
judicated without committee action.
Hospital Relations Committee. —
1. Responsibilities of Physicians and Hospitals Dur-
ing Disasters: In another state legal opinion has been
drafted in accordance with the laws of the state as a
guide to legal responsibilities of doctors and hospitals
during local disasters. Recommendation was made
that similar opinions in accordance with Michigan law
be secured and published by the Michigan State Medical
Society and the Michigan Hospital Association.
2. Cultists in Hospitals-. Discussion centered around
the present status of certain “healing groups.” Re-
commendation was made to the parent bodies of this
Committee that the enactment of legislation specifi-
cally eliminate the public danger involved in per-
mitting chiropractors professional access to public-sup-
ported hospitals.
Medical Procurement Advisory Committee — This
Committee held no meetings during the past year,
since no problems arose which called for a meeting
and no references were made by officers or committees
of the Society which required consideration. How-
ever, several members of the Committee have served
in various capacities in medical procurement. Grover
C. Penberthy, M.D., Detroit, Chairman of the Volun-
tary Advisory Committee to the Selective Service
System and your Chairman as Medical Advisor to the
Director of Selective Service of Michigan, advised on
June 25 that the Doctors’ Draft Law ceased on June 30,
1957. He expressed appreciation for the co-operation,
interest and assistance rendered his office during the
years 1950 to date of its close. He stated there is a
possibility that a standby committee of some type will
be continued.
Special Committee to Meet With Michigan Depart-
ment of Social Welfare — There have been five meet-
ings of this Committee with the Director of the Wel-
fare Department and members of his staff since Sept-
ember, 1956. Matters referred by the Commission were
studied and recommendations made. Some of the pro-
blems were: extension of coverage in the ADC cate-
gory, especially in cases utilizing vocational rehabilita-
tion; methods of using the new Federal grant for help
in county hospitalization costs; reappraisal of cases in-
volving mental disease determinations; improving the
local county consultant services; and other related
matters.
The Department of Social Welfare has again thanked
this Committee for its valuable contributions and for
its time so willingly spent.
Committee on Michigan Medical Service. — This
Committee had three meetings early this year, one of
which was a joint meeting with the Committee to
Study Comprehensive Prepaid Insurance Plans. After
thorough appraisal of the problems facing Michigan
Medical Service, The Council was asked to authorize
a Special Meeting of the House of Delegates, which
was authorized and the meeting was held in Detroit
on April 27, 1957. A perusal in detail of the Pro-
ceedings of this Special Meeting will clearly show the
extent of the thought and effort put into these pro-
blems and also the fine cooperation between this Com-
mittee and members of the administrative offices of
Michigan State Medical Society and Michigan Medical
Service.
Liaison Committee with Michigan Medical Service —
There were no matters, referred to this Committee
requiring its consideration during this year.
August, 1957
Liaison Committee to Michigan Society of Neurology
and Psychiatry and the Michigan Psychological Society —
The first meeting of this Committee, of the entire
personnel, was held on January 2, 1957 at which time
the minutes of the subcommittee of the Michigan State
Medical Society Legislative Committee to meet with
psychologists, dated February 3, 1954, and September
16, 1954, were reviewed, and discussed. It was moved
and carried that these minutes be received for in-
formation.
The items regarding certification of psychologists
from the Michigan State Medical Society Mental Health
Committee minutes of November 29, 1956, were then
discussed. Dr. E. Lowell Kelly distributed copies of
the proposed bill along with an article reproduced from
the American Journal of Psychiatry entitled “Psy-
chiatry, Psychology and the New York Law.” Dr. Kelly
stated that a legal definition was needed so that quasi
psychologists could be weeded out. After consider-
able discussion it was moved and carried that the joint
committee meet following the January meeting of the
Michigan Society of Neurology and Psychiatry for fur-
ther work on the problem of certification, and the
date of this next meeting was set for January 30, 1957.
At this meeting Dr. Jeffries reported that the Coun-
cil of the Michigan Society of Neurology and Psy-
chiatry had considered the proposed bill regarding the
certification of psychologists and he further stated that
the proposed psychologists certification bill was writ-
ten in such vague terms that it is open to broad inter-
pretations. Their concern was over the effect on the
community and over the lack of safeguards. The So-
ciety, after hearing the Council’s report, took a de-
finite stand that the bill was not acceptable. However,
The Council was instructed to continue working with the
psychologists in an effort to reach a mutually agreeable
solution. Further discussion followed at this time and it
was moved and carried that a subcommittee be appoint-
ed by Chairman Bohn to study the proposed psychologists
certification bill and to report recommendations to
the main Committee; the subcommittee to consist of
not more than three members each from the Michigan
Society of Neurology and Psychiatry and the Michigan
Psychological Association. The following subcom-
mittee was appointed: Benjamin Jeffries, M.D.; P. A.
Martin, M. D.; A. H. Hirschfeld, M.D.; E. L. Kelly,
Ph.D. ; William Knapp, Ph.D., and Mr. Alan Canty,
with Dr. Jeffries as Chairman.
Dr. Jeffries forwarded a communication dated
March 25, 1957, wherein he stated that since the last
meeting of the Committee as a whole on January 30,
the subcommittee had met on Monday, February 4 and
February 14, at which time exploration of the problems
relating to medical psychiatry and the proposed certi-
fication of psychologists was carried out. At the Febru-
ary 18 meeting it was decided to have Mr. Alan Canty
and Dr. Jeffries meet to develop an agenda for fur-
ther work regarding this subcommittee. Mr. Canty
and Dr. Jeffries met on Thursday, March 7, and
developed an agenda. The items had been studied by
the members of the subcommittee and they anticipated
a meeting of the total subcommittee in the next few
weeks.
A communication from E. Lowell Kelly, Ph.D.,
dated April 1, 1957, was received, wherein he stated
that in spite of several meetings the subcommittee had
made very little progress in resolving the issues grow-
ing out of the proposed certification bill. He further
stated that the executive council of the Michigan Psy-
chological Association voted to introduce the bill into
the legislature this year. He further stated that Mr.
Canty and Dr. Jeffries had been attempting to arrange
for another meeting of the subcommittee and that they
were still hopeful that some agreement could be reached
regarding what a certification bill can and cannot do —
and then asked whether there were improvements that
1035
ANNUAL REPORTS
could be made in the bill. Dr. Kelly also included a
copy of a letter which he addressed to Mr. Philleo of
Lansing in which he indicated that the Michigan Psy-
chological Association had asked Senators Minnema and
Ryan to co-sponsor the bill in the Senate and to ar-
range for a public hearing.
Later in April a communication was addressed to Dr.
E. Lowell Kelly by Dr. Jeffries, wherein the latter
stated that, since it had been decided to present the
proposed bill for certification of psychologists to the
legislature, it would be advisable to hold the intended
conference in abeyance until they had been apprised
of the pleasure of the legislature on this matter. Dr.
Jeffries concluded by stating “therefore, we will look
forward to picking up our agenda and continuing our
work as soon as possible after this has been ascer-
tained.”
Liaison Committee with Michigan State Pharmaceu-
tical Association — No problems have arisen during this
year that required a meeting of this Committee. Some
members of the Committee assisted in the clarification
of a related problem involving the Michigan State
Pharmaceutical Association, the State Board of Phar-
macy, the Michigan State Nurses Association, and
Michigan Hospital Association.
Liaison Committee with Michigan Veterans Organiza-
tions— Up to the time of preparation of this report,
no meeting of the Committee had been called. The
Chairman kept the group of service officers of the
four veterans service organizations up to date with
problems deriving from renegotiating the contract for
the Home Town Care Program in the event that their
assistance would be necessary. (See Contact with Gov-
ernmental Agencies. Item 2)
Committee on National Defense — It is with a great
deal of sorrow that the Committee on National Defense
reports the passing of its long-time Chairman, Dr. Wil-
liam H. Gordon, on May 5, 1957.
Dr. Gordon was an active chairman who stimulated
all of us with his keen interest in the problems of
civil defense and the necessity for statewide interest
in the development of planning. We shall miss his
guiding hand.
The Committee met at regular intervals throughout
the year, one of the meetings being held jointly with
Rural Medical Service Committee. At each of the
meetings there were reports from representatives of
the various professional groups of the state concerning
the status of activity in which they were engaged.
Representatives of the Michigan Department of Health,
the Michigan State Office of Civil Defense, and the
Detroit Office of Civil Defense kept the Committee
informed of their progress.
The Committee accepted and approved “Standing
Orders for Nurses in Mass Disaster” which was pre-
pared for the Health Division of the Detroit Office of
Civil Defense by a joint committee made up of phy-
sicians, nurses and hospital administrators, under the
chairmanship of Dr. Joseph Witter.
It was reported that training material for dentists
as well as for nonprofessional volunteers, which had been
developed by the Health Officer of the Detroit Office
of Civil Defense and approved by this Committee, had
been requested by civil defense organizations and dental
associations in eighteen states. Requests were also re-
ceived from many dental schools, military organizations
and other groups. It was reported that this training
material is being used very successfully in Detroit
and other cities in the State.
The Committee feels that it is imperative that all
physicians throughout the State be aware of planning
and their responsibilities in the care of casualties. This
applies to incidents which might occur locally as well
as mass disaster. Further, the Committee feels that all
physicians should participate in the training of other
professional groups and nonprofessional volunteers in
casualty care as well as planning. Mass disaster is no
longer a local problem but one which involves an en-
tire state, if not a region. With the existence of
thermonuclear devices current planning must be de-
veloped on a statewide basis using every resource
and potential of the entire state.
Committee to Study Package Arrangements Between
County Medical Societies and Local Welfare Depart-
ments.—
Last November the Committee on Study of Welfare
Package Arrangements mailed questionnaires to all coun-
ty medical societies in the State. The response was
very prompt and quite surprising, as replies were re-
ceived from fifty-four county medical societies. Only
one county of the State Medical Society failed to re-
port. Perhaps the response received is some indication
of the importance placed upon this matter by the com-
ponent medical societies.
The questionnaire on the medical care of welfare
cases consisted of seven items, most of which were
answered by the county medical society concerned.
Questions and answers are listed below:
1. Does your county medical society have any agree-
ment for the medical care of welfare cases?
Forty-nine county societies answered this ques-
tion in the affirmative and six counties indicated
that they had no agreement for the medical care
of welfare cases. Twenty-four societies indicated
that they were using the Uniform Fee Schedule
for Governmental Agencies as a basis for their
agreement, four used a Crippled Children’s fee
schedule, and eighteen based their agreement on
a local schedule. The balance apparently made no
report.
2. If the agreement is based on the Uniform Fee
Schedule for Governmental Agencies or that of the
Michigan Crippled Children Commission, does
your county society plan have any variations there-
from?
Seventeen counties indicated their agreement as
being based upon the Uniform Fee Schedule for
Governmental Agencies; twenty-two stated no;
sixteen made no comment. It is necessary to
tabulate the comments made under this heading
as follows:
a. One society used the Blue Cross-Blue Shield
plan entirely.
b. Muskegon changed to Uniform Fee Schedule
March 1, 1957.
c. Two societies indicated some variation in
arrangement for complicated cases.
d. Four societies used the Blue Cross fee sche-
dule for the $2,500 bracket.
e. Another society indicated Social Welfare
pays 75 per cent of the amount listed in the
Uniform Fee Schedule, the maximum being
$85.
f. Shiawassee County reports that the fees are
paid to the hospital staff fund which in turn
is used for laboratory, library and other
expenses of the staff. For children, the Crip-
pled Children Commission fee schedule is
used.
g. One county reports an agreement of house
calls at $5 to $7, based on hours and holi-
days; hospital calls $3.
h. Another society reports 50 per cent reduc-
tion in fees for hospitalized OAA patients.
i. One county has an annual contract with the
Social Welfare Department for the payment
of $10,000 to the medical society which
covers the care of all welfare cases.
1036
JMSMS
ANNUAL REPORTS
j. Another agreement covers $3 daily for the
first fourteen days for medical cases and then
$1.70 per visit; $200 maximum for a hos-
pital patient; no pay for EKG on a hospital
patient.
k. Another variation is the Uniform Fee
Schedule for surgery, a local plan for medi-
cal cases which covers four calls the first
week, two calls through each week there-
after.
l. Another variation: the medical cases are
paid on the Michigan Crippled Children
Commission fee basis.
m. Another county uses the Michigan Crippled
Children Commission fee schedule, with the
surgical fees higher in some cases and lower
in other cases.
n. One county pays 65 per cent of the fee
schedule but does not state the fee sched-
ule used.
3. What are the salient features of the local agree-
ment, if one is used?
In many cases this particular question was not
answered. We received twelve affirmative answers,
ten negative answers, and no answer at all in
thirteen cases, a total of thirty-five. It is inter-
esting to note the variation in answers made on
this question. They may be tabulated briefly as
follows:
a. County pays to doctor as agreed, hospitaliza-
tion authorized, keep costs down.
b. Set fee for home, office, major surgery.
c. Monies paid to county society (2).
d. Blue Cross $2,500 rate (4).
e. Based somewhat on Uniform Schedule ( 1 ) .
f. Practitioner submits prevailing fee for ser-
vice ( 1 ) .
g. Approved by local filter board ( 1 ) .
h. Specialists’ fees about $100, varies (1).
i. Patient referred to Welfare Department; no
uniform fee; decided by Welfare Depart-
ment (1).
j. County employs two physicians on salary
<2>. ; .
k. Lower than Michigan Uniform Fee Sched-
ule until revised ( 1 ) .
l. Salaried county doctor; health officer
O.K.’s other bills.
4. Does your county society have an agreement with
the county or city for the hospitalization of welfare
patients?
Thirty-five societies answered this in the affirmative,
and nineteen stated that they had no agreement
for the hospitalization of welfare patients.
A second part of this question asked: To whom
were the fees for the medical care of hospitalized
welfare patients paid?
Thirty-three societies answered that the fees
were paid to the attending physicians ; five state
the fees as being paid to the county medical so-
ciety, and three gave other methods of payment.
Many societies did not answer this part of the
questionnaire. The comments made under this
heading follow:
a. Usually whatever the Welfare Director will
give; ignores the agreement usually (1).
b. M. D. is paid by the county welfare officer
on a schedule agreed between the county
medical society and the Board of Super-
visors ( 1 ) .
c. Trust fund to be used to finance hospital
externships ( 1 ) .
d. Each case considered as it arrives (2).
e. Accept hospital rates, Blue Cross? (1).
f. Through county society (1),
August, 1957
g. Doctor bills Social Welfare Department (1).
h. Surgical fee to doctor; attending doctor for
medical cases ( 1 ) .
i. Hospital paid directly; doctor is paid $2
a visit (1).
j. Based on Michigan Medical Service (1).
k. Acute cases paid to attending M.D. (1).
5. Does the society have an agreement for the home
and office calls for welfare patients?
Thirty-seven societies answered in the affirmative,
sixteen in the negative. In general, throughout
the counties reporting, the majority of home day
calls are paid for at the rate of $3 to $4 as the
following figures will indicate:
Home Calls
Day
Night
$2 (with mileage 1 way) 2
$3.00
16
$3.00
. 5
$3.50
1
$4.00
12
$4.00
. 5
$5.00
7
$4.50
. 1
$5.00
.19
$6.00
. 2
$7.00
. 3
Office Calls
$1.50 1
$2.00 18
$2.50 1
$3.00 16
No set fee 1
6. How old is your county society agreement? If it
has been revised, indicate date.
The answers were about as follows:
Several years 1
Ancient 1
1 year 9
2 years 3
3 years 2
4 years 8
6 years 4
8 years 11
9 years 1
10 years 4
14 years 1
1 5 years 2
18 years 1
20 years 1
22 years 2
23 years 1
(no answer from eleven societies)
Only a few societies indicated that their agreements
had been revised recently.
7. Is there any provision for care of “medically in-
digent” cases? Give a brief explanation if the
answer is yes.
Thirty-nine county societies indicated in the af-
firmative that there was an agreement of this
nature; fifteen answered in the negative. A great
variety of answers was received to this question.
a. No standard procedure (1).
b. Cared for in the county infirmary (8).
c. Doctors take care of them gratis.
d. Paid by county: patient signs agreement to
repay county where able (3); patient signs
agreement to repay county when able (16).
e. Treated on local fee schedule after calling
Welfare Department (3).
f. Included in sum paid by county ( 1 ) .
g. Bills sent to county welfare department (11).
h. One county comments as fellows: “many
are referred to convalescent homes and the
supervisors’ board feels a hospital would be
financed at a cheaper rate with better super-
vision and control of patient, physician and
welfare department.”
1037
annual reports
i. County or state aid, or else an agreement
with the attending doctor to lower or can-
cel his fee ( 1 ) .
j. Hospital cases by physicians employed by
county; home calls paid by welfare society
and fees established by them (1).
k. Arranged with individual physicians ( 1 ) .
l. Screened by welfare agency and treated lo-
cally or at University Hospital (1).
m. Through the county bureau of social aid; re-
fers to notice in the Washtenaw County
Medical Society Bulletin of May 1956 (?)
n. A three-county society feels choice of phy-
sicians is being taken away from patients.
o. One tri-county society feels there is discrim-
ination.
8. At the bottom of the questionnaire, the societies
were asked to make any comments they cared to
for the benefit of the Michigan State Medical
Society. Not all answered this question, but so
variable are the comments that it seems best to
list them as they were received :
Allegan: We are well satisfied as the agreement is
the same as the Michigan Medical Service pays.
Clinton: Excellent relations with county welfare com-
mission; if met halfway, they cooperate well with us.
Chippewa, Mackinac : Many items are unsatisfactory,
as follows: (a) Welfare director insists on patient mak-
ing personal visit for authorization; this is unreasonable
as the patient may be too ill; (b) authorization for hos-
pital care dates only from the completion of the in-
vestigation.
Genesee: Our contract is up for revision; we have a
backlog of $75,000 for services over and beyond the
$10,000 limit of our contract.
Dickinson, Iron: (a) Difficulty with welfare depart-
ment administration; and (b) inequality of payments by
Michigan Crippled Children Commission with their
standard fees for service.
Ingham: “Excellent”
Barry: “Accept Blue Cross $2,500 rate. The further
comment was made that this plan was first called to
my attention by this form, since Welfare was called and
the director stated the above had been followed for the
past four to five years and she had never changed it
nor did she intend to.”
Jackson: “We like this — we pay our own men to run
a screening panel on the necessity for the treatment re-
quested and we also pay an auditing committee (at
$10 per hour) to check the bills.”
Kent: “Crippled Children’s and Vocational Rehabili-
tation patients are cared for according to the appropriate
or specific fee schedule and payment is to the physi-
cian directly.”
Lapeer: “Lapeer County Convalescent Hospital for
chronically ill patients hires a private physician on con-
tract. Patients not cared for here or at Lapeer County
General Hospital are cared for by private physicians on
fee basis.”
Lenawee: “Fees too low now; planning revision.”
Macomb: “Being a very busy suburban area, doctors
have cooperated well with County Board.”
Marquette : “We feel we get along well with the
County Welfare people. Plan has worked to mutual
satisfaction.”
Midland: Hardy Cancer Fund and Midland County
Crippled Children’s. Want provision for ADC other
than emergency and want indigent dental care.
Monroe: “Unwritten agreement that welfare cases
will be treated in the hospital without charge by the
physician (hospital gets paid for its services). We
would be anxious for an official recommendation by
MSMS which would be an excuse for opening discus-
sions with County Commissioner.”
Northern Michigan: “This was discussed at our last
meeting. There is feeling there should be some uni-
formity in charges and services. One county apparently
goes by the Michigan Crippled Children Commission’s
fees, another by the Blue Book, others by an inter-
county agreement social welfare directors set up in the
1930’s.”
Newaygo: “A meeting has been arranged with county
supervisors’ committee for January 1957 in attempt to
iron out some of the many problems and arrange a
standard procedure as well as a standard fee schedule.
Previous meeting not too successful ; however, probably
because the county monies appropriated to the Welfare
Committee are inadequate.”
Ottawa: County refers crippled children to commis-
sion and doctors not satisfied.
St. Clair: County should assume care and responsi-
bility of medically indigent.
Sanilac: The physician may lose contact with patient
when he is transferred from one hospital to a conva-
lescent home due to distance and no facilities for trans-
portation to physician’s office for periodic examinations.
Shiawasee : Hospital has agreement with County and
Welfare Agency.
Van Buren: “We have been running a pretty vicious
and nasty battle for about two years with county welfare
people and making some progress, but problem is not
settled. We have an urgent labor problem here also.”
Washtenaw: “Through Bureau of Social Aid. The
Washtenaw County Medical Society has on previous
occasions made attempts to cooperate with the Board of
Supervisors, but agreements have never been estab-
lished.”
Wayne: “In 1946 a special committee of the Wayne
Society tried to get Detroit and Wayne Welfare Boards
to adopt Michigan Uniform Schedule but the boards
adopted the schedule in principle but cut rates approxi-
mately one-third. This was not acceptable to our So-
ciety and no agreement was made.”
A study of these reports reveals that all component
societies do not have satisfactory agreements with their
county welfare agencies for the care of governmental
wards, and that doctors of medicine are being penalized
by being requested to perform services at considerable
loss to themselves. It seems advisable that a uniform
agreement for the care of welfare cases should be pre-
pared as a guide for the use of our component societies.
It is recommended that the material from this survey
be made available to the Permanent Advisory Commit-
tee on Fees and that this Committee be invited to
develop such an agreement as a guide for our com-
ponent societies.
Committee to Study Periodic Health Examinations
in Hospitals. — There has been no meeting of this Com-
mittee in 1956-57. So far as is known, eight hospitals
in Michigan conduct these examinations for persons
other than their own employes.
The Committee would welcome suggestions as to any
action that should be taken.
Permanent Conference Committee with Michigan Hos-
pital Association, Michigan League for Nursing, and
Michigan State Nurses Association.- — Regular meetings
have been held throughout the year which have been
well attended by all component groups. The more im-
portant subjects discussed were as follows: Joint Con-
ference on Rehabilitation, record librarians, economic
security program for nurses, legislation re hospital phar-
macies, practical nurse problems, nurse recruitment,
nursing care in disaster situations, legislation concerning
all three groups, nurse registration, and personnel poli-
cies in hospitals.
All component groups realize the benefit that accrues
to all of us through discussions such as these. There
is a much better understanding of each others problems
and it leads to better and closer cooperation.
1038
JMSMS
ANNUAL REPORTS
Committee on Rural Medical Service. — The Rural
Medical Service Committee found itself concerned with
two primary objectives during this past year:
1. The continuing need for consultation concerning
M.D. Placement Program. In connection with advising
the Michigan Health Council concerning its function,
a new field has been considered to further implement
the Placement Program, namely, the development of
plans for rural medical centers. These centers would be
variable in need and size and study has been going for-
ward with Mr. Jack Kantner concerning the develop-
ment of an outline for these medical facilities.
2. Considerable effort has been directed toward the
planning of national defense and mass casualty pro-
grams as especially applicable to the rural areas. A
joint meeting was held with the National Defense
Committee in October, 1956, at which time the mutual
aspects of civil defense were discussed between the urban
and rural community levels. It is the feeling of this
Committee that much needs to be done in the immediate
future properly to organize the rural areas and their
existing facilities, such as cataloguing equipment avail-
able, et cetera, and to develop plans for handling mass
evacuation of casualties from the urban areas in the
event of a catastrophe.
Committee to Meet with University of Michigan. — -
On November 19, 1956, your Committee met with
President Harlan Hatcher, A. C. Furstenberg, M.D.,
A. C. Kerlikowske, M.D.. and M. L. Niehuss represent-
ing the University
The question of handling medically indigent patients
released from the University of Michigan Hospital was
referred to a subcommittee for study.
The problem of press releases from the University was
referred to Drs. Furstenberg and Kerlikowske and Mr.
Niehuss for coordination with public relations director,
Mr. Allen Davis.
The House of Delegates resolution re Department of
General Practice in Medical Schools was discussed and
referred to Dr. Furstenberg for possible implementation
if feasible.
Dr. Furstenberg accepted the invitation of the House
of Delegates to send representatives of the third and
fourth year classes to the House of Delegates in Grand
Rapids in September, 1957.
The subcommittee subsequently met with Roger Nel-
son, M.D., Associate Director of the University Hospital
and developed a plan of action on release of patients
which should correct misunderstandings.
The Committee advanced and Dr. Nelson accepted
the suggestion that two practicing representatives of
the Society speak to the House Staff of the University
Hospital during their orientation program of July 2,
1957, and this has been implemented.
Legal Matters
1. Legal action of William A. Kopprasch, M.D.,
Allegan, against the Michigan State Medical Society,
the Allegan County Medical Society, et al. This effort
of Dr. Kopprasch to force entrance into the Allegan
Health Center of Allegan has been in the Circuit Court
since January 13, 1955. On March 27, 1957, a four-
hour pre-trial conference with the judge and counsel
for all parties was held in Allegan at which time the
judge urged plaintiff’s attorneys to drop their damage
and conspiracy claims and confine the litigation to the
simple issues as to whether legally the Allegan Health
Center could bar Dr. Kopprasch from use of the Hos-
pital’s facilities. Depositions were taken in Lansing on
May 7 by plaintiff’s attorney.
2. MSMS Legal Counsel Lester P. Dodd, Detroit,
rendered numerous legal opinions on questions facing
the State Society as a whole and inquiries proffered by
ndividual members on topics that affected the well-
seing of all members.
\ugust, 1957
Matters Referred to the Council by 1956
House of Delegates
1. A Committee on Uniform Fee Schedule for Gov-
ernmental Agencies was appointed, following instruc-
tion of the 1956 House of Delegates, and is now in the
arduous process of studying necessary revisions in this
Fee Schedule. This is not an easy task, entailing as it
does contacts with all interested specialty groups and
affected medical organizations.
2. Resolutions re Comprehensive Prepaid Medical
Care Insurance Plans: the Committee to Study Com-
prehensive Prepaid Insurance Plans was created and
held numerous meetings with interested and informa-
tional groups; the report of this Committee will be
presented to the House of Delegates in September, as
per instruction.
3. Resolution to include Michigan Medical Service
Annual Report in the Handbook for Delegates has been
complied with.
4. Resolution re practice of psychotherapy being the
practice of medicine: after an amendment recommend-
ed by Legal Counsel, copies of this resolution were
sent to the Governor, the Attorney General, and all
county society officers. The eventual answer of Attorney
General Thomas M. Kavanagh indicated that the think-
ing of the House of Delegates had not swayed him from
his original Opinion.
5. Resolution re plan for expediting work of House
of Delegates: two improvements will be inaugurated at
the 1957 Session: the use of the Vu-Lite to permit all
resolutions to be thrown in toto upon the screen as they
are being discussed; and a special printed form (in
quadruplicate) for all resolutions.
6. Resolution re continuation of Councilor Confer-
ences: this order has been fulfilled.
7. Resolution re expansion of medical school facilities
at Wayne State University: letters have been written to
the Governor, the Lieutenant Governor (as presiding
officer of the Senate) and the Speaker of the House
of Representatives, urging acomplishment of this resolu-
tion. A proposal to add to the budget of Wayne State
University the sum of $285,650 for expansion of teach-
ing personnel to provide for fifty extra medical students
was introduced, but not adopted by the legislature.
8. Resolution re establishment of Department of
General Practice in Medical Schools: this request was
forwarded to the presidents of the universities and the
deans of the two medical schools in Michigan. In addi-
tion, the resolution was discussed at the November 19
meeting of the MSMS Committee to meet with the
University of Michigan, at which time Dean A. C. Furs-
tenberg, M.D., explained that this had already been
presented before the Executive Committee of the Medi-
cal School. Dean Furstenberg stated that already there
is much teaching being done to accomplish the aims of
the resolution.
Dean Gordon H. Scott of Wayne State University
Medical School advised as follows: “Department of
General Practice Concept is being given careful study
by our faculty. We are not sure at this time that estab-
lishment of a department is the answer to the problem
of the generalist. Our entire curriculum is in the
process of being revised and we propose no action on
this question now.”
9. Resolutions re discipline of members: during the
past year the MSMS Committee on Mediation, Ethics
and Grievance sought the guidance and recommenda-
tions of all county medical societies. The important
report of this Committee, to appear in the Supplemental
Report of The Council, is invited to the special at-
tention of all House of Delegates members.
10. Resolution re Committee to Study Use of Word
“Clinic”: the special committee was advised by Legal
Counsel that there is no legal statute regarding the
word “clinic,” so the Committee could consider any
1039
ANNUAL REPORTS
ethical problem involved. The Committee’s report is
published above, among Committee Reports.
11. Resolution re new MSMS Headquarters: last
year, the House instructed that a new MSMS Head-
quarters be built and equipped and “that, for the
building of this new headquarters, the sum of $300,000
be raised by ( 1 ) the sale (at the proper time) of our
present headquarters: (2) by the use of present build-
ing reserves; and (3) by the increasing of dues in the
amount of $5.00 per year, beginning in the 1957 fiscal
year, said increase in dues to be used only for the
purpose of defraying the cost of building and equipping
a new MSMS Headquarters.” The “Big Look” and
Site Committees have been busy and will report their
up-to-date findings in the Supplemental Report of The
Council.
The Council feels that the sooner this building is
erected, the more money can be saved in a sharply rising
commodity market. We need money now to save money.
In order to have sufficient funds, therefore, to begin
early building operations, it was recommended by the
Finance Committee and approved by The Council on
July 12, 1957 that, for one year only, the dues for the
year 1958 be increased $50.00 per member — the pro-
ceeds to be used exclusively for the MSMS building
fund.
12. Resolution re Regulation of Ambulance Opera-
tion: this was referred to the MSMS Committee on
Study of Prevention of Highway Accidents, which spon-
sored a release to all newspapers in addition to the
news coverage at the Annual Session. Law enforce-
ment officials and official agencies were contacted as
well as the Michigan Funeral Directors Association.
13. Resolution re Adequate Funds to Carry Out
Civil Defense: this was referred to the MSMS Legisla-
tive Committee which supported legislative action for
this purpose. The Civil Defense department requested
$20. 000-plus this year for “Medical Civil Defense Co-
ordination and Training.” It was not granted by an
economy-bent legislature.
14. Resolution re Permanent Advisory Committee on
Fees: this was referred to the Speaker who appointed
the following committee: G. C. Penberthy, M.D., De-
troit, Chairman; J. F. Beer, M.D., St. Clair; M. A.
Darling, M.D., Detroit; H. F. Falls, M.D., Ann Arbor;
W. M. LeFevre, M.D., Muskegon; and M. L. Lichter,
M.D., Detroit.
15. Resolution Urging Total Participation of M.D.’s
in Michigan Medical Service: this was accomplished in
several ways: (a) a letter was sent to all county society
officers; (b) numerous articles in JMSMS; (c) the
County Secretaries Seminar last January devoted two
days to the need for total understanding in and co-
operation of all M.D.’s with Michigan Medical Serv-
ice; (d) the publicity resulting from the April 27 Spe-
cial Session of the MSMS House of Delegates (see above
report on MSMS Market-Opinion Study and the portion
covering M.D.’s).
16. Resolution re Annual Registration of M.D.’s (dis-
approved by 1956 House of Delegates) : the 1957 Legis-
lature tabled H.B. 515, which called for a $10.00 annual
registration fee from doctors of medicine, to allow the
matter to be amicably settled “out of court.” The
Council referred this matter to the Legislative Com-
mittee which will offer the following resolution for
the consideration of the 1957 House of Delegates:
“Whereas, the bulk of the revenue which the Leg-
islature appropriates to the Board of Registration in
Medicine is derived from the original ($50. 00-
plus) license fees collected from new doctors en-
tering practice, and
“Whereas, some of the burden on these new doc-
tors should be assumed by their colleagues now in
practice, and
“Whereas, it is evident that some new sources of
operating revenue must be found for the Board if
it is to properly serve the profession and the people
of this state, therefore be it
“RESOLVED : That this House of Delegates re-
spectfully requests the Board of Registration in
Medicine and appropriate Legislators to review
with The Council or its Executive Committee the
existing and projected programs and fiscal policies
of the Board to enable The Council to recommend
changes in the Medical Practice Act which will
effect some relief to the new M.D.’s and provide
adequate funds for the Board’s duties; and be
it further
“RESOLVED: That if such legislative changes
must necessarily embody a form of annual licensure
of M.D.’s that this House of Delegates endorses
a fee of five dollars.”
A recommendation on this subject follows.
17. Resolution re inviting medical student representa-
tives to attend House of Delegates Session: this has been
accomplished.
18. Resolution re Committee to Study Use of Excess
Beds in T uberculosis Sanatoria: the report of the Com-
mittee on this subject was as follows:
“RESOLVED THAT . . .
“A. This Committee recognizes that there is a
continual decline in the tuberculosis hospi-
talization requirements in the State of Michi-
gan. On the other hand, this Committee feels
that there are many persons with active tuber-
culosis who are not hospitalized. That, if we
can influence the State Legislature to enact an
adequate law for the management of recalci-
trant patients, many of the beds might be filled.
“B. The Committee endorses the following recom-
mendations to strengthen the economic position
of the state tuberculosis hospitals by:
“(1) Requiring that State-at-large patients
shall be hospitalized at a State sana-
torium whenever bed space is available;
“(2) Directing that veterans meeting county
residence requirements shall be treated
as county charge patients, rather than
as State-at-large patients ; and that vet-
erans who have not established residence
continue to be provided hospitalization at
State expense;
“(3) Providing that selected tuberculosis pa-
tients in mental hospitals may be trans-
ferred to state tuberculosis hospitals as
State-at-large patients when, in the opin-
ion of the medical directors of mental and
tuberculosis hospitals, the transfer will
be in the patient’s best interest;
“(4) Providing that selected corrections de-
partment prisoners with tuberculosis may
be transferred to the State tuberculosis
hospitals as State-at-large patients when
in the opinion of the director of said de-
partment and the director of the State
tuberculosis hospital, the transfer will be
in the best interest of the patient and the
public;
“(5) Establishing an effective security unit at
a State tuberculosis sanatorium and re-
quiring that all patients committed by
court order be isolated and treated in
this unit or in a county tuberculosis
sanatorium, if practicable.
1040
JMSMS
ANNUAL REPORTS
“C. Action should be taken to provide for the ad-
justment of tuberculosis care provisions to pa-
tient needs by:
“(1) Directing that the State Health Com-
missioner, with the concurrence of the
State Council of Health, may declare a
sanatorium or any portion of a sana-
torium to be in excess of reasonable tu-
berculosis hospitalization needs of any
area, and that on this basis, the Com-
missioner may
“(a) Withhold state subsidy from any sana-
torium so designated, or
“(b) Reduce the number of beds approved
for subsidy, making a proportionate re-
duction in the allowable per diem costs
for any patients hospitalized at State ex-
pense.
“(2) Stipulating that when State action re-
sults in the closing or reduced operation
of a sanatorium, funds be provided by
the Legislature to maintain diagnostic
and out-patient services for the tuber-
culosis in the area concerned.
“The Chairman asked for and received
a vote of approval by the Committee for
each separate action of the above resolu-
tion.
“The giving to counties and cities the
authority to use excess sanatorium beds
or sanatoria for other purposes, met with
a variance of opinion by members of the
Committee. Following discussion,
“MOTION : that we give counties and
cities the authority to use sanatorium
beds or sanatoria for the care of tuber-
culosis or other public health responsi-
bilities, such as our mentally ill, our in-
digent, our alcoholic and our tuberculosis
patients in State prisons; carried.”
19. Resolution re Uniform Autopsy Code: the draft
of this Code has been approved by The Council
and is attached herewith as addendum.
Recommendations
1. That The Council be authorized to send MSMS
representatives to Washington, D. C., in 1958 on the
occasion of the annual Michigan Day, as recommended
by last year’s House of Delegates.
2. That serious consideration be given to the rec-
ommendations of the Committee on Mediation, Ethics
and Grievance.
3. That the Legislative Committee’s Resolution re
Licensure of Doctors of Medicine be approved.
4. That The Council recommends that the Michigan
State Medical Society dues for 1958 — for one year only
— be increased $50.00 to raise sufficient funds to start
the MSMS building as soon as possible.
Respectfully submitted,
The Council
D. Bruce Wiley, M.D.
Chairman
W. B. Harm, M.D.
Vice Chairman
A. E. Schiller, M.D.
O. B. McGillicuddy, M.D.
H. J. Meier, M.D.
Ralph W. Shook, M.D.
C. Allen Payne, M.D.
H. H. Hiscock, M.D.
H. B. Zemmer, M.D.
L. C. Harvie, M.D.
G. B. Saltonstall, M.D.
W. S. Stinson, M.D.
W. M. LeFevre, M.D.
B. T. Montgomery, M.D.
T. P. WlCKLIFFE, M.D.
B. M. Harris, M.D.
G. Thomas McKean, M.D.
William Bromme, M.D.
K. H. Johnson, M.D.
Speaker
J. J. Lightbody, M.D.
Vice Speaker
Arch Walls, M.D.
President
G. W. Slagle, M.D.
President-Elect
L. Fernai.d Foster, M.D.
Secretary
W. A. Hyland, M.D.
T reasurer
W. S. Jones, M.D.,
Immediate Past
President
Addendum
CODE OF PROCEDURES AND ETHICS
RELATING TO AUTOPSIES
Purpose. — The performance of autopsies is essential
to the welfare and protection of the public and to the
advancement of medical science. All who are concerned
with the performance of the autopsy must serve the
interest of the relatives or friends of the deceased with
respect to the care of the body. In connection with
the autopsy, therefore, the hospital, the pathologist, and
the funeral director agree to discharge their responsibili-
ties on the highest professional standards, and to pro-
mote mutual trust, confidence, and good will.
Toward this end, the present Code has been arranged
by agreement between the Michigan Funeral Directors
Association, the Michigan Hospital Association, the
Michigan Pathological Society and the Michigan State
Medical Society.
Responsibilities of the hospital:
Preparation of the body. — In the preparation of the
body, the head and shoulders should be elevated to
prevent postmortem lividity in these exposed parts. The
arms should be crossed over the trunk and held by
cotton-padded strips of gauze, above the elbows but not
at the wrists. The eyes should be closed but nothing
should be placed under the eyelids. The mouth should
not be closed. (Strips of gauze used for this purpose
leave objectionable marks.) Surgical dressing should be
left in place. The bodv should be covered but not
wrapped and when possible kept refrigerated at 38 to
40° F.
Interest of hospital in autopsies. — The autopsy is per-
formed as a public service and in the interest of science.
It represents a considerable cost to the hospital.
Permission for autopsy. — Permission should be secured
with the least practicable delay. A suitable legal form
should be used and properly witnessed, a copy of which
shall be made available to the person granting permis-
sion. In general, a complete autopsy includes examina-
tion of the brain and organs of the neck, as well as the
contents of the thoracic, abdominal and pelvic cavities.
In requesting permission for autopsy, the nature and the
extent of the autopsy should not be misrepresented ;
the hospital staff shall not use coercion or threaten to
designate the death as a “coroner’s or medical exami-
ner’s case,” or refuse to sign the death certificate, if
the cause of death is known.
Notification. — The hospital administration should no-
tify the pathologist as soon as the autopsy permit is
signed. As soon as the hospital learns the name of the
funeral director, the hospital shall notify him that an
autopsy is to be performed and that the body will be
ready for delivery at a specified time. In order to ob-
viate any inconvenience to the family of the deceased
August, 1957
1041
ANNUAL REPORTS
and in order to facilitate the funeral arrangements, it is
essential that every effort be made to expedite the autop-
sy and permit the body to be delivered to the funeral
director with a minimum of delay.
Every effort should be made for the prompt comple-
tion of the death certificate or transit-permit.
When a promise has been made to relatives that they
will be informed of the autopsy findings, the person
making the promise should notify the pathologist of the
name and address of the family physician or attending
physician to whom the findings should be mailed. This
physician will then be in a proper position to interpret
the clinical manifestation of disease in the light of the
autopsy findings.
Responsibilities of the funeral director. — The funeral
director (and embalmer) recognizes that his work is
usually simplified in a body following a properly per-
formed autopsy.
The funeral director (or embalmer) shall co-operate
in every way with the hospital in requesting permission
for autopsy; he shall assist the hospital in locating rela-
tives in order to obtain permission for autopsy. It shall
be deemed improper for a funeral director (or em-
balmer) , by any manner or by implication, to dissuade
the family from granting permission for an autopsy
or to influence the family to change its mind after
permission has been given.
It shall be considered unethical for a funeral direc-
tor or embalmer to make an extra charge to the family
for preparation of a body following autopsy.
In order to correct misunderstanding or prevent pos-
sible criticism from any source, it is understood that the
funeral director and the pathologist will communicate
with each other at once if any question is raised in
connection with the performance of an autopsy.
The funeral director should telephone the hospital
to inquire when the autopsy will be completed, rather
than call or have his attendant call at the hospital,
without notice, to remove the body.
As a convenience to the family and as a courtesy to
the pathologist, the funeral director, upon receipt of
legal form granting consent for autopsy, will permit
autopsies to be performed in the funeral home.
Responsibilities of the bathologist. — The a"topsv shall
be performed and the body made ready for delivery
to the funeral director with the least practicable delay.
In some instances arterial embalming may be permit-
ted (in the autopsy room, morgue, funeral parlor), be-
fore autopsy. In general, however, such embalming in-
terferes with the proper performance of the autopsy,
as in septicemia, bacterial endocarditis, or suspected poi-
soning since there may be no way of knowing in
advance if any of these conditions are present.
If delay is anticipated by the pathologist in perform-
ance of the autopsy, the funeral director should be noti-
fied so that the time of delivery of the body to the
funeral director will be mutually satisfactory. If per-
mission for autopsy is obtained after 4:30 p.m. : the
body should he ready for delivery by 11:00 a.m. of the
next day; if permission for autopsy is obtained by 10:00
a.m., the body should be ready for delivery by 2:00 p.m.
of the same day; if consent is obtained between 10:00
a.m. and 4:30 p.m. the body should be ready for delivery
within six hours. It is obvious that the permission for
autopsy must be delivered to the pathologist immediately
after it has been obtained.
If any unusual procedure is found necessary for the
proper performance of the autopsy, which may inter-
fere with the work of the embalmer. the pathologist
shall attach a note to the body or telephone the funeral
director to explain the need for the procedure.
The pathologist should transmit his findings of the
cause of d°ath to the attending physician or responsi-
ble hospital medical officer as soon as possible to facili-
tate prompt completion of the death certificate or tran-
sit-permit.
Mutual responsibilities. — All hospitals, pathologists,
and funeral directors (and embalmers) shall periodically
instruct all members of their staffs, employees, or agents
who are concerned with these recommendations to en-
able them to carry out these provisions intelligently and
efficiently. (In hospitals, this personnel will include ad-
ministrative and office employees, nursing and medical
staff, telephone operators, orderlies, and morgue attend-
ants.) A copy of these provisions shall be posted in a
conspicuous location or made available to the personnel
concerned.
This Code shall be incorporated in the curriculum of
all schools of embalming, mortuary science, medicine and
nursing in the State of Michigan.
Recommended procedures in autopsy. — A “Y” incision
is recommended for routine use, both in males and fe-
males. In females, the incision should be made below
the breasts along the normal folds, and should not
extend laterally beyond the anterior axillary lines.
Should it be necessary to turn the body over in exam-
ining the spinal column, the forehead should be placed
on a support sufficiently high to prevent the face from
touching any surface. The entire face, and particularly
that portion of the forehead resting against the support,
should be protected with a heavy cotton pack.
In cranial examination special care should be taken
to preserve the normal facial features. A transverse
incision in the scalp should be made from behind one
ear, across the vertex (but not anterior to it), and to a
point behind the other ear. In the removal of the cal-
varium, the temporal muscles should not be excised; in-
stead, a single horizontal cut should be made through
the thickest portion of each muscle and the incised
portions bluntly reflected toward the cephalic and caudal
attachments. The lines of sawing of the calvarium should
be arranged to avoid over-riding by the replace bone.
One recommended procedure is to saw the occipital bone
as far posteriorly as possible, leaving an inverted V-
shaped or square projection on the remaining portion of
the bone. Laterally the excised calvarium in the region
of the mastoid process of each temporal bone should
form an obtuse angle. If autopsy is performed prior to
arterial embalming, the ends of the internal carotid and
vertebral arteries should be left as long as possible
and ligated prior to removal of the brain. Unless other
arrangements are agreed upon locally for restoration of
the cranial cavity, the latter should be left open. A few
sutures in the scalp will hold the skull cap in place
temporarily.
The nature of the autopsy will determine the extent
of the examination. In general, certain precautions
should be followed:
1. Incision in the posterior or lateral abdominal or ;
thoracic wall should be avoided.
2. Surgical incisions near the midline should be util-
ized as far as possible.
3. The breast plate should not be removed partially j
or retracted against the face. It should be disarticulated
at its clavicular junctions and be removed completely.
At the end of the autopsy it should be replaced.
4. Long stumps and long ligatures should be left
on the main arteries arising from the arch of the aorta.
If tissue is to be removed from the neck regions for
examination, the carotid and subclavian arteries should
remain intact and major branches should be tied. If the
trachea and larynx are to be removed, the superior 1
thyroid arteries should be ligated close to the external
carotid arteries.
5. The external iliac arteries should not be ligated
but long stumps should be left so that they may be used
for injection in embalming the interior portions of the
body. The internal iliac arteries should not be removed
unless necessary.
6. If it is desired to remove a section of an artery
of an extremity, the artery should be ligated beyond
TMSMS
1042
ANNUAL REPORTS
the cut ends prior to removing the section, unless the
body has been previously embalmed.
7. The testes should be removed through the inguinal
canals.
8. In removing the rectum, the anal stump should
be ligated and care should be taken not to cut the
rectum too close to the anus. The pelvic floor should not
be cut.
9. If the entire uterus is removed, the vaginal canal
should be closed by properly placed “purse-string” su-
tures, best applied externally.
10. As far as possible, all fluid shall be removed from
the body cavities.
1 1 . Depending upon local preference and agreement,
after examination the organs may be inserted within
plastic bags and placed within the body cavity, and the
main incision then approximated with a running suture.
12. Tissues such as corneas, eyes, skin, bones, and
blood vessels which are to be used for special purposes,
other than for pathologic examination, shall be retained
by the pathologist or the hospital, providing special per-
mission has been obtained. The embalmer should ap-
preciate that the removal of some tissues, such as skin,
may pose an additional problem for him.
Adjustment of Complaints. — If any violation of this
Code occurs, an effort to adjust the differences should
be made promptly by the funeral director, the patholo-
gist and the hospital concerned, or by a local co-ordinat-
ing committee appointed for this specific purpose.
If agreement is not reached through such efforts, the
violation may be referred to the State Committee on
Autopsies. This committee should be selected annually
and should be composed of one member selected by
each of the following organizations: Michigan Funeral
Directors Association, Michigan Hospital Association,
Michigan Pathological Society, and Michigan State
Medical Society. All complaints should be submitted to
this committee in writing. Decisions and recommenda-
tions made by the committee with respect to complaints
considered by the committee should be transmitted to
the organization concerned for appropriate action. Should
a member of the committee be involved in a dispute
and such dispute be referred to the committee for investi-
gation, an alternate member should be selected from
the organization which he represents to take his place
temporarily on the committee.
This Code was approved with thanks by The Council
of the Michigan State Medical Society on Tanuary 24
1957.
ANNUAL REPORT OF PUBLIC RELATIONS
COMMITTEE— 1956-1957
The goals of the Public Relations Committee during
1956-57 were to strengthen the position of the individual
doctor in his relations with his public, to build a
stronger public relations base at the county medical
society level, and to increase the scope and effectiveness
of the MSMS statewide PR program. Three separate
methods were employed to accomplish this:
1. Public education through news media, building
understanding and appreciation of the doctors’ work
and medical policy.
2. Specific assistance to county medical society PR
chairmen through meetings, staff visits and up-to-date
idea material.
3. Maintaining friends of medicine in the important
fields of communications, professional organizations and
the State and federal legislature.
At the July and January meetings, the Public Rela-
tions Committee embarked on several new programs to
meet the challenge of changing times.
MSMS Study
The most ambitious project under way in the PR
department is the MSMS study of public opinion regard-
August, 1957
ing medical service plans. Although not a responsibil-
ity of the Public Relations Committee, the four-part
study is of such PR import it bears reporting here.
The survey responsibility has been reserved to the Execu-
tive Committee itself with Public Relations Counsel
Hugh W. Brenneman assigned to administer the project.
David B. Luck, Director of the Bureau of Business Re-
search, Michigan State University, has been retained
as consultant, and the Market Opinion Research Com-
pany of Detroit will carry out an important section of
the study.
Acting upon instructions of the House of Delegates,
a statewide survey was authorized by The Council and
was under way in mid-May. More than 600,000 people
will have been reached when the survey is completed.
From these data, a final report will be drafted for presen-
tation to the September meeting of the House of Dele-
gates in Grand Rapids.
The PR impact of this study is significant. For the
first time anywhere, the public is being asked by doctors
what it prefers in the way of medical-surgical coverage
in any prepayment plan or health insurance policy.
And at this writing press reaction to the MSMS weekly
radio and press releases is most favorable, even though
we are only in the early stages of the project.
Operation Armor
Another campaign, concluded this spring, which met
with great success, was “Operation Armor.” This was
the doctors’ own effort to urge the public to take ad-
vantage of all immunization procedures. Special emphasis
was placed on having these done in the doctor’s office.
In connection with the campaign, the PR Committee
authorized a mail survey of all local health officers to
determine what percentage of immunizations had been
done in clinic and office. The facts disclosed that only
15 per cent of the immunizations had been done in
clinics and this information aided the Legislative Com-
mittee in warding off certain legislation inimical to
the public good.
New PR Library
Proudest undertaking of the year, perhaps, is the
establishment of the MSMS Public Relations Library.
Although not yet completed, the new service is func-
tioning under the direction of Librarian Vada Studt,
of the MSMS PR staff. Organization of material, filing,
indexing, et cetera, was directed by a professional li-
brarian on loan from the Michigan State Library.
We believe this to be the first such library in the
country devoted exclusively to medical public relations.
Films, tapes, manuscripts, television and radio scripts,
resource material on all socio-medical subjects are but
a few of the services to MSMS members and county
societies.
New Films
New films added to the Library during the past year
include the latest MSMS Production, “Something Called
Epilepsy.” The film is a fifteen-minute color picture
available for free loan to doctors and the public. Also,
the first two films of the “Medicine and the Bar” series
were purchased.
A kinescope of the live heart operation telecast dur-
ing the March Michigan Clinical Institute was made
by MSMS and distributed to out-State TV stations for
delayed showing, since many stations were not able
to carry the show direct. A copy of the kinescope is
now available from the PR Library.
At the January meeting of the Public Relations Com-
mittee, the production of a special documentary film was
recommended. The subject was to be the transition
of the Wayne County Medical Society from its present
quarters to the new David Whitney House now being
constructed on the medical campus of Wayne State Uni-
versity. The short feature film is being produced in color
under the supervision of a special committee, W. B.
1043
ANNUAL REPORTS
Harm, M.D., Chairman. First showing of the picture
will be at the dedication ceremonies for the new struc-
ture next spring.
Educational Exhibits
During the year, MSMS sponsored educational exhibits
at the Michigan Rural Health Conference, the Michigan
Clinical Institute, MSMS Annual Session, and the Mich-
igan State Fair. The Muskegon County Medical So-
ciety Woman’s Auxiliary was provided with an exhibit
for their local Health Fair, Because of many requests
for a lighter, more portable exhibit, the PR Committee
authorized the creation of a new exhibit which would
be more portable and adaptable to the needs of county
medical societies. It is expected that the new exhibit
will be available prior to September.
National Medical Education Week
National Medical Education Week, the second annual
salute, was once again a success in Michigan. MSMS
acted as statewide co-ordinator for the educational
drive and released information to all press, radio and
television stations, providing State-level support to the
active local campaigns of the various county medical
societies.
Radio and Television
In the field of radio and television, the Public Rela-
tions Committee felt that since the MSMS “Tell Me,
Doctor” programs were continuing to prove popular,
the transcriptions should be screened once again to elimi-
nate out-of-date material. This task was referred to
committee.
Television activity for the year continued at normal
level and no new program was inaugurated. Still
planned by the Committee, however, is a series of hour-
long TV shows to be produced over a Detroit station
at intervals of at least three months. This would allow
adequate time for preparation of a truly high quality
show.
Annual County Secretaries-PR Conference
From an educational standpoint, one of the highlights
of the year was the annual County Secretaries-PR Con-
ference held in Detroit at the Sheraton-Cadillac Hotel
in January. The three-day meeting evaluated the prob-
lems facing medicine in 1957 and featured prominent
panelists from the field of medicine, industry, labor and
prepayment medical service plans. Attendance topped
all previous records and both officers and PR Chair-
men expressed appreciation for the unusually informative
program.
The Committee felt that its 1957 report should con-
tain some facts regarding the lesser known services and
activities of the Public Relations staff. It felt that the
larger projects received deserved attention and recogni-
tion, but that the more routine duties were not known
to exist. As an example of the pace of office activity,
during the previous twelve months, 543 long distance
phone calls originated from Lansing in the conduct
of MSMS PR business. And more than 600 meetings,
conferences and business contacts were made by the
PR staff during the same period. Again. Michigan news
media received forty-one statewide press releases from
MSMS and innumerable local releases on individual
members. Reports and articles prepared for member
information totaled sixteen, not including preparation
of four issues of the Woman’s Auxiliary Bulletin. Dur-
ing the year, the legislature was in session a total of
ninety-six days, which required the attendance of at
least one staff member each day and evening.
Looking ahead is a vital part of this Committee’s
function, and we are sure the future holds this much
in store . . . work, and more of it. A cog in the public
relations wheel is communications. It’s a good cog only
if you have something to say. We do. And we’re going
to say it over and over again.
1044
Respectfully submitted,
R. W. Teed, M.D., Chairman
A. B. Gwinn, M. D.
S. E. Andrews, M.D.
H. G. Bacon, Jr., M.D.
J. F. Beer, M.D.
H. G. Benjamin, M.D.
F. C. Brace, M.D.
H. F. Bradfield, M.D.
M. W. Buckborough, M.D.
F. J. Busch, M.D.
M. O. Cantor, M.D.
E. M. Chandler, M.D.
S. E. Chapin, M.D.
H. D. Dykhuizen, M.D.
H. B. Fenech, M.D.
E. H. Fenton, M.D.
R. A. Frary, M.D.
W. G. Gamble, Jr., M.D.
L. E. Grate, M.D.
L. T. Henderson, M.D.
W. J. Herrington, M.D.
E. T. Hill, M.D.
L. W. Hull, M.D.
J. M. Jacobowitz, M.D.
K. H. Johnson, M.D.
R. C. Kingswood, M.D.
J. L. Leach, M.D.
Clayton Lewis. M.D.
E. C. Long, M.D.
F. E. Ludwig, M.D.
J. T. Manning, M.D.
J. M. Markley, M.D.
G. E. Millard, M.D.
E. S. Oldham, M.D.
E. S. Parmenter, M.D.
R. C. Peckham, M.D.
J. R. Pedden, M.D.
G. N. Petroff. M.D.
A. C. Pfeifer, M.D.
W. Z. Rundles, Sr.. M.D.
Sydney Scher, M.D.
T. M. Sheldon, M.D.
E. L, Spoehr, M.D.
W. F. Strong, M.D.
C. K. Stroup, M.D.
R. L. Thirlby, M.D.
T. J. Trapasso. M.D.
C. L. Weston, M.D.
Wayne L. Whitaker, M.D.
V. M. Zerbi, M.D.
L. Fernald Foster, M.D., Advisor
H. J. Meier, M.D., Advisor
B. T. Montgomery, M.D., Advisor
A. E. Schiller, M.D.. Advisor
T. P. Wickliffe, M.D., Advisor
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ANNUAL REPORT OF CHILD WELFARE
COMMITTEE— 1956-1957
The Child Welfare Committee, Michigan State Medi-
cal Society, and subcommittees continued their activities
of the previous year and initiated several new projects.
The Committee sponsored the March issue of The
Journal of the Michigan State Medical Society
with special attention given some of the projects of
the Committee, such as perinatal mortality, examination
of children’s eyes, the problems of adoption, and im-
munization routines.
The Subcommittee on Otolaryngology reports that
screening clinics for hearing defects are being held in
all county health areas for children with satisfactory re-
sults being obtained.
The Subcommittee on Ophthalmology has continued
studying the problem of prophylaxis in ophthalmia neo-
natorum, the efficacy of visual acuity testing equip-
ment, and other eye problems of children.
JMSMS
ANNUAL REPORTS
The Subcommittee on School Health has made prog-
ress toward a school health form suitable for the whole
state and has been co-operating with the State Depart-
ment of Education and with the Michigan School Health
Association.
Work has been initiated in the field of adoption.
Education of law and medical students in all phases
of adoption has been started and there has been co-
ordination and co-operation with other disciplines which
are interested in this field. The role of the doctor in
adoption was discussed in The Journal.
The Committee has started work on accident pre-
vention. An effort is to be made to set up poison
control centers, as well as a means to disseminate infor-
mation to hospitals and to these centers.
It is hoped within the near future that a meeting
may be held with representatives from each county
medical society to review with members of the Child
Welfare Committee what has been and what can be
done on a local county level in the field of child welfare.
The Committee wishes to express its appreciation for
the co-operation of the Michigan Department of Health,
Michigan Crippled Children Commission, and will con-
tinue to serve to the best of its abilities advising the
Michigan State Medical Society on current child welfare
problems.
Respectfully submitted,
R. M. Heavenrich, M.D., Chairman
W. S. Jones, Jr.. M.D.
G. E. Anthony, M D.
F. A. Barbour, M.D.
R. T. Blackhurst. M.D.
V. G. Chabut, M.D.
E. L. Cooper, M.D.
G. B. Corneliuson. M.D.
A. J. Cortopassi, M.D.
R. H. Criswell, M.D.
Carleton Dean, M.D.
N. E. Durocher. M.D.
R. G. Ferris, M.D.
I. P. Klein, M.D.
O. L. Lepard, M.D.
W. K. Locklin, M.D.
Don Marshall. M.D.
R. T. Mason. M.D.
M. H. Pike, M.D.
A. E. Schultz, M.D.
L. O. Shantz, M.D.
L. P. Sonda, M.D.
H. A. Towsley, M.D.
Frank Van Schoick, M.D.
E. H. Watson. M.D.
G. F. Wirle. M.D.
R. K. Wise, M.D.
ANNUAL REPORT OF BEAUMONT MEMORIAL
COMMITEE— 1 956-1957
Two serious problems have confronted the Beaumont
Memorial Committee ever since the dedication of the
Memorial in July, 1954.
First, the lack of finances for further development
of the project. The Committee at no time renuested
The Council of the Michigan State Medical Society to
advance additional sums of money, for it felt that the
financing of this Memorial was the responsibility of the
individual doctor of medicine of this state. It was
on that premise that the old American Fur Trading
Retail Store was restored as a memorial to Doctor Wil-
liam Beaumont. This problem to a large extent has been
solved. By resolution, the 1956 House of Delegates ur-
gently recommended that a special letter campaign be
conducted. Such a letter was mailed on November 29,
1956, and the response was most gratifying.
The second problem was a lack of any working agree-
ment between the Michigan State Medical Society and
August, 1957
the Mackinac Island State Park Commission. From time
to time attempts had been made to obtain an agreement
from the Commission as to what our part should be in
regards to the completion of the Memorial. Our efforts
all resulted in failure until Governor Williams called
a joint meeting of the Mackinac Island State Park
Commission, the Michigan Historical Commission, and
the Beaumont Memorial Committee in his office on April
22, 1957. At this meeting our problems were presented,
and it was mutually agreed that each desired the co-
operation of the other. On the recommendation of the
Governor, a representative of the Mackinac Island State
Park Commission and the Michigan State Medical So-
ciety, with an Assistant Attorney General, met on
May 1, 1957, to draft a mutually acceptable agreement.
The Committee is pleased that progress is now being
made toward a satisfactory working agreement, although
it will be some time before it can become official. The
document must first have the approval of both the
Mackinac Island State Park Commission and The Coun-
cil of the Michigan State Medical Society.
Respectfully submitted,
Otto O. Beck. M.D., Chairman
L. R. Leader, M.D.
C. T. Ekelund, M.D.
J. H. Fyvie, M.D.
S. W. Hoobler, M.D.
W. M. LeFevre, M.D.
A. H. Whittaker, M.D.
Mr. H. C. Fritsch
ANNUAL REPORT OF ETHICS
COMMITTEE— 1956-1957
During the year several inquiries from local medical
societies involving alleged ethics violations were referred
to this Committee by The Council or its Executive
Committee. With the exception of two cases, it was a
matter of informing the writers that the first thing for
them to do was to try to get an amicable agreement at
home between the parties involved. If this failed,
then their local Ethics Committee, in conformance with
Chapter 6 of the MSMS By-Laws, may solve the prob-
lem. Nothing further was heard from these sources so
it is assumed that they were handled satisfactorily on
a local basis.
One of the two exceptions was a letter forwarded by
a county medical society secretary that was received
from an attorney in his town asking for an opinion.
If the statements in the letter are true, it is, first, in-
conceivable that a doctor would be so crude as to offer
his uninvited criticism of a fellow practitioner to the
patient of another doctor in the scurrilous terms he
was alleged to have used. Second, if there are other
incidents like this that we do not hear about, it is no
wonder that the premiums for malpractice insurance
have skyrocketed to their oresent upner-’UratosDhere level.
A shrug of the shoulder is often as incriminating as the
spoken word.
To date, this glaring example of unethical conduct
must be under local discussion. The second of the
two exceptions was an appeal from a county society
ruling and necessitated a meeting of the Committee
during which every word of the accusations and denials
and the transcription of the final hearing on the case
were read and discussed. There was an unfortunate
delay in the forwarding of some of the pertinent data
during delivery of one letter. Therefore, we are unable
to include the final result of our consideration of the
case to meet the deadline of this report for the August
number of The Journal MSMS.
However, we feel fairly sure that both sides eventually
will be satisfied with the conclusion reached by our
deliberations. If not, the case may have to be reopened
by our successors appointed in September. The delay
was not ours.
We would like to recommend that each county society
1045
ANNUAL REPORTS
mention at some very early meeting that malpractice
rates can be controlled by US if we can impress upon
our members not to be so careless in their remarks about
the ability of their fellow members or so openly critical
of their work. It has become so expensive to insurance
carriers that in one well known county the new doctor
is being told the company will take his malpractice
insurance business IF, and ONLY IF, they can carry
ALL of his other insurance. Nobody else but us can
bring these rates down. The Ethics Committee recom-
mends we do something about it.
Respectfully submitted,
H. W. Porter, M.D., Chairman
W. L. Harrigan, M.D.
R. J. Hubbell, M.D.
F. H. Lindenfeld, M.D.
E. A. Oakes, M.D.
E. A. Osius, M.D.
A. H. Price, M.D.
W. F. Strong, M.D.
C. E. Umphrey, M.D.
M. R. Weed, M.D.
ANNUAL REPORT OF GERIATRICS
COMMITTEE— 1956-1957
The Geriatrics Committee met three times this past
year — in Lansing, Flint and Ann Arbor — and each
meeting was well attended.
As last year, members of our group helped in the
planning of the Conference on Aging — health for the
older person — which was held in Ann Arbor last July.
Several members participated in the Conference con-
tributing in different ways. Clinics were given at the
University Hospital under the direction of the Depart-
ment of Postgraduate Medicine at which geriatric prob-
lems were featured. Senior citizen forums were pre-
sented by members of the Committee on two different
afternoons and proved to be valuable contributions to
the Conference program.
The May issue of The Journal of the Michigan
State Medical Society was devoted to a panel dis-
cussion on the value of exercise and good nutrition in
improving the wellbeing of persons late in life. These
data were compiled almost entirely by our Vice Chair-
man, Dr. F. C. Swartz, of Lansing, and great credit
is due him for his efforts.
Meetings were held with Dr. A. E. Heustis and his
staff in an effort to formulate new standards for nursing
homes and homes for the aged. The licensure of nurs-
ing homes has been transferred to the Department of
Health during the past year.
Several members of the Committee have participated
in public forums in different areas of the state and
more are being planned for this next year.
Considerable time was given by a subcommittee this
past two years to investigating possible forms of insurance
for the older person. Credit is due Dr. S. C. Wiersma
for this effort and it is hoped that continued study
will encourage insurance companies to formulate some
form of coverage for persons unable to obtain it with
present policies.
This coming year we plan to give considerable atten-
tion to the problem of handling the older person who
is chronically ill.
Respectfully submitted,
A. Hazen Price, M.D., Chairman
F. C. Swartz, M.D
F. W. Baske, M.D.
H. B. Bennett, M.D.
T. H. Bottomley, Jr., M.D.
J. R. Brink, M.D.
W. P. Chester, M.D.
E. F. Crippen, M.D.
R. E. Dustin, M.D.
G. S. Fisher, M.D.
P. C. Gittins, M.D.
W. D. Harrelson, M.D.
E. J. Kulinski, M.D.
W. M. LeFevre, M.D.
Jack Rom, M.D.
Herbert Rosenbaum, M.D.
C. H. Ross, M.D.
L. F. Segar, M.D.
C. W. Sellars, M.D.,
S. C. Wiersma, M.D.
H. W. Woughter, M.D.
ANNUAL REPORT OF LEGISLATIVE
COMMITTEE— 1956-1957
Five years ago, the legislature began meeting in regu-
lar session every year instead of the traditional every-
other-year schedule. It was thought that this would
allow the work of the sessions to be spread out a little,
relieving the congestion in making laws for two years
at a time. While this may have lessened the annual
legislative activity of other groups, no relaxation has
been afforded the medical profession in its dedication
to maintaining for Michigan citizens the best health care
programs of the nation.
More legislation concerning health problems was in-
troduced this year than in any previous year. Of the
1,077 bills filed in the House and Senate, 133 were of
direct concern to the profession. Every phase of health
care was discussed. Highway accidents, mental health,
tatooing, tuberculosis, medical insurance, annual licen-
sure of M.D.’s and polio vaccine were but a few topics
on which the members of the legislature sought advice
from the doctors.
It is a tribute to both the wisdom of the lawmakers
and the counsel of the members of MSMS that no
legislation inimical to the public interest was passed dur-
ing this year’s four months’ deliberations. It should be
pointed out, too, that some desirable changes were made
in the statutes.
Passed were measures that: — made possible initiation
of more extensive research programs by the State Depart-
ment of Health by permitting physicians to voluntarily
submit confidential information without risk of violating
the patient-physician relationship; — provided for in-
voluntary commitment of tuberculosis patients to a state
institution for treatment: — established mental and physi-
cal examination standards for school bus drivers; — pro-
hibited tattooing of minors, except under physician’s
direction; — provided for certification of psychiatric at-
tendant aides under the present State Board of Nursing.
MSMS does not oppose certain legislation merely for
opposition’s sake. It does oppose proposed changes in
tbe laws such as those which would deprive the patient
of his right to a free choice of physician or which would
retard the advancement of medical science through
arbitrary governmental restrictions.
Some defeated proposals in the 1957 session, which
MSMS opposed would have: — increased narcotics license
fees second time in two years, this time from $2.00 to
$5.00; — provided for certification of psychiatric attend-
ant aides under a separate new board; — consolidated
health agencies of the state under a single administra-
tor and two advisory groups. A similar proposal was
introduced last year. MSMS sponsored an alternate plan
to effect the purposes of the introducers, which also
failed passage.
Other bills in which the MSMS showed interest and
which the legislature by-passed this year for further study
and possible re-introduction later would have: — estab-
lished controls on radiation, atomic energy and allied
materials ; — provided for chemical tests of suspected
drunk drivers; — designated prescription status for tran-
quilizers and alertness pills; — amended the 1913 county
hospital act which governs the administration of less
1046
JMSMS
ANNUAL REPORTS
than a dozen institutions ; — tightened physical and men-
tal standards of drivers’ license applicants.
Two examples of the necessity of constant everyday
legislative surveillance by MSMS are the polio vaccine
bill and a bill providing for annual registration of
M.D.’s.
Late in the session a measure was introduced in the
Senate providing emergency funds for the purchase of
more Salk vaccine for the “high risk” group in the
state. In a sudden move, and under a suspension of
rules, the Senate adopted an amendment which would
have provided that all such vaccine must henceforth
be administered only in “public health clinics.”
If the House had concurred in this drastic procedure
change, the group for whom the vaccine was intended
would have suffered immeasurably. In many counties
the establishment of such clinics would have been im-
possible; in others, they would have been overburdened
and unworkable. Therefore, when the true facts of the
situation were made known to the lawmakers by doctors
from all over the state, this ill-advised amendment was
removed.
The proposal for the annual registration (licensure)
of M.D.’s which appeared late in the session also
indicate how ideologic conflicts arise even in the field
of medicine. The bill, as originally introduced, called
for an annual fee of $5, ostensibly to provide sufficient
additional funds for the operation of the State Board
of Registration in Medicine. This bill was thought by-
passed for this session, but in the closing days it was
reported out of Committee to the House floor, but
amended to double the fee to $10! It became then,
purely and simply, a specific tax on the doctors; a
means of obtaining additional money for the general
operation of the state. When it was pointed out to
the legislature that MSMS members vigorously objected
to this arbitrary attempt to impose an obviously unfair
levy on their group under the excuse that “the doctors
can afford to pay it,” the bill was subsequently referred
back to committee.
It is expected, however, that a similar bill will appear
again next year, with possibly a lesser fee which will
provide only a sufficient amount of revenue to enable
the Board of Registration to operate a necessary and
desirable program.
As has been expressed many times before, any credit
due the Legislative Committee of MSMS for “successes”
in the legislative sphere must go to the individual M.D.
in the county society who makes available to his sena-
tor and representative his counsel, experience and judg-
ment in the field of health care, to which he is dedicated.
No less a tribute must be accorded the members of
the legislature who have continually displayed an earn-
est desire to safeguard the highest possible quality of
health care to Michigan’s citizens.
Respectfully submitted,
L. A. Drolett, M.D.. Chairman
O. B. McGillicuddy, M.D., Vice Chairman
A. B. Aldrich, M.D.
William Bromme, M.D.
G. V. Conover, M.D.
J. C. Elliott, M.D.
O. K. Engelke, M.D.
N. J. Hershey, M.D.
M. H. Marks, M.D.
H. L. Miller, M.D.
P. T. Mulligan, M.D.
J. S. Rozan, M.D.
G. W. Slagle, M.D.
E. C. Swanson, M.D.
H. A. Towsley, M.D.
R. V. Walker, M.D.
D. Bruce Wiley, M.D.
ON TAKING A VAGINAL CELL EXAMINATION
By the present established diagnostic methods, cancer
of the uterus can be detected early enough so that,
when treated, 89 to 90 per cent will survive five years
or more. This means that the disease must be diagnosed
during the preclinical or silent stage. Just as the periodic
health examination is incomplete without a thorough
vaginal examination, the pelvic examination is incom-
plete without a vaginal cell examination.
Smears may be obtained in several different ways —
usually your pathologist will give you instructions in the
method he prefers — as well as provide the materials
needed.
Vaginal pool aspiration is the simplest and most gen-
erally used. Material is aspirated — using a small pipette
made from a drinking tube with a capillary opening and
a bulb. The patient should not take a douche prior to
coming to the office. The smear is obtained before the
pelvic examination or before any instrumentation. Fix
the smear immediately in 95 per cent alcohol and ether.
Scraping material directly from the cervix is an ex-
cellent way to obtain a smear for early diagnosis of that
organ. A spatula, tongue blade or cotton applicator may
be used. It is important to get cells from as far up
in the canal as possible. Do not scrape vigorously.
Some pathologists prefer at least one smear from the
posterior fornix (aspiration) and one from the cervix
(scraping). Two smears are better than one.
The tampon method of obtaining smears needs more
study and evaluations before being used generally. It
may well prove to be the simplest and most accurate
method of obtaining a good sampling of vaginal exfolia-
tion.
Finally, the pathologist will do his part to preserve
doctor-patient relationship. He requires proper collection
and preparation of specimens. He also must correlate
cytologic findings with the biopsy as well as the clinical
status of the patient.
Harry M. Nelson, M.D.
IF0IRT LAUDIIRIDAIE BEACH HOSPITAL
125 N. BIRCH RD., FORT LAUDERDALE, FLORIDA
GERIATRICS (core of fhe aging)
REHABILITATION . . . CONVALESCENT CARE
A private hospital especially planned for the medical care and rehabilitation of the
CHRONICALLY ILL, the AGED, and the HANDICAPPED.
Departments of Medicine, Radiology, Laboratory, Dietary, Dentistry, Rehabilitation,
Occupational and Physiotherapy.
Patients accepted for long or short term care under direction of private physician.
MEDICAL RESIDENT STAFF
FOR information write to
Louis L. Amato, M.D., Medical Director Kenneth A. Dahl, Administrator
August, 1957
Say you saw it in the Journal of the Michigan State Medical Society
1047
Technical Exhibits
Abbott Laboratories Booth No. 505
North Chicago, 111.
HARMONYL®, a new transquilizer and antihyper-
tensive agent, will be among the new products Ab-
bott Laboratories will exhibit. Other products to
be shown will include a new therapeutic agent for
peptic ulcer, TRAL®; an aerosol solution for treat-
ment of chronic pulmonary diseases, TERGEMIST®;
an anticonvulsant for control of grand mal epilepsy,
PEGANONE®; an aid in the management of ather-
osclerosis, SAFF, and Abbott’s complete line of in-
travenous solutions and equipment.
A. S. Aloe Company Booth No. 419
St. Louis, Mo.
Visit Booth No. 419 where the A. S. Aloe Company
will have on display a cross-section of their most
complete line of physicians and laboratory supplies
and equipment.
Our representatives will certainly appreciate discus-
sing mutual items of interest with you.
American Ferment Company, Inc. Booth No. 104
New York 18, N. Y.
Stop at the booth for your personal supply of Falgos,
the buffered compound analgesic that acts quickly and
without gastric upset. Let us also explain the ad-
vantages of Carotid and Bile Salts Tablets, Alcaroid
Antacid, and Supligol, the whole bile-ketocholanic
acid compound.
Ames Company, Inc. Booth No. P-22
Elkhart, Ind.
The Ames Company exhibit will feature an entirely
new concept in the detection and evaluation of pro-
teinuria— a new colorimetric test supplied in two
forms: ALBUTEST Tablets and ALBUSTIX Reagent
Strips. Results are obtained in seconds. Demon-
stration by Ames representatives will show the many
advantages of this new principle.
Armour Labroatories Booth No. 513
Kankakee, 111.
The Armour Laboratories will feature Chymar, Tryp-
tar Antibiotic Ointment, and Arcofac, the new choles-
terol lowering factor recently added to the Armour
line. Our representatives will be happy to discuss
our products with all who wish to stop at the Armour
booth.
Atlas Pharmaceutical Laboratories, Inc.
Detroit 12, Mich. Booth No. 102A
The newest and most modern plant in the State of
Michigan, designed exclusively for the manufacture
of ethical injectable medicaments. We do not buy our
products — We make them.
Audio-Digest Foundation Booth No. 520
Glendale 6, Calif.
Audio-Digest Foundation — a subsidiary of the Cali-
fornia Medical Association — gives the busy physician
an effortless tour through the best of current medical
literature each week. This medical tape-recorded
“new-cast” — compiled and reviewed by a professional
Board of Editors — may be heard in the physician’s
automobile, home or office. The Foundation also
©ffers medical lectures by nationally recognized au-
thorities.
Ayerst Laboratories Booth No. 212
Chicago 41, 111.
The Ayerst exhibit will feature “Thiosulfil.” The
high degree of solubility of this single sulfa makes
it ideally suited for treating urinary tract infections
safely and effectively.
Baby Development Clinic Booth No. 509
Chicago 54, 111.
Baby Development Clinic invites you to visit space
509 to learn about New Lifebuoy with TMTD
(TMTD) is the new germicide developed by Lever
Brothers). Samples and literature available. See new
Evenflo bottles of Superplastic and other new feeding
products made by Pyramid Rubber Company, makers
of Patented Twin Air Valve Nipples; special samples
for demonstration. Revolutionary products by Model-
la promote good sleeping: Sleepy Drye waterproof
panties together with Mitey Drye liner prevent diaper
rash. Become acquainted with The Book House, a
reading plan for parents and children from infancy
through high school.
Baker Laboratories, Inc. Booth No. 504
Cleveland 3, Ohio
You are invited to visit our booth where Baker’s
Modified Milk and Varamel, two successful products
for infant feeding, are on display.
Baker representatives will be glad to discuss with
you the special features of Baker Milk products
which promote better tolerance, less colic, better gain
and improved tissue turgor for bottle-fed infants.
Bard-Parker Co., Inc. Booth No. 202
Danbury, Conn.
B-P surgical knife handles and Rib-Back blades. The
time and labor saving RACK-PACK which provides
extra blade protection. Blade forceps. The Reese
Dermatome. B-P Formaldehyde Germicide, which is
sporicidal, virucidal, and tuberculocidal. Chloro-
phenvl, and the new B-P concentrate “Halimide.”
Also B-P blade jars, instrument containers and trans-
fer forceps. C. F. pipettes with permanent mark-
ings.
Barry Laboratories, Inc. Booth No. 109
Detroit 14, Mich.
Barry Laboratories present a complete line of al-
lergy preparations to meet any patient’s individual
requirements. Sets to accurately test for irritants and
treatment to “specifically desensitize for perennial
results.”
Barry Laboratories also present a complete line of
sterile injectables in ampuls and multiple dose vials.
Baxter Laboratories, Inc. Booth No. P-25
Morton Grove, 111.
Baxter Laboratories, Inc., presents the latest develop-
ments in parenteral fluids and administration equip-
ment. INCERT — the only one-step sterile additive
vial for supplementing parenteral fluids. Add B vita-
mins with C, succinylcholine chloride, and electro-
lytes without needle or syringe.
See TRAVAD — ready-to-use disposable enema unit
featuring a pre-lubricated tip, 18 inches of flexible
tubing and finger tip volume control.
1048
JMSMS
TECHNICAL EXHIBITS
Borcherdt Company Booth No. 110
Chicago 12, 111.
Borcherdt is featuring a new use for Malt Soup Ex-
tract. In addition to its stool softening properties,
Malt Soup Extract, has been found very useful for
the problem of Pruritus Ani. Stop in for informa-
tion and a recently presented paper on this new
use. Information on the influence of aciduric in-
testinal flora in correction of constipation and relief
of pruritus ani is available.
The Borden Company Booth No. 201
New York 17, N. Y.
Borden’s Prescription Products booth is the place
to discuss the latest in infant nutrition. On display
are: MULL-SOY, the pioneer hypoallergenic formula
food; BREMIL, a complete food, patterned after breast
milk, for the normal infant; DRYCO, a high protein,
low fat product especially suited to prematures, and
BETA LACTOSE, the ideal milk sugar.
Bristol-Myers Products Division Booth No. 512
New York 1, N. Y.
BUFFERIN, the better-tolerated jntacid-analgesic for
long-term salicylate therapy, will be featured by
Bristol-Myers. Also AMMENS Medicated Powder,
a highly efficacious disperson of talc in cornstarch:
MINIT-RUB, a greaseless-stainless rubefacient; and
new THERADAN, for long-lasting relief of seborrhea
of the scalp.
Brooks Appliance Company Booth No. 410
Chicago 2, 111.
The Brooks Appliance Company will exhibit and
describe in detail the technique of applying the
combination pressure bandages. The moist medi-
cated Primer bandage plus the Dalzoflex Elastic Ad-
hesive bandage which are used in treating leg ulcers
and phlebitis. As distributors of anatomical supports,
our representatives will be in attendance to answer
questions and explain in detail our sacral, sacral-
lumbar and dorsal lumbar supports.
Elastic stockings, the Nulast Elastic Crepe bandages
and surgical instruments will also be displayed.
Burdick Corporation Booth No. 301
Milton, Wis.
Burroughs Wellcome & Co. Booth No. 204
Tuckahoe 7, N. Y.
NEW PRODUCTS: The extensive research facilities
of B. W. & Co., both here and in other countries,
are directed to the development of improved thera-
peutic agents and techniques.
Through such research B. W. & Co. has made not-
able advances related to leukemia, malaria, diabetes,
and diseases of the autonomic nervous system; and
to antibiotic, muscle-relaxant, antihistaminic, and anti-
nauseant drugs.
An informed staff at our booth will welcome the op-
portunitv to discuss our products and latest develop-
ments with you.
Cambridge Instrument Company, Inc. Booth No. 514
New York 17, N. Y.
The Cambridge Audio-Visual Heart Sound Recorder:
the well-known Cambridge “Simpli-Scribe” Model
Direct-Writing Portable Electrocardiograph and the
Cambridge Standard String Galvanometer Electro-
cardiograph, both in the “Simpli-Trol” Portable and
August, 1957
the Mobile Model Electrocardiograph-Stethograph
with Pulse Recorder, will be displayed at this booth.
Also, other important Cambridge instruments, in-
cluding the Operating Room Cardioscope, Educa-
tional Cardioscope, Multi-Channel Direct-Writing
Recorder, Electrokymograph, Plethysmograph, and
pH Meters.
The Cambridge Engineers in attendance will be glad
to give you complete information on these instru-
ments.
Carnation Company Booth No. 308
Los Angeles 36, Calif.
Carnation Company welcomes friends of long stand-
ing as well as new members of the Michigan State
Medical Society. At Booth 308, a refreshing drink
of Carnation Instant Nonfat Milk will be served.
Carnation representatives will be pleased to discuss
with you the physician-researched material for use
in your practice as a service of Carnation Company.
Central Pharmacal Co. Booth No. 508
Seymour, Ind.
The Central exhibit will feature NEOLAX for phy-
siologic treatment of chronic constipation; NEOPAR-
BEL, a highly effective product for the prevention
and treatment of primary dysmenorrhea; and the
NEOCYLATE FAMILY of potentiated salicylate
products.
Literature and samples of these specialties will be
available.
Chicago Pharmacal Co. Booth No. 316
Chicago, 111.
The following CHIMEDIC products will be featured:
URISED: Nationally known and clinically proven
tablet for both comfortable sedation and thorough
antisepsis in all types of genitourinary affections;
RESYDESS: The anti-obesity tablet which reduces
weight, yet calms the patient keeping him free from
stress and anxiety; plus a complete line of injec-
tables, tablets, liquids and ointments awaiting your
inspection.
Chicago Reference Book Company Booth No. Ill
Chicago 3, 111.
The Chicago Reference Book Co. are the official dis-
tributors of Webster’s New International Dictionary,
Second Edition, with Reference History for the state
of Michigan. We invite all visitors to the Annual
Session to inspect “The Supreme Authority” at Booth
No. 111. See the 1957 edition and ask about our
special offer of the Hammond Atlas and 33" x 50"
Wall Map of the World.
Equal in type matter to a 21 -volume encyclopedia
at only a fraction of the price of such a set. The
Dictionary with Reference History is still the greatest
bargain in reference books and will be in use almost
daily when once available in your home or office.
Christian Medical Society Booth No. 617
Chicago 6, 111.
Representatives of the Christian Medical Society
are here to explain the purpose and projects of the
Society. CHRISTIAN LIFE AND THE UNCON-
SCIOUS, PSYCHO-THERAPY AND THE CHRIS-
TIAN MESSAGE, A CHRISTIAN APPROACH TO
PSYCHOLOGICAL MEDICINE are among the
books and pamphlets on display. Copies of the
Christian Medical JOURNAL are available.
1049
TECHNICAL EXHIBITS
Ciba Pharmaceutical Booth No. P-3
Products, Inc.
Summit, N. J.
CIBA is exhibiting Vioform-Hydrocortisone Cream, an
extremely effective preparation for controlling a wide
variety of acute and chronic skin disorders. It is
antifungal, antibacterial, anti-inflammatory and anti-
pruritic— a four-way means for providing relief of
itching and inflammation and rapid healing. More-
over, it is effective where many antibiotic combina-
tions fail.
supermild. non-allergenic, pleasantly scented, de-
odorant.
Detroit X-Ray Sales Co. Booth Nos. P-16,
Detroit, Mich. P-17, P-18
We plan to show an entirely new line of X-Ray equip-
ment designed and styled by the Mattern X-Ray
Division of Land Air, Inc., to be known as the
“MEDALIST” series. We extend to the profession a
cordial invitation to visit and inspect these new de-
signs in X-Ray.
Coca-Cola Company Booth Nos. P-9, P-10
Atlanta 1, Ga.
Ice-cold Coca-Cola served through the courtesy and
co-operation of the LaSalle Coca-Cola Bottling Com-
pany, Grand Rapids, Michigan, and The Coca-Cola
Company.
Coreco Research Corporation Booth No. 502
New York 23, N. Y.
The coret camera embodies the principle of elec-
tronic flash and constant automatic control of such
factors as distance, aperture, field, and exposure.
Now, for the first time, coreco offiers a completely
automatic professional clinical camera purposely de-
signed to achieve the ultimate in surface, intra-oral,
and intra-tubular photography. Because of the
simplicity of operation, even an inexperienced doctor
or nurse can achieve consistently perfect color trans-
parencies.
Cottrell-Clarke, Inc. Booth No. P-1
Detroit 1, Mich.
For over 50 years specializing and paving the way
for the ultimate in case records and case record keep-
ing. Manufile case records and loose leaf binder pro-
ducts are the result of constant research into the doc-
tors needs in this field. Office stationery is also an
intergral part of our specialized service.
Darwin Laboratories Booth No. 611
Los Angeles 46, Calif.
DePuy Manufacturing Co. Booth No. 603
Warsaw, Ind.
See representative samples of the complete DePuy
line of splints and all types of fracture equipment. In-
cluded are those items that are of special interest to
the doctor in general practice. These are the pro-
ducts that are featured in the new General Practice
edition of our catalog. Be sure to reserve your copy.
Desitin Chemical Co. Booth No. 105
Providence, R. I.
DESITIN OINTMENT: the pioneer cod liver oil
ointment for the treatment of burns, ulcers, wounds,
diaper rash.
DESITIN POWDER: pioneer cod liver oil dusting
powder for the treatment of intertrigo, diaper rash,
exanthema, abrasions, etc.
DESITIN HEMORRHOIDAL SUPPOSITORIES:
relieve pain and itching, promote healing, give com-
fort in uncomplicated hemorrhoids, fissures. Contain
no anesthetics or styptics.
RECTAL DESITIN OINTMENT: for effective re-
lief in simple hemorrhoids, pruritus and fissures. No
anesthetics.
DESI I IN LOTION: soothing, protective, mildly
astringent for the treatment of pruritus, poison ivy
and non-specific dermatitis.
DESITIN COSMETIC AND NURSERY SOAP:
Dictaphone Corporation Booth No. 115
Detroit 1, Mich.
For busy doctors — the Dictaphone Time-Master
dictating machine with plastic Dictabelt record.
Word-work goes more easily with the Time-Master,
saving an hour a day and resulting in complete, ac-
curate case histories. Check the new Dictaphone
Time-Master dictating machine with facilities for re-
cording both sides of important telephone conversa-
tions. For doctors-on-the-move, the new Dictaphone
Dictet portable tape recorder. Less than three pounds
light, battery-powered, the Dictet brings a new di-
mension of voice recording usefulness to the medical
profession.
Dietene Company Booth No. 405
Minneapolis, Minn.
Have YOU tasted MERITENE — the whole protein
supplement that DOES taste good? Visit our booth,
enjoy a MERITENE Milk Shake with its multiple
nutritive values.
While you’re there, review the Dietene Diet based
on DIETENE Reducing Supplement. It provides the
rare combination of low calories (1000) with high
intake of protein and all essential vitamins and mine-
rals in an interesting, effective, SAFE weight reduc-
ing diet.
Doho Chemical Corporation Booth No. 414
New York 13, N. Y.
DOHO CHEMICAL CORPORATION is pleased to
exhibit:
AURALGAN: Ear medication in Otitis Media and
removal of Cerumen.
OTOSMOSAN: Effective, non-toxic Fungi"''
Bactericidal (Gram ne ’ -e-Cram positive)
suppurative and aurri vc ic ears.
RHINALGAN: Nasa* nt free from
systemic or circulatory •tlly safe to use
on infants as well as the aged.
NEW LARYLGAN: Soothing t. and
gargle for infectious and non-infectious sore throat
involvements.
Eaton Laboratories, Inc. Booth No. P-21
Norwich, N. Y.
Furadantin® is one of the most effective and rapidly
acting agents available at this time for the treatment
of prostatitis and acute and chronic urinary tract in-
fections.
Furadantin has specific affinity for the urinary tract,
producing antibacterial concentration in 30 minutes.
Five years of extensive use demonstrate negligible de-
velopment of bacterial resistance.
Paul B. Elder Co. Booth No. 312
Bryan, Ohio
We sincerely invite all members of the
Michigan State Medical Society and their
guests to our booth. We will feature OX-
SORALEN and BENOQUIN, two der-
matological products of note, as well as
MAGNOCYL Capsules and RAPAX In-
serts— new approaches to fecal softening
1050
TMSMS
TECHNICAL EXHIBITS
and peristalsis initiation. Features of these unique
specialties will be thoroughly explained by our staff.
Encyclopedia Americana Booth No. 411
Grand Rapids, Mich.
Encyclopedia Americana invites you to inspect its
1957 edition — the ultimate in modern reference. No
up-to-date school, college, university or library is
without it, as leading educators prefer and find it
superior to all others. We are extremely proud of the
fact that more than 1000 sets have been delivered to
the U. S. Government for use in every major depart-
ment. As usual, you will be most cordially wel-
comed.
Ferndale Surgical, Inc. Booth No. 216
Femdale, Mich.
Surgical instruments, diagnostic and examination
equipment. Pharmaceutical specialties of our own
manufacture. Inquires on special formulas will be
welcomed.
H. G. Fischer & Co. Booth No. 103
Detroit 27, Mich.
You can personally examine the most modern x-ray
equipment of the highest quality and greatest versa-
tility as well as a complete line of physical medicine
and rehabilitation equipment. Our Detroit office offers
you prompt and efficient service. Visit our booth and
ask for a free copy of our X-Ray Manual.
C. B. Fleet Company, Inc. Booth No. 208
Lynchburg, Va.
During the past fifty years PHOSPHO-SODA
(FLEET) has been a symbol of elegance in sodium
phosphate medication. FLEET ENEMA DISPOS-
ABLE UNIT — an enema solution of Phospho-Soda
(Fleet) — is a worthy companion product. The
single-use unit simplifies and assures satisfying pre-
paration for proctoscopy and as a routine enema it
is a boon to the hospitalized patient.
rrnt, Eaton & Company
' 111.
Eaton and Co’T
'Ven tolerated ur
Also' featured ;
plicated re,:-
tions.
Booth No. 413
features Ferrolip, a safe,
form of chelated iron,
for predictable, uncom-
/ in urinary tract infec-
E. FougCra & Company, Inc. Booth No. 409
New York 13, N. Y.
E. FOUGERA & COMPANY, INC. CORDIALLY
INVITES PHYSICIANS TO VISIT OUR BOOTH
WHERE PRODUCTS IN THE FIELDS OF CARD-
IOLOGY, DERMATOLOGY AND RADIOLOGY
WILL BE DISPLAYED. PROFESSIONAL SER-
VICE PERSONNEL WILL BE PRESENT TO DIS-
CUSS WITH YOU THESE PRODUCTS AND
SUPPLY CLINICAL MATERIALS IF DESIRED.
Freeman Mfg. Company Booth No. 416
Sturgis, Mich.
The Freeman line of Surgical Supports places parti-
cular emphasis on orthopedic braces for use when
conservative measures are indicated. Rigid control
and almost complete immobilization of the sacral,
lumbar and thoracic area are achieved through the
use of splint type construction in combination with
the block and tackle effect of straps and buckles.
Special designs and constructions are available for any
purpose.
August, 1957
Geigy Chemical Corporation Booth No. 619
Yonkers, N. Y.
The Geigy exhibit will feaure PRELUDIN — the new
chemically different appetite suppresant noted for its
absence of side actions. Also on display will be
BUTAZOLIDIN — potent non-hormonal antiarthritic;
new STEROSAN Hydrocortisone Ointment — anti-in-
flammatory, bacteriostat and fungistat, and other well
known Geigy products.
General Electric X-Ray Corp. Booth No. P-19
Detroit, Mich.
X-Ray Department, General Electric Company,
manufactures of complete X-Ray equipment from
portable diagnostic to 2,000,000 volt therapy ap-
paratus— electrocardiograph — diathermy — X-Ray ac-
cessories and supplies. X-Ray equipment of new de-
sign will be shown at this meeting. We are looking
forward to seeing you.
Gerber Products Company Booth No. 319
Fremont, Mich.
WHEN MILK IS CONTRAINDICATED as the
basic food for infants, Gerber "Meat Base Formula”
can provide a nutritionally adequate replacement. It
is well accepted and tolerated by infants of all ages.
Your Gerber detailman invites you to evaluate “Meat
Base Formula” and the complete line of supplemen-
tary baby foods.
Grand Rapids Creamery Booth No. P-7
Grand Rapids, Mich.
The Grand Ra-
pids Creamery,
local distribu-
tors of Sealtest
Milk and Dairy
Products, invite
you to stop at
the Sealtest
bottle of Sealtest
Gray Pharmaceutical Co., Inc. Booth No. 516
Newton, Mass.
L-Glutavite, while being considered neither as a
stimulant nor as a tranquilizer, promotes a favorable
change in the behavior pattern of the geriatric patient,
whether he be belligerent, agitated, catatonic or de-
pressed. L-Glutavite is available in three convenient
dosage forms: packets, economy canisters and cap-
sules.
Quinoplex, a neurotropic bowel tonic promotes the
return of normal peristalsis and bowel tone in patients
who have become constipated because of concurrent
use of hypotensive blocking agents or habitual use
of harsh irritating laxatives. Clinical studies report
Quinoplex to be effective in correcting constipation
at the low dosage level of 1-2 tablets upon retiring.
H. J. Heinz Co. Booth No. 210
Pittsburgh, Pa.
Heinz Baby Foods provide babies with the necessary
nutrients for steady growth and sound bodies. These
foods also make appetizing meals for older patients
and convalescents.
Here are the newest Baby Foods. They are Heinz
originals: Strained Vegetables, Egg Noodles and
Chicken, Strained Chicken Noodle Dinner; Strained
Potatoes (White); Junior Vegetables, Egg Noodles
and Chicken; Junior Chicken; Junior Breakfast —
Cereal, Eggs and Bacon; Junior Spaghetti, Tomato
Sauce and Meat; High Protein Cereal.
DAIRY PRODUCTS
booth and enjoy a complimentary
Milk.
1051
TECHNICAL EXHIBITS
The Nutritional Data Book for physicians and litera-
ture for mothers’ use are available.
Hoffmann-LaRoche, Inc. Booth No. 320
Nutley 10, N. J.
Gantrimycin combines 333 mg Gantrisin and 75 mg
oleandomycin for use in a wide variety of bacterial
infections. Oleandomycin is a new antibiotic prin-
cipally active against Gram-positive microorganisms.
It does not display cross resistance with most other
antibiotics. Gantrisin is effective against both Gram-
positive and Gram-negative pathogens. It is soluble
in acid urine. No alkalization or forcing of fluids is
needed.
Lipo Gantrisin usually provides therapeutic antibac-
terial blood levels for 12 hours with a single dose.
Just two doses a day are adequate in most infections.
Each teaspoonful of Lipo Gantrisin contains one gram
Gantrisin Acetyl, twice the concentration of most
aqueous sulfonamide suspensions. Useful in respira-
tory, localized, systemic, and urinary tract infections,
when due to susceptible microorganisms.
Holland-Rantos Co., Inc. Booth No. 101
New York 13, N. Y.
Interested physicians may obtain, on renuest from
H-R convention representatives, the leaflet “Facts
You Should Know About the Superiority of' KORO-
MEX Jelly” which summarizes positive proof that
KOROMEX is more spermicidal.
An improved diaphragm any patient can easily and
correctly place— the KORO-FLEX DIAPHRAGM—
also will be on exhibit for your inspection.
Other vaginitis-preparations failed? May we invite
you to investigate the merits of NYLMERATE Jelly
and Antiseptic Solution Concentrate — effectively
trichomonicidal, fungicidal and bactericidal — which
will be on display, along with HOLLANDEX Silicone
Ointment with natural vitamins A & D for minor
skin disorders of infants, children and adults.
G. A. Ingram Company Booth Nos. 302, 304
Detroit 1, Mich.
THE G. A. INGRAM COMPANY will, as usual,
have many new items of interest on display in spaces
302 and 304, and the salesmen in charge of this ex-
hibit will be in a position to give you full information
regarding both the new items as well as all other
equipment on display. We shall look forward with
pleasure to having you stop at our booths to say
“hello.”
Johnson and Johnson Booth No. P-11
New Brunswick, N. J.
Johnson & Johnson will display Johnson's Elastic
Hosiery and Johnson’s Baby Products along with other
new developments of the Johnson & Johnson Research
Laboratories. You will find well-informed representa-
tives pleased to discuss these products with you and
provide information on any other items made avail-
able by the world’s largest manufacturer of surgical
dressings and baby products.
C. B. Kendall Company Booth No. 317
Indianapolis 6, Ind.
You are cordially invited to visit the C. B. Kendall
Co. Exhibit featuring Tablets Basigets, which pro-
vides nonvirilizing anabolic hormones, hematinic fac-
tors and complete nutritional supplementation for
patients in the “Second Forty Years.” Also Fine-Sul
Tablets and Liquid presenting broadspectrum anti-
bacterial action that avoids fastness or complications
of side-effects in the treatment of urinary tract in-
1052
fections, will be exhibited. Informed representatives
will be on hand to discuss these and other fine phar-
maceuticals offered by the Company.
Kenfre Manufacturing Co. Booth No. P-13
Grand Rapids, Mich.
Latest types of transistor hearing aids. Audiometers —
pure-tone and speech reception — for individual and
group screening tests; custom-engineered for physi-
cians, industry, and schools. Manufactured by Audi-
vox, Inc., successor to Western Electric Hearing Aid
Division. Audivox hearing aids are licensed under
patents of American Telephone and Telegraph Com-
pany, Western Electric Company, Inc. and Bell Tele-
phone Laboratories, Inc.
Kremers-Urban Company Booth No. 601
Milwaukee 1, Wis.
The KREMERS-URBAN booth will feature the most
effective visceral antispasmodic LEVSIN . . . KUTA-
PRESSIN for the control of capillarv bleeding and
for rebellious skin diseases . . . MILKINOL “Im-
proved’ the new hydro-lipo-philic constipation cor-
rectant.
A. Kuhlman & Company Booth No. 420
Detroit, Mich.
The A. Kuhlman & Co. will display diagnostic and
surgical instruments as well as examining room furni-
ture and physical therapy equipment. Included in
our display will be a complete line of Stille surgical
instruments.
Lea & Febiger Booth No. 102
Philadelphia 6, Pa.
Be sure to see: Hewitt on Alcholism ; MacNeal,
Alpers and O’Brien on Headache ; Pollack — Tumor
Surgery of the Head and Neck; Blinick and Kauf-
man— Modern Office Gynecology ; Dufault — Diagnosis
and Treatment of Pulmonary Tuberculosis ; Faust and
Russell — Clinical Parasitology ; Schwartz, Tulipan and
Birmingham — Occupational Diseases of the Skin;
Quick — Hemorrhagic Diseases; Zimmerman, Netsky
and Davidoff — Atlas of Tumors of the Nervous Sys-
stem; and many others.
Lederle Laboratories Booth No. 214
Pearl River, N. Y.
You are cordially invited to visit the Lederle booth
where our medical representatives will be in atten-
dance to provide the latest information and literature
available on our line. Featured will be Achromycin
V, Vitamins, Kvnex, and many other of our depend-
able quality products.
Lewal Pharmaceutical Co. Booth No. 615
Chicago 14, 111.
A new therapeutic approach to the treatment of pru-
ritus ani will be featured at the Lewal Pharmaceuti-
cal Company’s booth No. 615.
HYDROLAMINS — topically applied amino acids —
have been found to bring rapid relief in 98% of cases
with complete healing in 88%. No side effects have
been reported.
Physical evidence of improvement will be shown with,
before and after kodachromes of actual clinical cases.
Liebel-Flarsheim Co. Booth No. 116
Cincinnati 15, Ohio
The Liebel-Flarsheim Company cordially invites you
to visit booth No. 116 in which their latest electro-
medical-electrosurgical equipment will be exhibited.
JMSMS
TECHNICAL EXHIBITS
We ask particularly that you stop and see the L-F
BasalMeteR, the first automatic, self-calculating met-
abolism unit ever offered. Capable representatives will
be on hand at all times.
Eli Lilly & Company Booth Nos. 517, 519
Indianapolis 6, Ind.
You are cordially invited to visit the Lilly exhibit
located in spaces numbers 517 and 519. The Lilly
salespeople in attendance welcome your questions
about Lilly products and recent therapeutic develop-
ments.
J. B. Lippincott Company Booth No. P-4
Philadelphia 5, Pa.
J. B. Lippincott Company presents, for your approval,
a display of professional books and journals geared
to the latest and most important trends in current
medicine and surgery. These publications, written
and edited by men active in clinical fields and teach-
ing, are a continuation of more than 100 years of
traditionally significant publishing.
Lybeck Business Systems Booth No. 613
Detroit, Mich.
Maico Detroit Company Booth No. 412
Detroit, Mich.
90% of America’s precision test instruments are
Maico made. Maico produced the first precision hear-
ing test instrument to receive acceptance of AMA’s
council on Physical Medicine in 1939. Maico pro-
duced the first wearable vacuum tube aid to receive
AMA acceptance 1940. Maico produced the first
all transistor hearing aid 1953.
Maltbie Laboratories Division Booth No. 211
Belleville, N. J.
You are cordially invited to visit the Maltbie Labora-
tories booth featuring the new Cholan-V, effective
hydrocholeresis with superior spasmolysis, in hepatic-
impairment and gallbladder dysfunction; Caldesene
Medicated Powder, for relief and prevention of diaper
rash; Bifran, to overcome excess weight and its con-
sequences; and Desenex. night and day protection and
treatment for Athlete’s Foot.
Marion Laboratories, Inc. Booth No. 609
Kansas City, Mo.
OYSTER SHELL CALCIUM— Naturally better as-
similation with OYSTER SHELL CALCIUM. Re-
search shows twice the percental increase of total
blood calcium and 40% greater increase in ionized
calcium than with other forms of calcium.
S. E. Massengill Company Booth No. 203
Bristol, Tenn.
The S. E. Massengill Company extends its wishes
for a most successful meeting and invites the con-
vention to visit its booth and discuss Massengill Phar-
maceutical products. The S. E. Massengill Company
will feature Adrenosem Salicylate (the unique sys-
temis hemostat), Homagenets (the only homogenized
vitamins in a solid form), Salcort (a safe effective
anti-arthritic) and Massengill Powder.
August, 1957
McNamara Medical Equipment Co. Booth No. 318
Detroit 21, Mich.
McNamara Medical Equipment Company will show
some of the latest equipment in the Physical Therapy
field. The latest in traction, vertical and horizontal.
Ille Whirlpools, Hydrocolator Steam Packs, and
other physical therapeutic devices.
Mead Johnson & Company Booth No. 205
Evansville, Ind.
The Mead Johnson exhibit has been arranged to give
you the optimum in quick service and complete pro-
duct information. The exhibit will be staffed by
specially trained representatives who will be prepared
to provide you with information on any of these pro-
ducts or product “families:” (1) Tempra — the first
physician controlled antipyretic/analgesic in drop and
teaspoon dosage form. (2) The Mead Johnson
Formula Products Family — the most complete feed-
ing service for well and sick infants. (3) The Deca
Vitamin Family — vitamins in three convenient dosage
forms providing comprehensive vitamin protection for
infants and children. (4) The Pablum Products —
featuring the new Pablum Assorted-Pak. (5) The
Colace Products Family for the management of con-
stipation.
Medco Products Co. Booth No. P-6
Tulsa, Okla.
Presenting the MEDCO-SONLATOR. Providing a
new concept in therapy by combining muscle simula-
tion and ultra sound simultaneously through a
SINGLE Three-Way Sound Applicator.
The MEDCO-SONLATOR is a distinct advance in
the effectiveness of physical therapy in your office or
hospital. A few minutes spent in our booth should
prove of value to your practice.
Medical Arts Supply Co. Booth Nos. 309, 311
Grand Rapids, Mich.
The Medical Arts Supply Company will exhibit the
latest in Ritter equipment. Hamilton examining room
equipment and the various styles of reception room
furniture.
The new Liebel Flarsheim Basalmeter, and the
Liebel Flarsheim Bovie and Short Wave, plus a fine
display of Stille instruments. Grand Rapids being our
home town, we invite all of our good customers to
visit our large show rooms.
Medical Protective Company Booth No. 117
Fort Wayne, Ind.
MALPRACTICE PROPHYLAXIS . . . Less Mal-
practice Publicity for public consumption, Individual
Insurance free from charges of a “doctor’s combine,”
Periodic Information to policyholders, Fighting De-
fense, Insurance Diagnosis that eliminates contribu-
tion. Avoidance of Insurance Overdose that increases
litigation and losses, plus 58 years of Specialized
Service make Medical Protective policyholders safer.
Merck Sharp & Dohme, Booth No. 218
Philadelphia, Pa.
The Merck Sharp & Dohme exhibit highlights steroid
therapy featuring new adrenal cortical steroid
preparations — “Meprolone,” “Hydeltra”-T.B.A., and
“Neo-Hvdeltrasol.”
New anti-bacterial agents of clinical significance are
also featured.
Technically trained personnel will be present to dis-
cuss these and other subjects of clinical interest.
1053
TECHNICAL EXHIBITS
Wm. S. Merrell Company Booth No. 506
Cincinnati 15, Ohio
Merrell representatives will be on hand to discuss
TACE, a new distinctive estrogen and Bendectin, a
new unique drug for the treatment and prevention
of nausea and vomiting in pregnancy.
Please stop at our booth ; our representatives will be
happy to talk with you.
Meyer and Company Booth No. P-14
St. Clair Shores, Mich.
Therapy of ARTERIOSCLEROSIS has evoked an
intensified interest among all members of the medical
profession.
The new Meyer product “ATHEMOL” whose action
is predicated upon its effect in the bloodstream upon
the colloidal stability of the blood and the return of
precipitated lipoprotein complexes into the blood-
stream, will be of paramount interest to every doctor
attending this meeting.
Michigan Medical Service Booth No. 305
Detroit, Michigan
You are cordially invited to visit Booth No. 305
and Suite to obtain current information regarding
Michigan Medical Service (Blue Shield). Our repre-
sentatives will gladly visit with you and answer any
questions you may have with regard to your Blue
Shield Plan. Hospitality Suite open 5:00 to 7:00
p.m.
Middleton’s Inc. Booth No. 114
Grand Rapids, Mich.
Middleton’s will have a display of the finest in
surgical products produced from plastics. Surgical
instruments and appliances, plus a demonstration and
display of plastic dressing and first aid supplies.
Also see the latest in German stainless steel instru-
ments and manometers; New Patterns, New Designs;
New Ideas.
Milex Products Booth No. 112
Oak Park 37, Mich.
Milex Company has a complete line of Gynecic
Specialties to offer the medical profession featuring
the Crescent Diaphragm with built-in inserter, Folding
Pessaries which are manually shapeable, a Cancer
Detection Unit, Marital Guides, Fertility Program,
“Lestens” for premenstrual tension and dysmenorrhea,
and several other unique products.
Miller Surgical Company Booth No. 315
Chicago, 111.
See the Miller Electro Surgical Units and accessories
such as Snares, Suction-Coagulation attachments,
Forceps, etc. A complete line of diagnostic equipment
consisting of illuminated Otoscope, Ophthalmoscope,
Eyespud with Magnet, Transillumination Lamps,
Mirror Headlite, Vaginal Speculum with Smoke
Ejector and Gorsch Operating Scopes, and stainless
steel Proctoscopes, all sizes, with magnification will
also be on display.
Mullers Shoes, Inc. Booth No. P-15
Grand Rapids, Mich.
In our booth you will see the latest in special feature
shoes and accepted wedge practices. Some of the
shoes shown will be Sabel’s completely new line,
Markell’s Supernators and Pronators, and our own
straight last shoes. We are set up to handle any
of your prescription shoe needs. Our trained staff
will be on hand to answer any questions.
National Live Stock & Meat Board Booth No. 605
Chicago 5, 111.
This nutrition exhibit emphasizes the importance of
a good breakfast. Colorful pictures show complete
breakfasts and the interesting variety of meats around
which good breakfasts are built. Meat for breakfast
helps provide one-fourth to one-third of the day’s
food needs, especially high quality protein.
Nepera Laboratories Division Booth No. 515
Morris Plains, N. J.
Biomydrin-Ophthalmic is the latest addition to the
Biomydrin family. It contains two antibiotics for
broad antibacterial effects plus an antihistaminic for
the control of allergic ocular infections. This unique
combination has been found effective in both acute
and chronic ocular infections and allergies. Available
in a unique dropmatic bottle. Methyl cellulose has
been added to assure prolonged contact.
Mandelamine Suspension is a new, pleasantly flavored
liquid from Methanamine Mandelate in Sesame oil,
for use particularly in pediatric urinary tract in-
fections. It is safe, effective, practical and economical
especially for long-term therapy.
Cholarace, a new product of Nepera research, is a
combination of Choledyl (Choline theophyllinate) ,
Racephedrine and Pentobarbital for use in the im-
mediate and prolonged treatment of acute broncho-
spasm due to or associated with asthma, hay fever,
emphysema, bronchitis, bronchiectasis.
Wm. R. Niedelson Co. Booth No. 401
Detroit 21, Mich.
The Jones “AIR-BASAL”— the Profexray “ROCKET”
series and other diagnostic equipment in the latest
designs will be demonstrated. Ultrasound equipment
and techniques will be fully described to those
interested in the newest modality in Physio-Therapy
today.
Noble-Blackmer, Inc. Booth Nos. 118, 119
Jackson, Mich.
Your friendly representatives from Noble-Blackmer,
Inc., will be in attendance at Booths 118 and 119
(corner at the end of the first row). Please stop in
and look over our display of the latest and most
modern equipment and supplies being manufactured
for the modern physician.
Nordmark Pharmaceutical Laboratories, Inc.
Booth No. 417
Irvington, N. J.
New Iron therapy — FERRONORD (TM) tablets, a
brand of ferroglycine sulfate complex iron — will be
featured. Extensive research has developed an
aminoacetic complex of iron which supplies ferrous
ions protected against oxidation in pH ranges of
stomach and intestine. FERRONORD provides for:
(1) Optimal absorption of ferrous iron; (2) freedom
from the side effects usually associated with iron
therapy; (3) rapid increase of serum iron levels in
days; and (4) correspondingly higher hemoglobin
levels in days.
So well tolerated, FERRONORD should be given on
an empty stomach, or between meals, for optimal
absorption.
Ortho Pharmaceutical Corporation Booth No. P-12
Raritan, N. J.
ORTHO cordially invites you to Booth P-12. Fea-
tured will be DELFEN Vaginal Cream, Ortho’s most
spermicidal contraceptive. RARICAL Iron-Calcium
Tablets, a compound for use in iron-deficiency
anemias and in all cases requiring calcium supple-
mentation. and RARICAL Iron-Calcium With
Vitamin Tablets will also be displayed. Ortho
1054
TMSMS
TECHNICAL EXHIBITS
representatives welcome this opportunity to discuss
their products with you.
Parke, Davis & Company Booth No. 306
Detroit 32, Mich.
Medical service members of our staff will be in
attendance at our exhibit for consultation and dis-
cussion of various products. Important specialties,
such as Penicillin S-R, Benadryl, Ambodryl, Dilantin
Suspension, Vitamins, Oxycel, Milontin, Eldec,
Amphedase, Thrombin Topical, etc., will be featured.
You are cordially invited to visit our exhibit.
Pelton & Crane Company Booth No. 206
Charlotte 3, N. C.
The original autoclaves that create, then store steam
under pressure will be demonstrated. Pelton is the
originator of the double-jacketed, portable office
autoclave that has eliminated waiting time between
sterilizing cycles.
Only in Pelton autoclaves can a mercury column
thermometer be installed in the discharge line at a
small additional charge to insure accurate reading of
chamber temperature.
Pet Milk Company Booth No. P-20
St. Louis 1, Mo.
We will be pleased to have you stop and discuss the
variety of time-saving material available to busy
physicians. Our representatives will be on hand to
discuss the merits of “Pet” Evaporated Milk for
infant feeding and INSTANT “Pet” Nonfat Dry
Milk for special diets. A miniature “Pet” Evaporated
milk can will be given to all visitors.
Pfizer Laboratories Booth No. 213
Brooklyn 6, N. Y.
The Pfizer exhibit spotlights its recent and original
therapeutic concepts represented by SIGMAMYCIN
(Brand of Oleandomycin), a combination of Matro-
mycin and Tetracyn; and the newest advance in
topical corticosteroid therapy, Magnacort and Neo-
Magnacort, the first water soluble corticoid. Also
MODERIL — Pfizer’s new alkaloid of rauwalfia.
ATARAXOID, the first and only ataraxic-corticoid,
as well as Bonamine and Sterane.
Procter & Gamble Company Booth No. 113
Cincinnati 1, Ohio
Ivory Soap (Procter & Gamble)
offers a series of time-saving
leaflet pads for doctors, each pad
containing fifty identical tear-out
sheets. These sheets, which may be
given to patients, contain routine
instructions covering six different
topics. There are also samples of
other free, helpful material pre-
pared especially for physicians.
Professional Management Booth No. 403
Battle Creek, Mich.
PROFESSIONAL MANAGEMENT
1932-1957
Twenty-five years of business counsel
to Michigan physicians.
PM executives will welcome you at
Booth No. 403.
Purdue Frederick Company Booth No. 107
New York 14, N. Y.
The Purdue Frederick Company will feature:
SENOKOT Tablets and Granules — new non-bulk,
non-irritating constipation corrective acting selectively
on the parasympathetic (Auerbach’s) plexus in the
large bowel, physiologically stimulating the neuro-
muscular defecatory reflex.
PRE-MENS — the multidimensional premenstrual ten-
sion therapy.
SOMATOVITE — clinically proven to promote weight
gain, increase appetite and reduce hyperactivity and
restlessness.
SIPPYPLEX — the modern comprehensive therapy for
peptic ulcer.
Randolph Surgical Supply Co. Booth No. 219
Detroit, Mich.
RANDOLPH SURGICAL SUPPLY COMPANY will
again exhibit outstanding equipment of latest design.
Of particular interest are the new uses for the
Barron Food Pump, which will be displayed, and
competent personnel will be on hand to answer any
questions.
We are looking forward to seeing our many friends
again this year.
R. J. Reynolds Tobacco Co. Booth No. 501
Winston-Salem, N. C.
Welcome to the R. J. Reynolds Tobacco Company
Exhibit! You are cordially invited to receive a
cigarette case (monogrammed with your initials) con-
taining your choice of CAMEL, WINSTON Filter,
Menthol Fresh SALEM, or CAVALIER King Size
Cigarettes.
A. H. Robins Co., Inc. Booth No. 407
Richmond, Va.
Physicians attending the meeting of the Michigan State
Medical Society are extended a cordial invitation to
visit the exhibit of the products of the A. H. Robins
Company.
Experienced medical representatives will be in attend-
ance to welcome you and answer inquiries relative to
any of Robins prescription specialties.
J. B. Roerig & Co. Booth No. 217
New York 17, N. Y.
J. B. Roerig and Company will feature ATARAX, the
new “Peace of Mind” drug. It’s an all new chemical
and is specially indicated for the “more normal” per-
son, to bring relief from the common everyday ten-
sions and anxieties. Co-featured with ATARAX
will be BONADOXIN, the anti-emetic for relief of
the nausea and vomiting of pregnancy; also effective
in postanesthetic nausea and postradiation sickness.
Literature and samples available to physicians at the
booth which you and. your friends are cordially in-
vited to visit.
Ross Laboratories Booth No. 418
Columbus, Ohio
Ross Laboratories: Current Concepts in Infant Feed-
ing, stressing the critical aspects of preventive care.
Your Similac representative will be happy to discuss
the role of physiologic feeding in providing good
growth, sound development, and optimum clinical
benefits. Copies of the latest Ross Pediatric Research
Conference Reports are available.
Rupp and Bowman Company Booth No. 518
Berkley, Mich.
Our representatives, Mr. Tony Ferrara, Mr. Eric T.
Goullaud. Mr. A1 Hemmingsen, Mr. Alex MacKinnon,
Mr. Tony Patti, Mr. Myron Ripp and Mr. Bert
Williams will be on hand to greet you and to
demonstrate the new Raytheon Electrocardiograph.
Also shown will be surgical instruments, diagnostic
instruments and examining room furniture.
Sandoz Pharmaceuticals Booth No. 313
Hanover, N. J.
Sandoz Pharmaceuticals cordially invites you to visit
our display at Booth No. 313.
BELLERGAL SPACE Tabs assure around the clock
August, 1957
1055
TECHNICAL EXHIBITS
control of functional complaints (example — meno-
pause symptoms) in the periphery where they
originate.
CAFERGOT PB. the most effective oral medication
for the relief of migraine headache with gastro-
intestinal disturbance accompanied by tension.
SANDOSTENE Space Tabs around the clock control
of itching and hay fever.
Any of our representatives in attendance will gladly
answer questions about these and other Sandoz
products.
W. B. Saunders Company Booth No. P-2
Philadelphia 5, Pa.
Harold Rozema will again be on hand with the com-
plete Saunders line. Books of particular interest, and
just new, include: Cecil & Conn: SPECIALTIES IN
GENERAL PRACTICE : Nesselrod : PROCTOLOGY:
Mulholland: CURRENT SURGICAL MANAGE-
MENT; Artz and Reiss: BURNS; and Tracy: THE
DOCTOR AS A WITNESS.
Schering Corporation Booth No. P-8
Bloomfield, N. J.
An informed staff of Schering representatives will
welcome the opportunity to discuss the latest thera-
peutic developments and clinical data on TRILAFON,
CHLOR-TRIMETON and the “Meti” drugs.
Julius Schmid, Inc. Booth No. 209
New York 19, N. Y.
An interesting and informative exhibit featuring
RAMSES Flexible Cushioned Diaphragm; RAMSES
Vaginal Jelly; VAGISEC jelly and liquid for vaginal
trichomoniasis therapy; and XXXX (Fourex) Skin
Condoms, RAMSES and SHEIK Rubber Condoms
for the control of trichomonal reinfection.
G. D. Searle & Co. Booth No. P-26
Chicago 80, 111.
You are cordially invited to visit the Searle booth
where our representatives will be happy to answer
any questions regarding Searle Products of Research.
Featured will be Nilevar, the new anabolic agent:
Rolicton, the new safe, nonmercurial oral diuretic;
Vallestril, the new synthetic estrogen with extremely
low incidence of side reactions; Banthin and Pro-
Banthine, the standards in anti-cholinergic therapy:
and Dramamine, for the prevention and treatment of
motion sickness and other nauseas.
Smith, Kline & French Laboratories Booth No. P-5
Philadelphia, Pa.
SKF is proud to attend your meeting.
This year, our exhibit features “Compazine” Span-
sule capsules, the new sustained release medication
producing emotional calm without impairing mental
alertness or physical activity.
Visit our booth for the latest information on this
unique new transquilizer.
E. R. Squibb & Sons Booth No. 106
New York 22, N. Y.
E. R. Squibb & Sons has long been a leader in de-
velopment of new therapeutic agents for prevention
and treatment of disease. The results of our diligent
research are available to the medical profession in
new products or improvements in products already
marketed.
At booth No. 106, we are pleased to present up-to-
date information on these advances for your consid-
eration.
The Stuart Company Booth No. 310
Chicago, 111.
The Stuart Company invites all physicians attending
the Michigan State Medical Society meeting to visit
1056
our booth. Our representatives will be glad to an-
swer any of your questions on our products.
Swift and Company Booth No. 314
Chicago 9, 111.
“Fruit Flavored” Meats for Babies — Pork with Apple-
sauce, Ham with Raisin Sauce, Lamb with Mint —
prepared both for infants and those in the toddler set,
is announced by Swift & Company. Designed especial-
ly for infants’ appetities, these meat preparations are
offered for your inspection. See and taste them at
the Swift booth.
Testagar & Company, Inc. Booth No. 507
Detroit, Mich.
Testagar & Co., Inc., is proud to announce that we
have assumed the manufacture and sales of the Fel-
lows Medical Manufacturing Corp. line of pharma-
ceutical specialties in the United States.
The Fellows Medical Manufacturing Corp. was found-
ed in 1866 and is a very fine, ethical pharmaceutical
specialty house.
Fellows' Chloral Hydrate products will be featured as
well as some new Testagar pharmaceutical specialties.
S. J. Tutag & Company Booth No. 207
Detroit, Mich.
S. J. Tutag & Company will exhibit Buffonamide, the
triple-sulfa suspension that is buffered. The use of
sodium citrate as buffering agent with the acet-dia-
mer sulfonamides makes Buffonamide ideal; this for-
mula is less toxic, well-toierated, readily absorbed,
with increased crystalluria protection. The two tasty
flavorings, cherry and mixed fruit, of this suspension
makes Buffonamide the drug of choice for all ages.
The Upjohn Company Boath No. 408
Kalamazoo, Mich.
June 3, 1957, marked an important event to a large
percentage of diabetics in the United States. On that
date ORINASE, the new ORAL anti-diabetic was
made available to physicians in the United States.
Upjohn representatives will be on hand at Booth
No. 408 to discuss ORINASE with visiting physicians
along with other Upjohn products of interest.
U. S. Vitamin Corp. Booth No. P-23
New York, N. Y.
On display . . . NEW 3-dimensional BIVAM sup-
plies biologically active whole water-soluble citrus
bioflavonoid complex (as provided in C.V.P.) with
multiple vitamins and minerals. Extends prophylaxis
beyond usual dietary supplements in pregnancy and
lactation ... in medical, surgical and gynecologic
practice ... in geriatrics.
Professional samples and literature distributed also
on our complete line of nutritional and pharmaceu-
tical specialties.
Wallace Laboratories Booth No. P-24
New Brunswick, N. J.
Wallace Laboratories will feature these drugs at Booth
No. P-24:
MILTOWN: a proven tranquilizer, MILTOWN re-
lieves both anxiety and muscle tension. Its toxicity
is low, side effect minimal and it is well suited for
prolonged therapy.
MILPREM: the combined action of MILTOWN
plus conjugated estrogens (eguine) provides both
emotional and hormonal balance in the treatment of
the menopause.
MILPATH: the ataractic action of MILTOWN in
combination with an anticholinergic agent effectively
manages both the psychogentic element and somatic
symptoms of organic and functional disorders of the
gastrointestinal tract.
JMSMS
TECHNICAL EXHIBITS
Warner-Chilcott Laboratories Booth No. 108
New York 11, N. Y.
A visit to the Warner-Chilcott booth will pay divi-
dends, especially in the interests of your cardiovas-
cular patients and those with various emotional and
psychological disturbances. The company is featuring
clinically tested and proven agents to help you pre-
vent attacks of angina pectoris, and to treat many
other clinical conditions.
Westwood Pharmaceuticals Booth No. 215
Buffalo, N. Y.
FOSTEX CREAM and FOSTEX CAKE are new,
easy to use, therapeutically effective cleansing type
medications for the treatment of dandruff, acne vul-
garis and seborrheic dermatitis. They contain Se-
bulytic*, a unique combination of penetrating anionic
soapless cleansers and wetting agents which are highly
antiseborrheic, and exert antibacterial and keratolytic
effects.
•Trademark
White Laboratories Booth No. 307
Kenilworth, N. J.
Winthrop Laboratories, Inc. Booth No. 406
New York 18, N. Y.
MEBARAL, sedative
and antiepileptic, pro-
duces tranquility virtu-
ally without drowsiness.
I4J0 BROADWAY, NEW YORK 18, N. Y.
WINDSOR, ONT.
Yakes Office Supply Company Booth No. 510
Grand Rapids, Mich.
TALK YOUR WAY TO A SHORTER DAY WITH
A STENORETTE. ALL THE FEATURES OF
UNITS THAT COST TWICE AS MUCH. Despite
its amazingly low price, the Stenorette is a complete
dictating and transcribing machine — not just a “re-
corder.” It is a fully equipped precision electronic
instrument. See Gregary and Leonard Office Equip-
ment Company in Detroit.
Yorke Publishing Company Booth No. 415
New York 19, N. Y.
The Yorke Publishing Company cor-
dially invites you to visit Booth No. 415
where advance information can be had
on its newest publication, THE AMER-
ICAN JOURNAL OF CARDIOLO-
GY, which is to appear in January,
1958. Also prominently displayed are
these other publications of the Yorke Group: THE
AMERICAN JOURNAL OF MEDICINE; THE
AMERICAN JOURNAL OF SURGERY; THE
AMERICAN JOURNAL OF CLINICAL NUTRI-
TION; and THE MODERN DRUG ENCYCLO-
PEDIA.
Zimmer Manufacturing Company Booth No. 402
Toledo 6, Ohio
C. A. Fisher & Sons, your Zimmer Distributor, extend
a most cordial invitation to the members of the
Michigan State Medical Society to visit their exhibit
at BOOTH NO. 402.
A complete line of Orthopedic Instruments and Frac-
ture Equipment will be on display. Items of sD~cial
interest, BADGLEY NAIL & PLATE for Intracap-
sular and Neck Fractures of the femur, Schneider
Self-Broaching Intermedullary Pins, Street Pins for
Radius & Ulna, Titanium Prostheses, Townley Cup
Stem Prostheses and Hip Screws.
ZIMMER, your guarantee of quality and prompt
service.
ADVANCE REGISTRATION OF DELEGATES
Sunday, September 22, 1957
8:00 to 10:00 pan.
Lobby of Pantfind Hotel
HOTEL RESERVATIONS
MICHIGAN STATE MEDICAL SOCIETY
92nd Annual Session
Grand Rapids, September 25-26-27, 1957
The reservation blank below is for your convenience
in making your hotel reservations in Grand Rapids.
Please send your application to the Committee on Hotels
for MSMS Convention, Pantlind Hotel, Grand Rapids,
Michigan. Mailing your application now will be of
material assistance in securing hotel accommodations.
As very few singles are available, registrants are
requested to co-operate with the Committee on Hotels
by sharing a room with another registrant, when con-
venient.
Committee on Hotels,
Michigan State Medical Society
c/o Pantlind Hotel
Grand Rapids, Michigan
Please make hotel reservation (s) as indicated below:
Single Room(s) persons
>
Double Room(s) for persons
Twin-Bedded Room(s) for persons
Arriving September hour A.M P.M.
Leaving . hour A.M P.M.
Hotel of First Choice:
Second Choice:
Names and addresses of all applicants including per-
sons making reservation :
Name Address City State
Date. Signature.
Address.
City.
August, 1957
1057
Michigan's Department of Health
Albert E. Heustis, M.D., Commissioner
MICHIGAN-CORNELL AUTOMOTIVE
CRASH INJURY STUDY
The Michigan program of research into the nature,
extent and cause of injury received in passenger automo-
bile accidents began on June 15, 1957. Nineteen coun-
ties in southwestern and central Michigan were chosen
as the first sampling areas. These areas will be used for
six months. Then and each successive six months for a
two-year period different areas have been selected.
The plan is being sponsored in Michigan by the
Michigan Department of Health and the Michigan State
Police, with the endorsement and cooperation of the
Michigan State Medical Society and the Michigan Hos-
pital Association. It is coordinated and directed by
Cornell University Medical College as part of an inter-
state program composed of fourteen states at this time.
The study is confined to passenger autos, and in the
Michigan study area only to those accidents investigated
by the Michigan State Police. Accident reports and
photographs are forwarded from participating Michigan
State police posts to the East Lansing headquarters, and
thence to the Michigan Department of Health. Medical
report forms will be delivered to the physician or hos-
pital by state police trooper for each person on whom a
report is necessary. When completed, these forms are
mailed directly to the Michigan Department of Health
as is indicated on the form. They will there be matched
with the accident report and photographs, and then
sent to Cornell University Medical School for tabulation
and study.
When the completed data are assigned numbers at
Cornell Medical College, the name of the person is re-
moved from the report and is destroyed. Until that time,
the name is essential to insure proper matching. Recent
legislation allows the State Commissioner of Health to
collect data for research purposes without its becoming
an available public record. This, plus the fact the
Michigan Department of Health will not make or retain
copies of medical reports, insures their confidential
nature.
We are all fully cognizant in Michigan of the benefits
the passenger automobile has brought us. As physicians,
we are also painfully aware it has brought with it a
dangerous by-product. This by-product can be classified
as a mass traumatic disease which is producing path-
ologic results for approximately 1,200,000 United States
citizens each year. Data from the National Safety Coun-
cil indicate that probably 100,000 of these more than a
million injuries result in permanent disability each year.
Statistical data from the Bureau of Vital Statistics of
the U. S. Public Health Service reveal it can be said
this mass traumatic disease is one of the most likely
items to produce death in the ages five through thirty-
nine. The motor vehicle actually ranks in first place
in ages fifteen through twenty-four.
The primary cause of motor vehicle accidents must be
1058
conceded to be the complex mistakes in human judg-
ment. Because of the complex cause factors, too many
for too long have believed there was little which could
be done about the inevitable price of accidents in death
and injury.
A research group at Cornell University Medical Col-
lege has been gathering data which could be useful in
examining the cause of injury as differentiated from the
data which seek to establish the cause of the accident.
If the proper quality and quantity of data on the
cause of injury can be gathered, it is known that mean-
ingful correlations can be established between the host
who has “traumatic disease” (occupant of the passenger
vehicle), the agent which produces the disease (the items
observed in the interior of the passenger vehicle), and
the environment in which the disease is acquired (the
highway or street where the accident occurs) .
By this epidemiologic approach, it is possible for med-
ical research to find those items which stand most in need
of change in the automobile. With conclusive data, the
design engineer, the manufacturer, can then make
changes which should lead to a calculated reduction in
the frequency and the severity of injury or death ob-
served during automobile accidents. This does not pre-
clude continued search for practical solutions to the
complex mistakes in human judgment, which are be-
lieved to be the primary cause of motor vehicle accidents.
Medicine and its allied sciences are most qualified to
apply the scientific disciplines necessary for studying the
mass traumatic disease seen in motor vehicle accidents.
Although the police reports contain specific information
concerning the type of accident, extent of damage to
automobile structures, and the mechanical causes of in-
juries sustained by car occupants, it cannot be expected
that troopers can furnish the precise facts as to the
nature, location, and extent of injuries which are im-
perative to the success of this study. In addition, one
of the primary objectives of this program is to collect in-
formation on automobile accident-injuries and their
causes which will be statistically reliable. When a num-
ber of medical reports from a sampling are missing, the
reliability of the data becomes questionable and the
value of the entire state effort is thus materially reduced.
The successful continuation of the present team work
by the medical research, and an alert and progressive
minded automotive industry promises great hope for the
future in controlling the mass disease problem, which
today is an outstanding characteristic of our social and
economic way of living.
Until the time comes when the causes of cancer are
known and preventive programs or specific cures are
developed, progress in treatment must depend on earlier
detection and prompt and skillful use of known weapons.
JMSMS
EFFECTIVE, DEPENDABLE THERAPY FOR VAGINITIS
Floraquin eliminates
trichomonal and mycotic infection;
restores normal vaginal acidity
Leukorrhea is by far the most frequent symp-
tom of vaginitis; trichomonads and monilia are
the most common causes. Many authors have
reported2 trichomonal protozoa in the vagina
of 25 per cent of obstetric and gynecologic
patients. Increased use of broad spectrum
antibiotics has resulted in a sharp rise in the
incidence of monilial infections.
Floraquin effectively eradicates both tricho-
monal and monilial vaginal infections through
the action of its Diodoquin® content. Floraquin
also furnishes boric acid and sugar to restore
the normal vaginal acidity which inhibits patho-
gens and favors the growth of protective Doder-
lein bacilli.
Pitt1 recommends vaginal insufflation of
Floraquin powder daily for three to five days,
followed by acid douches and the daily inser-
tion of Floraquin vaginal tablets throughout one
or two menstrual cycles. G. D. Searle & Co.,
Chicago 80, Illinois. Research in the Service of
Medicine.
1. Pitt, M. B.: Leukorrhea. Causes and Management, J. M.
A. Alabama 25:182 (Feb.) 1956.
2. Parker, R. T.; Jones, C. P., and Thomas, W. L.: Pruritus
Vulvae, North Carolina M. J. 16: 570 (Dec.) 1955.
August, 1957
Say you saw it in the Journal of the Michigan State Medical Society
1059
In Memoriam
Important
Announcement of
Arteriosclerosis
Treatment
GEROT PHARMACEUTIKA, own-
ers of United States Letters Patent
#2-776-973 issued January 1957 to
Gerhard Gergely of Vienna, Austria,
have licensed MEYER AND COM-
PANY of Detroit, Michigan, to syn-
thesize and market 3, 7-dimethyl-xan-
thine double salt in the United States
of America.
3, 7-dimethyl-xanthine double salt with
oleic acid and magnesium, a stable
compound marketed in Austria since
1950 under the name “Perskleran” and
used in the treatment of ARTERIO-
SCLEROSIS is being marketed by
MEYER AND COMPANY under the
trade name of “Athemol.”
The product is now available in tablet
form.
Literature and clinical samples are
available on request.
Pharmaceutical Manufacturers
16361 Mack Ave.
Detroit 24, Michigan
—
1060
Say you saw it in the Journal of th
Douglas R. Coyne, M.D., aged fifty-eight, Detroit
physician for thirty-two years, died June 1, 1957. Dr.
Coyne was a member of Detroit Commandery No. 1,
Knights Templar, and Lincoln Park Lodge No. 539,
F. & A. M.
Mark E. Maun, M.D., aged forty-seven, Grosse Pointe
Park, was director of the Owen Chemical Laboratory in
the David Whitney Building for the past ten years. He
was a director and organizer of the Metropolitan Hos-
pital, Doctors Hospital and St. Clair Hospital, and
served as consultant pathologist at Jennings, St. Joseph,
Deaconness and St. Mary’s Hospitals. A graduate of
Northwestern University College of Medicine in 1936.
he was associate professor of pathology at Wayne State
University from 1938-1945. He died on May 20, 1957.
Buell H. Van Leuven, M.D., aged sixty-nine, Petoskey
surgeon for thirty years, died June 18, 1957, at Munson
Hospital. Dr. Van Leuven was a former public health
officer and mayor of Petoskey. He served as a Coun-
cilor of MSMS for five years in the early forties.
Norman D. Wilson, M.D., aged eighty-five, Jackson
physician, graduated from Lennox College, Iowa, in
1911 and attended the Georgian Eclectic College of
Medicine and Surgery. Dr. Wilson began his practice
in Jackson in 1924. He was long active in the Kiwanis
Club. He originated a depression time agriculture
project which encouraged unemployed persons to pro-
duce their own vegetables. On November 11, 1949, he
was presented a plaque by the Kiwanis Club and 4-H
organizations for his service to youth clubs. Dr. Wilson
was a life member of the Jackson County Medical So-
ciety, Masonic orders, Kiwanis and High 12 clubs, and
a member of the First Methodist Church. He died
June 13, 1957.
AMA NEWS NOTES
(Continued from Page 960)
see the warm, human story of the home and profes-
sional life of William Phillips, M.D. You’ll learn about
the many ways the radiologist uses x-ray in diagnosis
and therapy. You’ll watch the doctor apply his special
knowledge to meet critical situations. The film was
produced by E. I. du Pont Nemours & Co., Inc., in
cooperation with the American College of Radiology.
Medical societies may arrange for bookings through
the Film Library. The film will be particularly suit-
able for school, club and other public gatherings.
JMSMS
Michigan State Medical Society
NEWS MEDICAL
MICHIGAN AUTHORS
Ellis J. Van Slyck, M.D., F.C.C.P., Detroit, is thr
author of an article entitled, “Diffuse Interstitial Pul-
monary Fibrosis (Hamman-Rich Syndrome): Diagnosis
by Lung Biopsy; Treated with Cortico-Steroids,” pub-
lished in Diseases of the Chest Official Journal of the
American College of Chest Physicians, May, 1957.
Herbert Rosenbaum, M.D., Detroit, is the author of
an article entitled, “Highlights 1957 Meeting, American
College of Physicians,” published in Harper Hospital
Bulletin, May-June, 1957.
Hermann Pinkus, M.D., Detroit, is the author of an
article entitled, “The Problem of Multicentricity In Skin
Cancer,” published in the Wayne State University Col-
lege of Medicine Bulletin, Vol. 4, No. 1, June 1957.
Ronan O’Rahilly, M.D., Detroit, is the author of an
article entitled, “Reflections on Histology and Embryol-
ogy,” published in Wayne State University College of
Medicine Bulletin, June, 1957.
K. L. Krabbenhoft, M.D., Detroit, is the author ol
an article entitled, “The Present Status of Radioisotopes
In Medicine,” published in Harper Hospital Bulletin,
May-June, 1957.
R. J. Whitty, M.D, Detroit, is the author of an
article entitled, “Prolapse and Procedentia of the Rectum
In Children,” published in Harper Hospital Bulletin,
May-June, 1957.
Harvey Krieger, M.D., Detroit, is the author of an
article entitled, “Papanicolaou Smears In The Diagnosis
of Premature Rupture Of The Amniotic Sac,” published
in Harper Hospital Bulletin, May-June, 1957.
Lloyd J. Lemmen, M.D., Pittsburgh, Wallace W.
Tourtellotte, M.D., James E. Higgins, B.A., and Julius
A. Parker, B.A., Ann Arbor, are the authors of an
article entitled, “Study of Cerebrospinal Fluid Proteins
with Paper Electrophoresis,” published in the University
of Michigan Medical Bulletin, May, 1957.
B. I. Hirschowitz, M.D., C. W. Peters, Ph.D., and
L. E. Curtiss, LSA ’58, Ann Arbor, are the authors
of an article entitled, “Preliminary Report on a Long
Fiberscope for Examination of Stomach and Duode-
num,” published in the University of Michigan Medical
Bulletin, May, 1957.
James C. Breneman, M.D., Galesburg, is the author of
an article entitled, “Clinical Use of Tolbutamide (Ori-
nase) In Office and Home Care of Diabetics,” published
in the Journal of the American Medical Association,
June 8, 1957.
L. Burton Parker, M.D., Indianapolis, and Leonard
F. Bender, M.D., Ann Arbor, are the authors of an
article entitled, “Problem of Home Treatment in Arth-
ritis,” read at the 34th Annual Session of the American
Congress of Physical Medicine and Rehabilitation, Atlan-
tic City, September, 1956, and published in Archives of
Physical Medicine and Rehabilitation, June, 1957.
John M. Weller, M.D. and Henry K. Schoch, M.D.,
Ann Arbor, are the authors of an article entitled, “The
Pathogenesis, Clinical Course, and Treatment of Acute
Renal Insufficiency,” published in the University of
Michigan Medical Bulletin, May, 1957.
Brian F. McCabe, M.D., Ann Arbor, is the author of
an article entitled, “Unilabyrinthine Crisis Without Ver-
tigo,” published in the University of Michigan Medical
Bulletin, May, 1957.
Michael H. Lashmet, Ann Arbor, Clifford W. Gurney,
M.D., Chicago, and William H. Beierwaltes, M.D., Ann
Arbor, are the authors of an article entitled, “Thyroid
Response to TSH in Normal Human Subjects,” pub-
lished in the University of Michigan Medical Bulletin,
May, 1957.
Roger F. Milnes, M.D., and Rients Vander Woude,
M.D., Ann Arbor, are the authors of an article entitled,
“A Stainless Steel Disc Oxygenerator for Cardiac By-
Pass,” published in the University of Michigan Medical
Bulletin, May, 1957.
Roger F. Milnes, M.D., Rients Vander Woude, M.D.,
Joe D. Morris, M.D., and Herbert Sload, M.D., Ann
Arbor, are the authors of an article entitled “Induced
Asystole for Open Cardiotomy,” published in the Univer-
sity of Michigan Medical Bulletin, April, 1957.
Robert J. Bolt, M.D., William S. Wilson, M.D., and
H. Marvin Pollard, M.D., Ann Arbor, are the authors
of an article entitled, “Gastric Ulcer: Evaluation of
Methods of Treatment,” published in the University of
Michigan Medical Bulletin, April, 1957.
Lloyd J. Lemmen, M.D., Pittsburgh, Wallace W.
Tourtellotte, M.D., Janice G. Glimm, James E. Higgins,
Julius A. Parker, B.A., Ann Arbor, are the authors of
an article entitled, “Study of Cerebrospinal Fluid Pro-
teins with Paper Electrophoresis IV. Methods for Con-
centrating Dilute Protein Solutions,” published in the
University of Michigan Medical Bulletin, April, 1957.
John B. Stetson, M.D., Ann Arbor, is the author of
an article entitled, “Resuscitation Under Anesthesia:
Some Interesting Early Reports,” published in the Uni-
versity of Michigan Medical Bulletin, April, 1957.
J. C. Breneman, M.D., of Galesburg, Michigan, is
author of an original article “Clinical Use of Tolbuta-
mide (Orinase) in Office and Home Care of Diabetics”
which appeared in the Journal of the American Medical
Association, June 8, page 627.
Samuel J. Levin, M.D., Detroit, is author of an orig-
inal paper “Prednisone in the Treatment of Allergic
August, 1957
1061
NEWS MEDICAL
BRIGHTON HOSPITAL
A non-profit Foundation
FOR ALCOHOLISM
A facility designed to rehabilitate or to aid
the addict in arresting his addiction.
Walter E. Green, M.D., Superintendent and Medical Director.
Brighton Hospital meets the stand-
ards established by the Michigan
State Board of Alcoholism and is
recommended by that Board.
12851 East Grand River
(U.S. 16)
Brighton, Michigan
Academy 7-1211
Diseases in Children" presented at the AMA Annual
Session in New York, June 5.
* * *
Borden Awards. — A total of 254 senior medical stu-
dents have received $500 Borden Undergraduate Re-
search Awards in Medicine over the past thirteen years.
This is reported in a new Borden Company Foundation
directory which, for the first time, lists all the college
and university scholarship awards and prizes sponsored
by the foundation. The awards, at twenty-six schools,
are for senior medical students whose research as under-
graduates has been deemed to be the most meritorious
in their class.
The basic purpose of the program is to furnish in-
centive for high scholastic attainment and to dramatize
the importance of such attainment.
Schools at which these medical awards are made are:
University of California. University of Chicago, Univer-
sity of Cincinnati, Columbia University, Cornell Uni-
versity, Duke University, Harvard Medical School, Uni-
versity of Illinois, State University of Iowa, Johns Hop-
kins University. University of Michigan, University
of Minnesota, New York University, Northwestern Uni-
versity, Ohio State University, University of Pennsyl-
vania, University of Rochester, Saint Louis University,
Stanford University, University of Texas, Tulane Univer-
sity, Vanderbilt University, Washington University, West-
ern Reserve University, University of Wisconsin, and
Yale University.
In all instances the colleges select the award students
and administer the grants.
1062
Joint Session — Sight-saving and inter-American friend-
ship were twin objectives at the joint session of the
Fourth Interim Congress of the Pan American Associa- ,
tion of Ophthalmology and the annual conference of the
National Society for the Prevention of Blindness (U. S. ) ,
held in New York City, April 7-10, 1957. More than
1,000 persons devoted to the saving of sight registered for
the Congress. Of 540 who attended the Pan American
Association’s session, same 400 were practicing ophthal-
mologists and seventy-four were residents in ophthal-
mology.
Sixty-six ophthalmologists represented the Latin Amer-
ican countries — Argentina, Boliva, Brazil, Chile, Colom-
bia, Costa Rica, Cuba. Dominican Republic, El Salvador,
Jamaica, Mexico, Nicaragua, Panama, Paraguay, Puerto
Rico, Uruguay and Venezuela. Seven come from Can-
ada and one from the Virgin Islands. The annual con-
ference of the National Society for the Prevention of
Blindness attracted some 500 physicians, nurses, educa- j
tors and volunteer workers.
Mayor Robert F. Wagner of New York urged that
in order to stem the tide of loss of sight, “each phy-
sician's office, each clinic and each hospital become
a screening site for early recognition of diseases of the
eye” with referral to ophthalmologists for specialized
care.
The opening session was the scene of the presentation
of Leslie Dana Gold Medals for the Prevention of Blind-
ness to two distinguished leaders: Mrs. Eleanor Brown
Merrill, formerly Executive Director of the National
JMSMS
Say you saw it in the Journal of the Michigan State Medical Society
NEWS MEDICAL
Society, now living in Baltimore; and Miss Evelyn Car-
penter, formerly Executive Secretary of the Philadel-
phia Committee for the Prevention of Blindness. The
Dana Medal is awarded by the St. Louis Society for the
Blind.
The scientific sessions of the two organizations were
held separately. The Pan American Association held
symposiums in the mornings, Monday through Wednes-
day. These dealt with diseases of the ocular fundus,
ocular surgery and ocular therapy.
Dr. H. Saul Sugar, Detroit, was one of the speakers.
His subject was “Coats’ Disease.”
The Association’s next assembly, a Caribbean cruise
congress, is scheduled for February 1-14, 1958. More
than 300 have already made reservations for the cruise,
which will be held aboard the Queen of Bermuda. Dr.
William L. Benedict, Rochester, Minnesota, is chairman
of the organizing committee. A program of lectures,
seminars and motion pictures is being planned for ses-
sions to be held on shipboard. The party will visit
San Juan, Puerto Rico; Ciudad Trujillo, Dominican Re-
public; Kingston, Jamaica; Port-au-Prince, Haiti; and
Nassau in the Bahamas. Information about the cruise
may be obtained from the travel agent, Mr. Leon V.
Arnold, 33 Washington Square West, New York 11, New
York.
Dr. J. Wesley McKinney, Memphis, is Executive Sec-
retary of the Association for countries north of Panama,
and Dr. Jorge Balza, Buenos Aires, for South of Pan-
ama.
Lewis Cohen, M.D., presented an exhibit on “Elec-
trovasography: Quantitative Diagnosis in Vascular Dis-
orders” at the annual meeting of the American Medical
Association in New York June 3-7, 1957. The exhibit
was awarded a Certificate of Merit in the Physical Medi-
cine section.
* * *
University of Michigan Television. — A program in the
television series, “Doctors for Michigan,” appeared on
the Lansing station, July 28, Sunday, 11:30 A.M. The
Kalamazoo station will also carry a program in this series
sometime in August.
* * *
Aging. — To avoid shaky hands and a tottering gait
in later life give up your coffee break for a brief walk
or some other good exercise, is the advice of Frederick
C. Swartz, M.D., of Lansing.
Dr. Swartz told a workshop session of the U-M’s
tenth anniversary Conference on Aging that physical
exercise “begun early in life and continued into the
advanced years is capable of delaying the physical stig-
ma of aging and prolonging life expectancy as much
as eight to ten years.” If begun early in life, walking
and other forms of daily physical exercise can ward off
symptoms of bursitis, myositis, and fibrositis, Dr. Swartz
indicated. “These represent degenerative rather than
inflammatory prcesses. What one sees under the micro-
scope ... is the result of lack of activity and function.”
All important laboratory exam-
inations; including —
Tissue Diagnosis
The Wassermann and Kahn Tests
Blood Chemistry
Bacteriology and Clinical Pathology
Basal Metabolism
Aschheim-Zondek Pregnancy Test
Intravenous Therapy with rest rooms for
Patients
Electrocardiograms
Central Laboratory
Oliver W. Lohr, M.D., Director
537 Millard St.
Saginaw
Phone. Dial 2-4100—2-4109
The pathologist in direction is recognized
by the Council on Medical Education
and Hospitals of the A.M.A.
a proven
suppressor of
postoperative
nausea and
vomiting . . .
Pfi
ze
BRAND OF MECLIZINE HYDROCHLORIDE
*Trademark
August, 1957
Say you saw it in the Journal of the Michigan State Medical Society
1063
NEWS MEDICAL
ST. JOSEPH’S RETREAT
Member: American Hospital Association
Catholic Hospital Association
National Association of Private
Mental Hospitals
The Central Neuro-Psychiatric
Hospital Association
Under the direction of the
Daughters of Charify of Sf. Vincent de Paul
Serving Metropolitan Detroit
and Michigan almost a century
Martin H. Hoffmann, M.D.
Medical Director
23200 West Michigan Avenue
Dearborn
Logan 1-1400
The Twenty-Second Annual Congress of the United
States and Canadian Sections of the International Col-
lege of Surgeons will be held at the Palmer House, Chi-
cago, September 8-12, 1957.
* * *
Tuberculosis infection rates w ere
found to be 42 per cent among
adults over fifty-five and 1.5 per
cent among children under ten in
a mass tuberculin testing program
conducted last year in Arenac
County. The infection rate for the
county as a whole was estimated to
be 19 per cent. A total of 5,362
persons — more than half of the
county’s population — were checked
with the Mantoux tuberculin test.
“In the future, tuberculin tests probably will have a
prominent place in case finding,” Dr. C. M. Sharp,
director of the Bureau of Tuberculosis Control for the
Florida State Board of Health, predicted in the Na-
tional Tuberculosis Association Bulletin. “This test is
a sensitive epidemiological barometer, especially when
used in young children with limited adult contact. When
the infection rate in the population decreases to a suffi-
ciently low degree, as it has already done in some sec-
tions of the midwest, tuberculin-testing surveys of the
general school and adult population may eventually be
our most economical and productive case-finding tech-
nique.”
Research Awards Announced. — Award of thirty-one
unclassified life science research contracts in the fields of
medicine, biology, biophysics and radiation instrumen-
tation was announced by the U. S. Atomic Energy Com-
mission. The contracts were awarded to universities
and private institutions as part of the AEC’s continuing
policy of assisting and fostering research and development
in fields related to atomic energy as specified in the
Atomic Energy Act of 1954, and as amended in 1956.
The Michigan awards, which are for one year, are
as follows:
Kresge Eye Institute: Effects of Neutrons and Other
Radiations on the Ocular Lens. V. E. Kinsey, $11,-
790.00.
University of Michigan: Immunological Study of
Tumors. W. J. Nungester, $25,000.
Parke, Davis and Company: Factors Elaborated by
Animal Tissues Which Stimulate Rate of Regeneration of
Hematropoietic Organs of Animals Exposed to Total
Body Irradiation with Gamma Rays. J. K. Weston,
$80,000.
* * *
The American Association of Physicians and Surgeons
has announced its 1958 Essay Contest for high school
students with a choice of two subjects: “The Advan-
tages of Private Medical Care,” or “The Advantages of
the American Free Enterprize System.” County, state,
and auxiliary medical societies are invited to sponsor
these contests. This is the twelfth Annual contest held
under the auspices of this organization.
1064
Say you saw it in the Journal of the Michigan State Medical Society
JMSMS
NEWS MEDICAL
The National Association For The Prevention Of
Tuberculosis and Diseases of the Chest and Heart,
incorporating the Annual Conference of the British Tu-
berculosis Association, announces that its next Confer-
ence will be held in London from July 1 to July 4, 1958.
The last conference was held in 1955 and was attended
by 1,700 representatives from sixty countries.
* * *
M. K. Newman, M.D., Detroit, addressed the Physi-
cal Medicine Section of the American Medical Associa-
tion in New York City on June 6, 1957. The title
of his paper was, “Electromyographic Examination and
its Clinical Application in Muscular Atrophies.” On
June 7, 1957, at the New York State Rehabilitation
Hospital at Haverstraw, New York, he presented a sem-
inar in “Diagnosis and Management of Muscular Atro-
phies.” In Detroit on June 18, 1957, at the Jewish
Home for the Aged, he presented a discussion on “Ac-
tivity Participation in the Home for Happier Living.”
* * *
Mount Sinai Hospital, New York, in affiliation with
Columbia University, is offering postgraduate courses
in Clinical Medicine for practitioners. These courses are
not designed for the purpose of training physicians to
become specialists, but are designed to offer the facili-
ties of the Mount Sinai Hospital for continuation train-
ing and advanced experience in the clinical fields of
medicine. Detailed information regarding the courses
may be obtained by applying to the Registrar for Post-
graduate Medical Instruction at the Mount Sinai Hos-
pital, Fifth Avenue and One-hundredth Street, New York
29, New York.
* * *
Participants in the 10th Anniversary Conference on
Aging at the University of Michigan on June 25, 1957,
at Ann Arbor, included M. K. Newman, M.D., Detroit,
who discussed “Physical Rehabilitation in Pre-Retirement
Conditioning.”
* * *
CARBASED
ACETYLCARBROMAl TABLETS
• Proved safe and effective by 6 years'
clinical use.
• Soothes the central nervous system,
produces calmness without hypnosis.
• Non-toxic, non-cumulative, non-addict-
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• Does not impair mental or physical
function.
American Board of Obstetrics and Gynecology. —
Applications for certification (American Board of Ob-
stetrics and Gynecology), new and reopened, Part I,
and requests for re-examination Part II are now being
accepted. All candidates are urged to make such appli-
cation at the earliest possible date. Deadline date for
receipt of applications is September 1, 1957. No ap-
plications can be accepted after that date.
Candidates for admission to the Examinations are re-
quired to submit with their application, an unbound
854x11" typewritten list of all patients admitted to
the hospitals where they practice, for the year preced-
ing their application, or the year prior to their request
for reopening of their application. This information
is to be attested to by the Record Librarian, Superin-
tendent, or Director of the hospitals where the patients
are admitted. Current Bulletins outlining present re-
quirements may be obtained by writing to Robert L.
Faulkner, M.D., Secretary, 2105 Adelbert Road. Cleve-
land 6, Ohio.
• Orally effective within 30 minutes for
sustained action up to 6 hours.
• Economical.
Indications: Tension, nervousness,
anxiety and muscular spasm.
Supplied: White round tablets
Acetylcarbromal 5 gr. in bottles
of 100, 1000.
Write for samples and literature
There’s Always A Leader
MALLARD, inc
3021 WABASH, DETROIT 16, MICHIGAN
August, 1957
Say you saw it in the Journal of the Michigan State Medical Society
1065
NEWS MEDICAL
"WHY TAKE CHANCES?"
No practice is too small — no group too large
to benefit from PM's management experience
WRITE OR CALL FOR INFORMATION
PR0FESSI0I1AL
RUIUI EDI HI
Security Bank Building — Battle Creek
SAGINAW — GRAND RAPIDS — DETROIT
A COMPLETE BUSINESS SERVICE FOR THE 111 E D I C A L PROFESSION
Affiliated Offices in Other Cities
The American College of Surgeons will hold its 43rd
Annual Clinical Congress at Atlantic City, October 14-18,
1957. They have invited students from thirty-six medi-
cal schools to attend, and published the names. No
one is listed from Michigan. It is hoped to stimulate
special interest by offering the papers and attention from
famous leaders in surgery. Under supervision, the stu-
dents will attend a number of special lectures in addi-
tion to the scheduled program.
* * *
M. D. LOCATIONS— THROUGH JULY 1, 1957
Placed by
Michigan Health Council:
Arthur R. Basel, M.D.
Frederik M. Wessels, M.D.
Benjamin F. Koepke, M.D.
Assisted by
Michigan Health Council:
James Briggs, M.D.
Austin Craymer, M.D.
Open Practice in
Cheboygan
Hillsdale
McBain
Holt
Ludington
*
*
The National Society for Crippled Children and
Adults will hold its annual convention October 31-
November 2 at the Palmer House, Chicago. For pro-
gram and information, write James B. Johnson. M.D.,
11 South LaSalle Street. Chicago, Illinois.
*•*■■*■
A medical history of the Copper Country was pub-
lished in the Daily Mining Gazette, Houghton, during !j
the June Upper Peninsula Medical Society’s meeting.
The interesting sketch of past medical days in that his-
tory-packed region of Michigan was prepared by Simon
Levin, M.D., of Houghton. The story included pen
sketches on such interesting medical giants of the past
as E. T. Abrams, M.D., Philip D. Bourland, M.D., W.
H. Matchette, M.D., and R. B. Harkness, M.D.
* * *
The Detroit Branch of the American Urological As-
sociation announces its new officers for the year: Presi-
dent, Robert P. Lytle, M.D., Detroit; President-Elect,
Harold V. Morley, M.D., Detroit; Secretary-Treasurer,
A. Waite Bohne, M.D., Detroit.
■* * *
Harry M. Nelson, Jr., M.D., son of Dr. and Mrs. Har-
ry M. Nelson, Detroit, was awarded the William H. Hon-
or Memorial Award for excellence in the study of surgery
during the recent Wayne State University College of
Medicine’s Convocation, June 13. Lewis P. Sonda, Jr.,
M.D., received a specially inscribed scroll from the
senior class in recognition of service. Dr. Sonda is a
son of L. Paul Sonda, M.D., Detroit. Loren W. Shaffer,
M.D., Detroit, administered the Oath of Hippocrates to
the sixty-three men and two women graduates.
“People to People” is what President Eisenhower
called CARE, the great international relief agency
which not only sends CARE food packages to the needy
in other countries but sponsors the donation of every
article that will help professional and trade people in
those states. Medical books for doctors and nurses, nets
for refugee Chinese fishermen, a plow for a farmer, a
tool that will double or treble his harvest and replace
his ancient crooked stick — all are requested by CARE,
for shipment overseas. If you can help, direct your in-
quiry to CARE, Washington 6. D. C.
MARY POGUE SCHOOL, Inc.
Complete facilities for training Retarded and Epi-
leptic children educationally and socially. Pupils
per teacher strictly limited. Excellent educational,
physical and occupational therapy programs.
Recreational facilities include riding, group games,
selected movies under competent supervision of
skilled personnel.
Catalogue on request.
G. H. Marquardt, M.D. Barclay J. MacGregor
Medical Director Registrar
26 GENEVA ROAD, WHEATON. ILL.
(Near Chicago)
1066
Say you saw it in the Journal of the Michigan State Medical Society
JMSMS
NEWS MEDICAL
“The Code of Hammurabi” is the name of the second
painting in the Parke Davis & Company series depict-
ing the history of medicine. In this full-color oil paint-
ing, a Babylonian physician defends his professional
practices against the complaint of a dissatisfied patient
seeking invocation of the Code of Hammurabi. The
ancient king’s code established physicians’ fees for serv-
ices and severe penalties for neglect of duty. This
critical drama of medicine 4000 years ago was painted
by artist Robert Thom of Birmingham, Michigan. The
painting was displayed for the first time at the recent
AMA Annual Meeting in New York.
* * *
The Ohio Academy of General Practice announces
its Seventh Annual Scientific Assembly at the Franklin
County Veterans Memorial in Columbus, Ohio, Sep-
tember 18-19, 1957. For program, write Earl D. Mc-
Callister, M.D.. 209 S. High Street, Columbus 15.
* * *
Looking back: In 1927, some wise economists warned
of business recession one or two years ahead. The
Sacco-Vanzetti case made headlines the world over.
Henry Ford put out his new Model A. A new toy,
called television, was demonstrated but was not very
practical. Charles Lindberg flew the Atlantic in May
and became a hero overnight.
1937: Roosevelt at the peak of his career, tried to
pack' the Supreme Court and also purge certain mem-
bers of his party (beaten at both). Rising prices on one
hand and first signs of an economic slide on the other.
1947: Taft-Hartley Law enacted. The first of the
huge foreign aid programs inaugurated — Marshall Plan.
* * *
During the World Congress of Gastroenterology to be
held in Washington, D. C., May 25-31, 1958, the official
languages will be English, French and Spanish — rend-
ered in simultaneous translation. Adequate space for
for modern
control of
salt retention
edema
CUMERTILIIf
fBrand of Mercumatilin, Endo)
Tablets
• effective oral diuretic with no sig-
nificant gastrointestinal irritation1
• Suitable for long-term mainte-
nance therapy.
• eliminates need for injections in
certain cases, lengthens interval
between injections in others
• basically different in chemical
structure, extending the therapeu-
tic choice in organic mercurials
DOSAGE: 1 to 3 tablets daily as required.
SUPPLIED: As orange tablets, in bottles
of 100 and 1000. Also available —
CUMERTILIN Sodium Injection, 1- and 2-cc.
ampuls, in boxes of 12, 25, and 100; and
10-cc. vials, individually and in boxes
of 10 and 100.
1. Pollock, B. E., and Pruitt, F. W.: Am. J. M.
Sc., 226:172, 1953.
THE G. A. INGRAM COMPANY
4444 Woodward Avenue, Detroit 1, Mich.
August, 1957
Say you saw it in the Journal of the Michigan State Medical Society
1067
NEWS MEDICAL
Protection against loss of income from
accident and sickness as well as hospital
expense benefits for you and all your
eligible dependents.
PHYSICIANS CASUALTY & HEALTH
ASSOCIATIONS
OMAHA 2, NEBRASKA
Since 1902
scientific exhibits will be available; those desiring to
participate may write G. G. McHardy, M.D., 3636 St.
Charles Avenue, New Orleans 15, Louisiana. For fur-
ther details on the Congress, write H. M. Pollard, M.D.,
Secretary General, 1313 E. Ann Street, Ann Arbor.
* * *
The Sixth Conference on Physicians and Schools,
sponsored by the AMA, will be held at the Lorraine
Hotel, Highland Park, Illinois, on October 30-Novem-
ber 2, 1957.
* * *
The Olin Memorial Health Center and Hospital of
Michigan State University, recently enlarged into a
$2,500,000 building, was dedicated June 13. Facilities
of the Hospital were increased from seventy-two to 129
beds, capable of servicing MSU’s anticipated enrollment
of 30,000 in the next ten years. C. G. Menzies, M.D.,
Lansing, is Medical Director of the Olin Memorial
Center.
* * *
The American Psychiatric Association announces the
award of nineteen Smith, Kline and French Laboratory
Fellowships in Psychiatry. These projects, for 34 un-
dergraduates in medical school, will range from a study
of the chemical functionings of the brain to an analysis
of Seattle’s high suicide rate. The awards totaled $16,-
733. For information write Kenneth E. Appel, M.D.,
Chairman, Fellowship Committee, Box 7929, Philadel-
phia, Pennsylvania.
in
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Ethinyl Estradiol 0.0 1 mg.
Ferrous Sulfate 50 mg.
Rutin 10 mg.
Ascorbic Acid... 30 mg.
B-12 1 meg.
Molybdenum 0.5 mg.
Cobalt 0.1 mg.
Copper 0.2 mg.
Vitamin A 5,000 I.U.
Vitamin D 400 I.U.
Vitamin E 1 I.U.
Cal. Pantothenate 3 mg.
Thiamine Hcl. 2 mg
Riboflavin 2 mg
Pyridoxine Hcl. 0.3 mg
Niacinamide 20 mg
Manganese 1 mg
Magnesium 5 mg
Iodine 0.15 mg
Potassium 2 mg
Zinc I mg
Choline Bitartrate.... 40 mg
Methionine 20 mg
Inositol 20 mg
Write for Latest Technical Bulletins.
‘REFERENCE: J.A.M.A. 163: 359, 1957 (February 2)
DETROIT
MICHIGAN
1068
Say you saw it in the Journal of the Michigan State Medical Society
JMSMS
NEWS MEDICAL
McKesson Emergency Oxygen
& Resuscitation Unit
Richard A. Ferrington, M.D. (center) was recipient
f a $1,000 Award for Graduate Training in General
'ractice. The certificate was presented by E. Clarkson
.ong, M.D., Detroit, secretary of the Michigan Acad-
my of General Practice, at the May 27 meeting of
tie Midland County Medical Society. Also pictured is
Iharles M. Coffman (right), representative of the Mead
ohnson Company which provides the funds for the
ward.
* * *
Meyer Perlstein, M.D., Chicago, held a cerebral palsy
linic for the Michigan Society for Crippled Children
nd the Michigan Commission for Crippled Children
1 Kalamazoo on August 20 and 21, 1957.
* * *
The New York Academy of Medicine announces a
ostgraduate Week, October 7-11, with daily evening
:ctures, afternoon panel meetings, and a scientific ex-
ibit on “Research Contributions to Clinical Practice.”
or complete program and information, write the
cademy at 2 East 103rd Street, New York 28.
* * *
Dr. E. C. VonderHeide has been appointed Medical
onsultant in the Research Division and Dr. J. K.
/eston is now Director of the Clinical Investigation
epartment of Parke Davis & Company, Detroit. Con-
ratulations!
* * *
Dr. Reuben L. Kahn, world-famous discoverer of the
ahn blood test for syphilis, has officially retired at the
niversity of Michigan after twenty-nine years of serv-
e. But the U. of M. will continue Dr. Kahn as Re-
arch Consultant in the Department of Dermatology
id Syphilology. Congratulations, Dr. Kahn, on a
uitful life — beneficial to millions of persons through-
lt the world.
* * *
Winthrop N. Davey, M.D., of Ann Arbor was elected
overnor of the American College of Chest Physicians
■r Michigan at its recent New York City annual meet-
A small portable unit extremely simple to operate,
yet efficient for all cases requiring oxygen.
The unit, in addition to supplying oxygen to any
patient, can be used as a resuscitator by simply
Squeezing the bag, which forces oxygen into the lungs.
The flow valve is designed with an adjustable zero
position, thus the scale will always indicate the ap-
proximate flow rate. The scale is graduated from 0
to 10.
Since the flow valve will open only one turn, it pro-
vides a distinct protection to inexperienced personnel
should the flow valve be left open when the unit is
attached to a full cylinder of Oxygen.
The carrier is designed for carrying either D or E
size cylinders and is equipped with rubber feet to
prevent the marring of highly polished surfaces.
Weight of carry stand valve and rubber parts — 5%
lbs.
No. 310 Emergency Oxygen unit complete with car-
rier, flow valve, tank pressure gauge, cylinder valve
wrench, exhaling valve and body, plus all rubber
parts — $59.50.
Noble-Blackmer, Inc.
267 W. Michigan
Jackson, Michigan
ugust, 1957
Say you saw it in the Journal of the Michigan State Medical Society
1069
NEWS MEDICAL
ing. New Fellows from Michigan include: John L. Is-
bister, M.D., Lansing; Edna M. Jones, M.D., Northville;
Richard A. Rasmussen, M.D., Grand Rapids; Ellis J.
VanSlyck, M.D., Grosse Pointe; and Robert F. Ziegler,
M.D., Detroit.
* * *
Horace Wray Porter, M.D., Jackson, Chairman of
the MSMS Ethics Committee, participated on a panel
on ethics with Milton L. Davidson, an attorney from
Jackson, and G. E. Snyder, a professional engineer
from Jackson, at the annual meeting of the Society of
Professional Engineers held in Jackson, June 21-22.
Michael Kolivosky, presently professor of sociology at
Hillsdale College, acted as moderator.
SAMMOND PLEASANT LODGE
Oilers to the elderly and chronically ill
Peace and quiet. Freedom oi a large and richly
furnished home and acres of lawns and wooded
rolling grounds, scientifically prepared tasty
meals, congenial companionship. A real
"Home away from Home"
Approved by the American Medical Association
and Michigan State Department of Social Wel-
fare— Highly recommended by members of the
Medical Profession who have had patients at
the Lodge.
For further information write to:
SAMMOND PLEASANT LODGE
124 West Gates Street
Romeo, Michigan
“Immunization Information for Internationa] Travel”
is the title of a good booklet published recently by the
Department of Health, Education and Welfare, Public
Health Service. For copies write the Superintendent of
Documents, Government Printing Office, Washington 25,
D. C. (25c per copy).
* * *
The South Dakota State Medical Association is spon-
soring a Fall Hunter’s Medical Meeting, October 26-30,
in Mitchell, South Dakota. The meeting is limited to
100 out-of-state doctors of medicine. Registration fee
of $100.00 includes hunting license, hunting grounds
and guides, scientific sessions and four dinners. If wives
come with husbands and hunt, the registration fee is the
same for each; if wives do not hunt, their registration
fee is $75.00. A special motel has been reserved by
the SDMA for out-of-state physicians. For information
and registration blank, write John C. Foster. Executive
Secretary, South Dakota State Medical Association, 300
First National Bank Building, Sioux Falls, South Dakota.
THE PROBLEM OF THE BIOLOGIC FALSE
POSITIVE SEROLOGIC TEST FOR SYPHILIS
(Continued from Page 1016)
3. Portnoy, Joseph, and Magnuson, Harold J. : Im-
munologic studies with fractions of virulent T re-
ponema pallidum. J. Immunol., 75:348 (Nov.)
1955.
4. Moore, Joseph E., and Lutz, W. Beale: The natural
history of systemic lupus erythematosus: an ap-
proach to its study through chronic biologic false
positive reactors. J. Chron. Dis., 1:297 (March)
1955.
5. Curtis, Arthur: Personal communication (Depart-
ment of Dermatology, University Hospital, Ann
Arbor, Michigan).
6. Harvey, A. McGehee, et al: Systemic lupus erythe-
matosus: review of the literature and clinical
analysis of 138 cases. Medicine, 33:291, 1954.
Plainuell
Sanitarium
PLAINWELL, MICHIGAN
Member American Hospital Association
EDWIN M. WILLIAMSON, M.D.
Psychiatrist-in-Chief
Professional care for the nervous
and mentally ill.
Telephone MUrray 5-8441
1070
Say you saw it in the Journal of the Michigan State Medical Society
JMSMS
THE DOCTOR’S LIBRARY
Acknowledgments of all books received will be made in this column,
and this will be deemed by us as full compensation to those
sending them. A selection will be made for review , as expedient.
EPILEPSY. Grand Mai, Petit Mai, Convulsions. By
Letitia Fairfield, C.B.E., M.D., D.P.H. New York, N.
Y. : Philosophy Library, Inc. Price $4.75.
The problems and the questions arising in the treat-
ment of epilepsy are numerous and, fortunately, are
sometimes only the result of a simple lack of knowl-
?dge on the part of the patient or his family. In a
straightforward and well organized fashion, the author
af this volume has presented an excellent review of the
nature and the treatment of this disorder. In addition,
there are chapters on the problems arising in infancy
and childhood ; problems arising in relation to employ-
ment; and problems arising in the areas of driving li-
:ensure and criminal responsibility.
Though the book was written primarily for the Brit-
ish patient and his family, the information is applicable
to the American patient as well. The book is highly
recommended for all those lay persons who need a good
sound knowledge of this disorder.
F.M.
PRACTICAL GYNECOLOGY. By Walter J. Reich,
M.D., F.A.C.S., F.I.C.S., Attending Gynecologist and
Section Chief. Fantus Clinics of the Cook County Hos-
pital; Attending Gynecologist, Cook County Hospital;
Professor of Gynecology, Cook County Graduate School
of Medicine; Assistant Professor of Obstetrics and
Gynecology. Chicago Medical School; Attending Gyne-
cologist and Obstetrician and Former Chairman of
the Department, Grant Hospital; Consulting Gynecol-
ogist, Oak Forest Infirmary, Oak Forest Tuberculosis
Hospital; Hazelcrest General Hospital, Fox River Tu-
berculosis Sanatorium, Geneva Community Hospital,
and Mitchell J. Nechtow, M.D., F.A.C.S., F.I.C.S.,
Associate Attending Gynecologist, Cook County Hos-
pital and Fantus Gynecologic Clinic; Associate Pro-
fessor of Gynecology and Obstetrics, Chicago Medical
School ; Associate Professor of Gynecology, Cook Coun-
ty Graduate School of Medicine; Attending Gynecol-
ogist. Northwest Hospital; Chief of Gynecology and
Obstetrics. Norwegian-American Hospital. Second
Edition. 284 Illustrations, including sixty-eight Sub-
jects in Color. Philadelphia and Montreal: J. B.
Lippincott Company. Price $12.50.
The first edition of Practical Gynecology which ap-
peared in 1950 was an authoritative, well written, well
illustrated quick reference designed for the general prac-
titioner. This second edition is still more comprehen-
sive, being expanded with nine chapters of new ma-
terial.
The added chapters discuss pediatric gynecology, diag-
nosis of early pregnancy in problem cases, radiation ther-
apy in gynecology, geriatric gynecology, and pitfalls in
diagnosis.
Usefulness of the book has been enhanced by careful
revisions. There is added emphasis to the relation of
the acute gynecologic abdomen and the gastrointestinal
and genitourinary systems. Malignancy of the ovary
Flint Medical Laboratory
633 Mott Foundation Building
Flint
Phone CE. 4-9312
E. G. Murphy, M.D.
W. T. Hill, M.D.
W. L. Eaton, M.D.
C. J. Flanagan, M.D.
J. D. Wheeler, M.D.
W. Caraway, Ph.D., Biochemist
M. Dumoff, Ph.D., Microbiologist
COMPLETE SERVICES IN LABORATORY
MEDICINE
Tissue diagnosis
Serology
Chemistry
Bacteriology
Protein bound iodine
Exfoliative cytology
Basal Metabolism
Electrocardiograms
Pregnancy tests
Hematology
Urinalysis
Autopsies
BRAND OF MECLIZINE HYDROCHLORIDE
prevents nausea,
dizziness, vomiting
of motion sickness
in minutes
♦trademark
August, 1957
Say you saw it in the Journal of the Michigan State Medical Society
1071
THE DOCTOR’S LIBRARY
Literature
illustrating and
describing the
EK-2 will be sent
you on request.
THE BURDICK CORPORATION
MILTON, WISCONSIN
Broncfc Offices: CHICAGO • NEW YORK
Regional Representatives:
ATLANTA • CLEVELAND • LOS ANGELES
THE G. A. INGRAM COMPANY
4444 Woodward Avenue, Detroit 1, Michigan
The EK-2 is sold through 296 qualified medical supply
houses throughout the United States. Over 1,500 Bur-
dick sales representatives are backed by complete
service facilities for all your Burdick equipment.
The cardiogram, as part of
your regular examination,
gives you a valuable diag-
nostic record. Your patient
is spared the inconvenience of seeing an-
other physician. You are saved the time
awaiting his report.
The Burdick EK-2 portable unit combines
simplicity of operation with exceptional
accuracy. A flick of the switch gives a clear,
permanent record. Leads are permanently
marked. No chemicals, darkrooms, or proc-
essing are needed. You can make an accu-
rate diagnosis in minutes.
and the importance and usefulness of the Papanicolaou
stain are discussed more fully than in the earlier edi-
tion. The fern test is described and its multiple uses
in the office explained. The importance of frequent
breast examinations during prenatal and postnatal pe-
riods is emphasized.
The entire book is as practical, as its title claims. Its
organization, conciseness, and numerous illustrations make
it especially useful.
S.T.L.
THE ART OF COMPOUNDING (Scoville’s). By Glenn
L. Jenkins, Dean and Professor Chemistry, Purdue
University School of Pharmacy, Lafayette, Indiana;
Don E. Francke, Chief Pharmacist, University Hospital,
LTniversity of Michigan, Ann Arbor, Michigan; Ed-
ward A. Brecht. Dean and Professor of Pharmacy,
University of North Carolina, School of Pharmacy,
Chapel Hill, North Carolina: and Glen J. Sperandio,
Associate Professor of Pharmacy, Lafayette, Indiana.
Ninth Edition New York, Toronto. London: The
Blakiston Division, McGraw-Hill Book Company, Inc.,
1957. Price $11.00.
Compounding used to be taught in our father's and
grandfather's courses in medicine, but is now assumed
to be done. This book by four authors, one being Don
E. Francke, D.Sc., Chief Pharmacist at the University
Hospital. University of Michigan, gives a complete de-
scription and discussion of the art. Some hospitals have
need for this service and probably most of them should,
but doctors have formed the habit of ordering pharma-
ceuticals already compounded. On occasions, however,
it is deemed necessary to compound one's own and it
is well for our doctors to understand much of the
compounding art. Such knowledge avoids use of in-
compatible prescriptions with which our pharmaceutical
suppliers are already familiar. This book has much use-
ful information.
RYPIN'S MEDICAL LICENSURE EXAMINATIONS.
Topicl Summaries and Questions. By Walter L. Bier-
ring, M.D.. M.A.C.P., M.R.C.P., Edin. (Hon.), For-
mer Member, National Board of Medical Examiners,
American Board of Internal Medicine, Iowa State
Board of Medical Examiners ; Iowa State Commission
of Health; Professor Emeritus, Theory and Practice of
Medicine; College of Medicine, State University of
Iowa: Secretary, Federation of State Medical Boards
of the United States; Chairman (Hon.), 1933-53,
American Board of Preventive Medicine, Inc. : Direc-
tor, Division Gerontology. Heart and Chronic Diseases,
Iowa State Dept, of Health. With the collaboration
of a Review Panel. Eighth Edition. Philadelphia
and Montreal: J. B. Lippincott Companv. Price
$10.00.
The State Board of Licensure examinations face every
medical student and each one is concerned with pass-
ing them. This book is developed on the questions asked
over a term of years at various times, giving an ade-
quate discussion of each topic in the usual fields. The
final few pages of each section are questions and ac-
ceptable answers. There is also a field glossary and
alphabetical index. The book is well concveived and
will be found very useful.
1072
Say you saw it in the Journal of the Michigan State Medical Society
JMSMS
OUTCOME OF IOWA LITIGATION
(Continued from Page 968)
ology were specialties within the practice of medi-
cine; (b) the practice of medicine requires quali-
fications which cannot be met by a corporation;
(c) that pathologists were violating the law in
Iowa by permitting hospitals to render bills for
their services without the patients’ consent.
This decision was appealed to the state supreme
court; it is presumed that this appeal will now
be withdrawn, inasmuch as the new law is based
on a joint agreement (declaration) between the
hospital trustees and the physicians of that state.
Such a legal battle is a sorry way to settle
disagreements arising from the rendering of medi-
cal services. Poorer public relations cannot be
imagined. Bitterness and antagonism cannot solve
such problems. The hospitals and physicians need
each other and a wholesome regard and respect,
mutually held, is essential. It is hoped that the
physicians and hospitals in Iowa, and elsewhere,
will work harmoniously within the spirit of this
new legislation. O.A.B. in Detroit Medical News,
April 22, 1957.
WOLVERINE
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AYERST LABORATORIES
New York, N.Y. • Montreal, Canada
5646
August, 1957
Say you saw it in the Journal of the Michigan State Medical Society
1073
Communication
MEDICAL ADVISORY COMMITTEE
TO THE SELECTIVE SERVICE SYSTEM
Mr. W. J. Burns, Executive Secretary
Michigan State Medical Society
606 Townsend Street
Lansing, Michigan
Dear Mr. Burns:
On behalf of the staff and members of the State Com-
mittee of the Medical Advisory Committee to the Selec-
tive Service System, I wish to express appreciation for
the co-operation, interest and assistance rendered this
office through the years 1950 to date. As you know, the
Doctors’ Draft Law ceases as of 30 June 1957, and
there is a possibility that a standby Committee of some
type will be continued.
Thanking you, and with kind regards, I am
Sincerely yours,
Grover C. Penberihy, M.D.
Chairman, Selective Service System
State Advisory Committee for Michigan
June 25, 1957
Classified Advertising
$2.50 per insertion of fifty words or less, with an
additional five cents per word in excess of fifty.
OBSTETRICIAN-GYNECOLOGIST, Pediatrician,
Ophthalmologist, Board eligible or certified, to join
14-man group in metropolitan Detroit. $14,000-$16,-
000. Lakeside Medical Center, 987 E. Jefferson Ave-
nue, Detroit 7, Michigan.
INTERNIST : With special interest and fellowship
training in cardiology, desires association with group in
Michigan, preferably one academically inclined, con-
centrating on full, personal patient care. Board
eligible, 31, family, veteran. Especially interested in
Ann Arbor area. Reply Box 4, 606 Townsend Street,
Lansing 15, Michigan.
The death rate from pneumonia, influenza and tu-
berculosis has dropped about 90 per cent since 1900
in the United States, Health Information Foundation
reports. HIF attributes the improvement to medical
advances, particularly new drugs, and to better living
conditions.
* * * *
Declining mortality from tuberculosis since 1900 has
had its greatest impact among young adults (ages
fifteen to forty-four) in the peak income and childbearing
years. The highest mortality from the disease now oc-
curs in the upper grades among those over sixty-five.
* * *
In 1900, influenza and pneumonia took a toll of 80
persons per 100,000 population in the young adult
ages (fifteen to forty-four). By 1955, mortality from
these causes had dropped to around four per 100,000
persons in the same age group.
MSMS OFFICERS NIGHT
DINNER DANCE
Ballroom, Pantlind Hotel, Grand Rapids
Wednesday, September 25, 1957
You and Your Lady are Cordially Invited
I
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can never be recalled"
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George A. Triplett and Richard K. Wind
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Telephone University 2-8064
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CALIFORNIA STATE
assignments for
PHYSICIANS AND PSYCHIATRISTS
Three Salary groups:
$1 1 ,400-$ 1 2,600
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Streamlined employment procedures —
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Calif, license required.
Write:
Medical Recruitment Unit, Box A
State Personnel Board, 801 Capitol Avenue,
Sacramento, California
1074
Say you saw it in the Journal of the Michigan State Medical Society
JMSMS
THE JOURNAL
of the Michigan State Medical Society
VOLUME 56 SEPTEMBER, 1957 NUMBER 9
Contributors to This Issue
G. J. Curry, M.D.
F. B. House, M.D.
S. E. Miller, M.D.
J. M. Dorsey, M.D.
F. H. Mayfield,
M.D.
Table of Contents
Are Your Patients Physically Qualified to Drive?
Harold E. DePree, M.D 1125
Use of Chemical Tests for Intoxication in
Michigan Law Enforcement
C. W. Muehlberger, Ph.D 1127
Drugs and Driving
Seward E. Miller, M.D 1131
The Highway Accident Problem in Michigan
and What Has Been Done About It
Gordon H. Sheehe 1133
Automotive Crash Injury Research in Michigan
Robert M. Tracy 1137
Traffic Accidents and Safety
George J. Curry, M.D., F.A.C.S 1139
The Speeding Ambulance
George J. Curry, M.D., F.A.C.S., and Sydney
N. Lyttle, M.D., F.A.C.S 1140
Whiplash Injuries
Frank H. Mayfield, M.D., and Jack C. Griffith,
M.D 1142
Emotional Problems in Driving
John M. Dorsey, M.D 1147
Function of an Amputee Clinic
Frederic B. House, M.D 1159
Asian Influenza
Michigan Department of Health 1162
Detroit Surgical Association: Meetings of
March 25 and April 22, 1957 1163
President’s Message:
Doctor — to Serve Society Better 1165
Editorial:
Traffic Safety Number 1166
The Physician and Traffic Safety 1166
Do Doctors Charge Too Much? 1167
The “Why” 1167
The Value of our Money 1167
Is Medical Practice Changing? 1168
The Program 1168
Assistant Editor Named 1169
Heller Report 1169
Michigan’s Department of Health 1170
In Memoriam 1172
Doctor, We Need Your Opinion 1173
Legal Opinion 1174
News Medical 1176
The Doctor’s Library 1196
You and Your Business 1084
Heart Beats 1092
PR Report 1102
AM A Washington Letter 1106
AMA News Notes 1112
© 1957 by Michigan State Medical Society
Ieptember, 1957
1079
fo^^p'r-'S
THE JOURNAL
of the Michigan State Medical Society
:VOLUME 56
SEPTEMBER, 1957
NUMBER 9 :
PUBLICATION COMMITTEE
G. B. SALTONSTALL, M.D., Chairman Charlevoix
WILLIAM BROMME, M.D Detroit
B. M. HARRIS, M.D Ypsilanti
O. B. McGILLICUDDY, M.D Lansing
W. S. STINSON, M.D Bay City
T. P. WICKLIFFE, M.D Calumet
Office of Publication
2642 University Avenue
Saint Paul 14, Minnesota
Editor
WILFRID HAUGHEY, M.D.
610 Post Bldg., Battle Creek, Michigan
Assistant Editor
L. J. BAILEY, M.D.
620 Vinewood Avenue, Birmingham, Michigan
Secretary and Business Manager of THE JOU RN AL
L. FERNALD FOSTER, M.D.
441 E. Jefferson, Detroit, Michigan
Executive Director
WM. J. BURNS, LL.B.
606 Townsend Street, Lansing 15, Michigan
All communications relative to exchanges, books for review, manu-
scripts, should be addressed to Wilfrid Haughey, M.D., 610 Post
Bldg,, Battle Creek, Michigan.
All communications regarding advertising and subscription should
be addressed to Wm. J. Burns, 2642 University Avenue, Saint
Paul 14, Minnesota, or 606 Townsend Street, Lansing 15, Michigan.
Telephone Ivanhoe 57125.
© 1957, by Michigan State Medical Society.
Published monthly by the Michigan State Medical Society as its
official journal at 2642 University Avenue, Saint Paul 14, Minnesota.
Entered at the post office at Saint Paul, Minnesota, as second
class matter, May 7, 1930, under the Act of March 3, 1879.
Acceptance for mailing at special rate of postage provided for
in Section 1103 Act of October 3, 1917, authorized August 7, 1918.
Yearly subscription rate, $6.00; single copies, 60 cents. Additional
postage; Canada, $1.00 per year; Pan-American Union, $2.50 per
year; Foreign, $2.50 per year.
PRINTED IN U.S.A.
OFFICERS OF THE SOCIETY
1956-1957
President ARCH WALLS. M.D Detroi
President-Elect G. W. SLAGLE M.D Battle Creel
Secretary L. FERNALD FOSTER, M.D Detroi
Treasurer W. A. HYLAND, M.D .Grand Rapid
Speaker K. H. JOHNSON, M.D Lansini
Vice Speaker J. J. LIGHTBODY, M.D Detroi
Editor WILFRID HAUGHEY. M.D Battle Creel
Assistant Editor L. J. BAILEY, M.D Detroi
THE COUNCIL
D. BRUCE WILEY, M.D., Chairman, Utica
W. B. HARM, M.D., Vice Chairman, Detroit
L. FERNALD FOSTER, M.D., Secretary, Bay City
Term
District Expire
A. E. SCHILLER, M.D 1st Detroit 196:
O. B. McGILLICUDDY, M.D 2nd Lansing 1961
H. J. MEIER. M.D 3rd Coldwater 1961
RALPH W. SHOOK, M.D 4th Kalamazoo 196
C. ALLEN PAYNE, M.D 5th Grand Rapids 196
H. H. HISCOCK, M.D 6th Flint 196
H. B. ZEMMER. M.D 7th Lapeer 195'
L. C. HARVIE, M.D 8th Saginaw 195
G. B. SALTONSTALL. M.D 9th Charlevoix 195'
W. S. STINSON, M.D 10th Bay City 195
W. M. LeFEVRE. M.D 11th Muskegon 195:
B. T. MONTGOMERY. M.D 12th Sault Ste. Marie... 195:
T. P. WICKLIFFE, M.D 13th Calumet 195'
B. M. HARRIS, M.D 14th Ypsilanti 195'
D. BRUCE WILEY, M.D 15th Utica 196
G. THOMAS McKEAN. M.D 16th Detroit 196
W. B. HARM, M.D 17th Detroit 195
WILLIAM BROMME, M.D 18th Detroit 195
ARCH WALLS, M.D President Detroi
G. W. SLAGLE, M.D President-Elect Battle Cree
K. H. JOHNSON, M.D Speaker Lansin;
J. J. LIGHTBODY, M.D Vice Speaker Detroi
L. FERNALD FOSTER, M.D Secretary Detroi
W. A. HYLAND, M.D Treasurer Grand Rapid
W. S. JONES, M.D Past President Menomine
EXECUTIVE COMMITTEE OF THE COUNCIl
D. BRUCE WILEY. M.D Chairmai
W. B. HARM. M.D Vice Chairmai
W. M. LeFEVRE. M.D Chairman, County Societies Committe
G. B. SALTONSTALL, M.D Chairman, Publication Committe
RALPH W. SHOOK, M.D Chairman, Finance Committe
K. H. JOHNSON, M.D Speaker, House of Delegate
J. J. LIGHTBODY. M.D Vice Speaker, House of Delegate
ARCH WALLS, M.D Presideu
G. W. SLAGLE, M.D President-Elec
L. FERNALD FOSTER, M.D Secretar
W. A. HYLAND, M.D Treasure
Dermatology and Syphilology
Wm. T. Kruse, M.D Grand Rapids
Chairman
Coleman Mopper, M.D Detroit
Secretary
Gastroenterology and Proctology
N. D. Nigro, M.D Detroit 1
Chairman
E. J. Tallant, M.D Detroit
Secretary
General Practice
F. P. Rhoades, M.D Detroit 2
Chairman
F. C. Brace, M.D Grand Rapids
Secretary
Gynecology and Obstetrics
J. H. Beaton, M.D Grand Rapids
Chairman
R. W. McClure, M.D Detroit 26
Secretary
Medicine
J. M. Kaufman, M.D Detroit 26
Chairman
J. W. Hall, M.D Traverse City
Secretary
Delegates
SECTION OFFICERS
Nervous and Mental Diseases
W. R. Slenger, M.D Ann Arbor
Chairman
S. C. Mason, M.D Ann Arbor
Secretary
Occupational Health
O. J. Johnson, M.D Bav City
Chairman
P. B. Rastello, M.D Detroit 9
Secretary
Ophthalmology and Otolaryngology
B. C. Wildgen. M.D Muskegon
Chairman (Ophth.)
W. K. Locklin, M.D Kalamazoo
Co-Chairman (Oto.)
H. A. Dunlap, M.D Detroit H
Secretary (Ophth.)
H. L. LeVett, M.D Lansing
Co-Secretary (Oto.)
Pediatrics
C. E. Booher, M.D Grand Rapids
Chairman
A. M. Hill, M.D Grand Rapids
Secretary
DELEGATES TO A. M. A.
Public Health and Preventive
Medicine
J. D. Monroe, M.D Pontia
Chairman
J. K. Altland, M.D Lansing
Secretary
Radiology, Pathology, Anesthesiolog
R. B. Sweet, M.D Ann Arbc
Chairman (Anes.)
E. R. Jennings, M.D Detro
Vice-Chairman (Path.)
E. O. Pearson. M.D Kalamazc
Secretary (Rad.)
Surgery
E. T. Thieme, M.D Ann Arbc
Chairman
H. M. Bishop, M.D Sagina
Secretary
Urology
R. P. Lytle, M.D Detroit
Chairman
J. F. Harrold, M.D Lansir
Secretary
Alternates
A. Hyland, M.D.. Grand Rapids, Chairman 1957
S. DeTar, M.D., Milan 1957
I. Owen, M.D.. Detroit 1957
. D. Barrett, M.D., Detroit 1958
. H. Huron. M.D.. Iron Mountain 1958
L. Novy, M.D., Detroit 1958
W. W. Babcock, M.D.. Detroit 19!
E. F. Sladek, M.D:. Traverse City 19!
O. J. Johnson. M.D.. Bav City 19;
William Bromme, M.D.. Detroit 19!
J. R. Rodger, M.D., Bellaire 19!
G. W. Slagle, M.D., Battle Creek 19!
Section Delegate
G. C. Penberthy, M.D. (Surgical Section)
Detroit
1080
JMSM
ki bronchial asthma and respiratory allergies
1
specify the buffered “predni-steroids”
to minimize gastric distress
combined steroid-antacid therapy ,
‘Co-Deltra’ or ‘Co-Hydel- Multiple
tra’ provides all the bene- SSs
fits of “predni-steroid”
therapy and minimizes the
likelihood of gastric distress
which might otherwise im-
pede therapy. They provide
easier breathing — and
smoother control— in bron- 2-5 m®r "Is*
chial asthma or stubborn prednisoionef plus
respiratory allergies. 300 mg. of dried
, aluminum
SUPPLIED: Multiple Compressed hvdroxide
Tablets ‘Co-Deltra’ or ‘Co-Hy- ge, and 50 mg>
deltra’ in bottles of 30, 100, and of magnesium"
500- trisilicate.
‘CO-DELTRA* and 'CO-HYDELTRA* are
, registered trademarks of Merck & Co.. Inc*
Go Deltra
(Prednisone buffered)
CoHydeltra
MERCK SHARP & DOHME
DIVISION OF MERCK & CO.. INC.
PHILADELPHIA I. PA.
September, 1957
Say you saw it in the Journal of the Michigan State Medical Society
1083
You and Your Business
1958 MICHIGAN CLINICAL INSTITUTE
“Yesterday’s Hopeless” is the
theme of next year’s Michigan
Clinical Institute to be held in
Detroit, March 19-20-21, 1958.
“Y e s t e r d a y’s Hopeless”
points to the miracle of mod-
ern medicine: with today’s
medical practitioners and the
use of miracle drugs, yester-
day’s hopeless are now re-
turned quickly to useful, happy
and healthy lives.
C. E. Umphrey, M.D., Detroit, Past President
of the Michigan State Medical Society, will be
General Chairman of the 1958 MCI.
The “block system” of subjects will be con-
tinued in 1958 — the MCI blocks being as follows:
Surgery and Cancer: Wednesday morning, March 19
Trauma: Wednesday afternoon, March 19
Heart and Rheumatic Fever: Thursday morning,
March 20
Steroids: Thursday afternoon, March 20
Obstetrics-Gynecology-Pediatrics: Friday morning,
March 21
Everyday Problems of the Family Doctor: Friday aft-
ernoon, March 21
Closed circuit color television facilities again
will be beamed to the Ballroom of the Sheraton-
Cadillac Hotel, Detroit, during the MCI, through
the co-operation of Smith, Kline and French
Laboratories and the Henry Ford Hospital (1:00
to 2:30 p.m., daily). Only live patients will be
demonstrated on the television program.
Every afternoon, at the close of the scientific
assembly, Discussion Conferences with all speakers
on the platform will be featured.
In a word, the 1958 Michigan Clinical Institute
will stress clinical medicine of daily value to the
medical practitioner.
MEDICARE CONTRACT EXTENDED
The Dependents of Servicemen Medical Act
went into effect December 7, 1956. Michigan
State Medical Society, and Michigan Medical
Service as its fiscal administrator, signed a con-
tract with the Department of Defense dated No-
vember 16, 1956. The contract originally was to
run from December 7, 1956, to June 30, 1957.
It was to be reviewed and revised before that date.
Subsequently, due to multiplicity of agreements
with various state medical societies — Blue Shield
Plans — and because of lack of experience, etc., the
Defense Department set up a schedule of dates for
renegotiating contracts. The Michigan contract is
1084
scheduled to be renegotiated prior to March 31,
1958. The present contract, therefore, was extend-
ed under its present form to March 31, 1958, with
the approval of the MSMS Executive Committee
of The Council June 30, 1957. No better arrange-
ment was possible.
This extension does not preclude the reconsider-
ation of the “Schedule of Allowances” if inequit-
able. The allowances may be increased or de-
creased as mutually agreed by the Department
of Defense and the Michigan State Medical
Society.
Emergency Care Authorized under the Depend-
ents of Servicemen Medical Act. — Acute emerg-
ency care of any nature at a hospital is covered.
Such emergency care for an illness or condition
not otherwise covered is only authorized pending
arrangements for care elsewhere. However, this
does not eliminate the requirement for admission
as an inpatient to a medical facility for 18 consecu-
tive hours or more except for shorter periods of
hospitalization for surgical procedures, treatment
of fractures or other bodily injuries or in instances
in which death occurs in a lesser period of time.
Consequently, emergency treatment is not in itself
sufficient grounds for inclusion within the Depend-
ents’ Medical Care Program.
Essentially, the Dependents’ Medical Care Pro-
gram is an inpatient program providing for out-
patient care only in the following areas:
1. Obstetrical and maternity services.
2. Bodily injuries, limited to the treatment of
fractures, dislocations, lacerations and other
wounds.
3. Diagnostic tests and procedures prior to
and/or following hospitalization for the same
bodily injury or surgical procedure for which
hospitalized.
4. Radio therapy prescribed during a period
of hospitalization and continued or carried
out on an outpatient status.
Irrespective of the existence of an emergency
the above constitutes the only areas in which out-
patient care can be authorized under the Medi-
care Program.
The foregoing emergency care, to be payable
by the Government under the Medicare Program,
must be either:
1. Outpatient care as stated above which is
normally provided for under the Program;
or
2. Care furnished to a patient who is admitted
to a hospital as an inpatient irrespective of
whether the hospital meets the definition of
a “hospital” as defined in the joint directive.
(Continued, on Page 1086)
C. E. Umphrey, M.D.
TMSMS
Overeating is a bad habit—
you can help your patients
to break it
TEMBER, 1957
Say you saw it in the Journal of the Michigan State Medical Society
1085
YOU AND YOUR BUSINESS
MEDICARE CONTRACT EXTENDED
(Continued from Page 1084)
This eliminates from coverage emergency care,
not related to an obstetrical or injury case, that
is performed in a doctor’s office or clinic.
Government Liability in Obstetrical and Mater-
nity Service under Medicare — The scope of ob-
stetrical and maternity services for which Medi-
care is liable is indicated in the definition of
Maternity and Infant Care in the joint directive,
which is: the provision of care “incident to preg-
nancy.” Hence, outpatient “antepartum” care of
pseudocyesis, or the outpatient administration of
examinations and diagnostic procedure which lead
to diagnosis that the patient is not pregnant, are
not proper charges against the Government under
Medicare legislation.
MEDICARE: $65 is doctor’s average bill.
Medicare in seven months of operation, has
billed total benefits of $566,295 in Michigan, ac-
cording to a recent report by Blue Cross-Blue
Shield, fiscal agents of the Program for the hos-
pitals and the medical profession of this State.
Instituted by Congressional action to provide
civilian hospital and medical-surgical care for
dependents of servicemen on active duty, Medi-
care has helped pay the bill for more than 1,800
babies born in Michigan hospitals since the inaug-
uration of the program (representing 55 per cent
of the 3,300 hospital admissions handled under
the Defense Department Program).
Runners-up to the babies were tonsil and ade-
noid cases with 10 per cent of admissions.
Of the total of $566,295, about $366,000 was
billed in hospital benefits and $200,295 for doc-
tors’ services making the average costs per hospital
case about $110.00 per case and the average
physician’s bill about $65.00 per case.
HIGHLIGHTS OF THE COUNCIL
Session of July 11-12, 1957
• Decisions of great import to the Michigan
State Medical Society and its future were made
by The Council at its mid-summer session of
1957. Chief among the 117 matters favorably
considered by the The Council were:
1. A recommendation of the Finance Com-
mittee that dues for the ensuing year (1958
only) be increased $50.00 for immediate
erection of a new MSMS home.
2. An agreement with the Michigan Mackinac
Island State Park Commission, whereby
the effects in the Beaumont Memorial on
Mackinac Island are to be the personal
property of the Michigan State Medical
Society, to facilitate annual variety in
exhibitions and room displays.
3. Approval of “Statement of Principles Gov-
erning Physicians and Lawyers” — a joint
endeavor between the Michigan State Me*
ical Society and the State Bar of Michiga !
(to be published in toto in JMSMS).
Other items of importance, decided by T!
Council, were:
• Semi-annual financial reports covering the var
ous departments of MSMS including Th
Journal.
• Progress report on the MSMS Market Opinic
Survey: The distribution of the questionnaire
to the public and to the medical profession h:
been completed. A return of 15 per cent fro:
the public and 35 per cent from the M.l
questionnaires is anticipated, showing high ii 1
terest in this survey among both the medio
profession of Michigan and the public gei
erally.
• Medicare contract was extended on the san !
terms except that individual items in the Fi j
Schedule may be negotiated at MSMS reques
• Veterans Administration Home Town Medic
Care Program: report that the contract h £
been extended with important revisions in tl
form and nature of same. Authority was givf
a special committee on an interim basis
negotiate with VA re revisions in individu
fees.
• Group Life Insurance for MSMS Member
Procuring information on this type of insuran
for presentation to the 1957 House of Del
gates was authorized.
• Appointments: V. George Chabut, M.D., Nort'
ville, was appointed as MSMS representative
the AMA 6th National Conference of Physicia
and Schools, Highland Park, 111., October 3
The Chairman of the Rural Medical Servi
Committee and the Public Relations Couns
were authorized to attend the AMA Rut
Health Seminar, Purdue University, Octob
4-5. Louis Jaffe, M.D., Detroit, was appoint*
to represent MSMS on the Michigan Comm:
tee on Nursing in National Defense.
• Certain Recommendations of Chairman Ar*
Walls, M.D., of the Healing Arts Study Coi
mittee were accepted as an interim report.
• President-elect G. W. Slagle, M.D., present*
his MSMS Committee appointments for tl
year 1957-1958.
• L. J. Bailey, M.D., Detroit, was elected as A
sistant Editor of The Journal.
• Governor’s Study Commission on Prepaid Ht
pital Care Plans: MSMS pledged co-operati<
with the Commission and the University
Michigan (the latter to make this study), su
ject to provisions as outlined in the submitt
proposed prospectus “Study Objectives ai
Scope” of July 4, 1957.
(Continued on Page 1090)
JMS»
1086
UNSURPASSED EFFICACY
in disorders of menstruation and pregnancy
NORLUTIN: Progestational Effect on Endome-
trium ‘. . . 10 mg. [norlutin] given twice
daily represents a reproducibly effective
dose in women for the production of marked
progestational changes in the endometrium.”3
Presecretory to secretory endometrium after 5 days
treatment.
NORLUTIN : Thermogenic Effect “This prepara-
tion was found to have a marked ther-
mogenic, and other physiologic effects in
comparatively small dosage.”4
NORLUTIN: Abolition of Arborization in Cervical
Mucus NORLUTIN . . inhibits the fern leaf
pattern in cervical mucus.”5
1. Fern leaf pattern. 2. Arborization completely
abolished by NORLUTIN.
Induction of Withdrawal Bleeding
“As little as 50 mg. of [NORLUTIN] admin-
istered in divided doses over a five-day
period was sufficient to induce withdrawal
bleeding.”2
o
PARKE, DAVIS & COMPANY - DETROIT 32, MICHIGAN
YOU AND YOUR BUSINESS
HIGHLIGHTS OF THE COUNCIL
(Continued from Page 1086)
• Michigan State Board of Registration in Medi-
cine: The names of twenty-five nominees for
the five vacancies, as of September 30, 1957,
were selected for submission to the Governor
pursuant to the Medical Practice Act.
• A vote of thanks was extended to Chairman
Grover C. Penberthy, M.D., Detroit, and his
Medical Advisory Committee to the Selective
Service System, for outstanding work in con-
nection with this military activity throughout
the years. The Council recommended that
the present committees be retained on a stand-
by basis on both State ?.nd County levels.
• William A. Hyland, M.D., Grand Rapids, was
reported as having been appointed Chairman
of the important AMA Committee to Study
the Heller Report.
• The Annual Report of The Council was pre-
sented, studied in detail, and approved for
reference to the House of Delegates on Sep-
tember 23.
• Councilor Conferences were authorized to be
called by each Councilor for the purpose of ac-
quainting delegates, alternate delegates, presi-
dents and secretaries of component societies
with necessary information that may be pre-
sented to the 1957 House of Delegates.
• Committee Reports: The following Committee
Reports were presented : County Societies,
Finance, and Publication Committees of The
Council, meetings of July 12; Ethics Committee
meeting of June 13; Committee on Study of
Uniform Fee Schedule for Governmental Agen-
cies, June 23; Geriatrics Committee, June 25;
Joint Committee with the State Bar of Michi-
gan, June 26.
• Annual joint meetings of the MSMS Council
with (a) Michigan Hospital Association Board
representatives which presented its Resolution
endorsing the MSMS Market Opinion Survey;
(b) Michigan Crippled Children Commission
representatives; (c) Michigan Health Council.
Matters of mutual interest were discussed at
these three meetings.
• Nominations for Michigan’s Foremost Family
Physician: The Council nominated to the 1957
House of Delegates the names of Daniel J.
O’Brien, M.D., of Lapeer; John W. Rigterink,
M.D., of Grand Rapids; and Paul Van Riper,
M.D., of Champion.
• The “Big Look” Committee requested authori-
zation to (a) secure a site for the new MSMS
building; (b) select and employ an architect;
(c) have preliminary plans prepared for dis-
play to the House of Delegates and member-
ship at the 1957 MSMS Annual Session in
Grand Rapids. This was granted.
II• **1
• Michigan Health Commissioner A. E. Heustis,
M.D., presented progress report on poliomyeli-
tis; designation of medical research studies;
standards for atomic radiation protection; rules
and regulations for nursing homes ; occupational
disease activity ; and preliminary report on mul-
tiple screening.
• The Publication Committee allocated Journal
Numbers to specific subjects for the year 1958;
also recommended as a new feature in The
Journal a colored insert with last minute medi-
cal socio-economic information.
• The County Societies Committee recommended
that The Council Chairman be authorized to
appoint a committee to review the problem of
medical professional liability, said committee
to submit recommendations re methods of action
applicable to Michigan.
AFL-CIO AND MEDICINE
The AFL-CIO Committee on Social Security
has taken a firm stand against the actions of medi-
cal societies who fail to go along with union labor
medical programs, according to the “Summer
News Letter” issued by the Association of Labor
Health Administrators. This association is a group
of medical directors, labor administrators and
other representatives of labor health plans.
5P!
The publication calls for action in opposing the
“attack and harrassment of component medical
societies against union plans, particularly in the
states of Pennsylvania, Illinois and Colorado.” It
states that at a meeting in Washington on May 15
at the “merged headquarters,” the AFL-CIO Ex-
ecutive Committee approved funds to encourage
and promote the work of the ALHA in providing
“technical aid to the trade union groups in devel-
opment of better health service programs for the
benefit of workers and their families.” The letter
also stated the association “will stand ready to
bring experienced technical and legal counsel on
request to the defense of the victims of any efforts
on the part of medical power groups to destroy the
programs which endeavor to improve the quality
and scope of prepaid health services available to
working individuals and their families.” The work
will be carried out in co-operation with AFL-CIO
through the department of Social Service. — AMA
Secretary’s Letter.
1090
.TMSMS
in Hay Fever or Asthma * , «
Family Physicians use •
desensifizafion
for perennial
results
easily, pleasantly and economically
PECIFIC DESENSITIZATION
PERENNIAL RESULTS
easily accomplished quickly and accurately
r any physician. First, skin test each patient
’ the simple scratch test method and determine
what allergens the patient reacts. Barry has
small Pollen Pak for Hay Fever and seasonal
thma cases. Cost $1.50 for 21 tests of tree,
ass and weed pollens, fungi, house dust —
dividual selection to meet your botanical re-
lirements. Simple, safe, time proven technique
complete directions for your nurse. Ready to
e report forms included. Send for yours today.
FREE SCRATCH TEST SET
with each Rx Specific Desensitization Set
prepared according to your
patient’s own skin test reactions.
are obtained by desensitization against those specific
irritants to which your patients reacted by the scratch
test. Record your reactions on the convenient report
card enclosed in each test set. Each desensitization
formula is individually prepared for each patient ac-
cording to his own needs and thereby renders the best
specific results of any medication possible. Each treat?
ment 3-vial set (20 doses) is ready mixed and diluted
with individually planned treatment schedule. If you
already have skin tested your patient, send your reac-
tions to the Allergy Division, Barry Laboratories, Inc.
Complete service $12.50. Prompt 7-10 day service for Rx’s.
BARRY LABORATORIES, INC
Allergy Division
DETROIT 14, MICHIGAN
since | 1928
Heart Beats
PREVENTION OF RHEUMATIC FEVER AND BACTERIAL ENDOCARDITIS
THROUGH CONTROL OF STREPTOCOCCAL INFECTIONS
Rheumatic fever is a recurrent disease which, in
most instances, can be prevented. Since both the
initial and recurrent attacks of the disease are pre-
cipitated by infections with Group A streptococci,
prevention of rheumatic fever and rheumatic
heart disease depends upon the control of Strepto-
coccal infections. This may be accomplished by
(1) early and adequate treatment of streptococcal
infections in all individuals and (2) prevention of
streptococcal infections in rheumatic subjects.
Treatment of Streptococcal Infections
In the General Population
Following epidemics and in certain population
groups, it has been found that about 3 per cent of
untreated streptococcal infections are followed by
rheumatic fever. Adequate and early penicillin
treatment, however, will eliminate streptococci
from the throat and prevent most attacks of rheu-
matic fever.
Diagnosis — In some instances, streptococcal in-
fections can be recognized by their clinical mani-
festations. In many patients, however, it is impos-
sible to determine the streptococcal nature of a
respiratory infection without obtaining throat cul-
tures. The following section on diagnosis has been
included in order to assist physicians in making
a positive diagnosis and assuring adequate treat-
ment.
The accurate recognition of individual strepto-
coccal infections, their adequate treatment and the
control of epidemics in the community presently
offer the best means of preventing initial attacks
of rheumatic fever.
Common Symptoms
Sore throat — sudden onset, pain on swallowing.
Headache — common
Fever — variable, but generally from 101° to 104° F.
Abdominal pain — common, especially in children; less
common in adults.
Nausea and vomiting — common, especially in children.
This statement was prepared by the Committee on
Prevention of Rheumatic Fever and Bacterial Endo-
carditis appointed by the Council on Rheumatic Fever
and Congenital Heart Disease of the American Heart
Association. The committee is cognizant of the fact that
no recommendations of any group can be final at this
time. The present approach may not be the eventual
solution of the problem of preventing rheumatic fever.
Revisions and changes will be made as new knowledge
may indicate.
Common Signs
Red throat.
Exudate — -usually present.
Glands — swollen, tender lymph nodes at angle of jaw.
Rash — scarlatiniform.
Acute otitis media
(frequently due to the streptococcus
Acutei sinusitis
In the absence of the common symptoms and
signs, occurrence of any of the following symptoms
is usually not associated with a streptococcal infec-
tion: simple coryza; hoarseness; cough.
Laboratory Findings. — Throat culture — hemoly-
tic streptococci are almost invariably recovered on
culture during acute streptococcal infections.
White blood count — generally over 12,000.
Treatment. — When streptococcal infection is
suspected, treatment should be started immediate-
ly. Penicillin is the drug of choice. Effective blood
levels should be maintained for a period of ten
days to prevent rheumatic fever by eradicating the
streptococci from the throat.
Penicillin may be administered by either in-
tramuscular or oral route. Intramuscular admini-
stration is recommended as the method of choice
since it ensures adequate blood levels for a suffi-
cient length of time. Oral therapy by contrast is
dependent upon the co-operation of the patient.
In the treatment of streptococcal infections in
known rheumatic subjects, parenteral penicillin
should be employed in at least the maximum doses
recommended in the accompanying schedules.
Recommended Treatment Schedules
Intramuscular Penicillin
Benzathine Penicillin G
Children — one intramuscular injection of 600.000 to
900.000 units.
Adults — one intramuscular injection of 900,000 to
1.200.000 units,
or
Procaine Penicillin with Aluminum
Monosterate in Oil
Children — one intramuscular injection of 300,000
units every third day for three doses.
Adults — one intramuscular injection 600,000 units
every third day for three doses.
Oral Antibiotics
To prevent rheumatic fever by eradicating strepto-
cocci, therapy must be continued for the entire ten days
(Continued on Page 1098)
1092
JMSMS
SMALL CALIBER
INTUBATION
TUBE
REPLACEMENT
OF UPPER
TRO-INTESTINAL
FLUIDS
New concept in
patient feeding
ALIMENTARY
INGESTION
OF NATURAL
.FOODS
THE BARRON
FOOD PUMP
T he restoration and maintenance of proper
nutrition, fluid, and electrolyte balance is
an ever present problem in the care of many
medical and surgical patients. Increasing
evidence stresses more and more the com-
plexity of the nutritional needs of the human
body. From the known nutrients of a gener-
ation ago the number of factors known to be
necessary for healthy cellular metabolism
has greatly increased, and undoubtedly,
even more will be discovered in the future.
The BARRON FOOD PUMP permits an ad-
justable controlled administration of liqui-
fied natural foods through a small (2.5mm)
caliber plastic intubation tube at a regulated
constant rate of delivery while the patient
is allowed to sit up, lie down, or turn on
either side as desired.
The BARRON FOOD PUMP also provides
a means by which gastric juice, bile, pan-
creatic, and other upper gastro-intestinal
fluids containing essential electrolytes, en-
zymes, etc. can be returned to the body by
adding them to the food bottle.
The mechanically proven construction of the
BARRON FOOD PUMP with its silent opera-
tion requiring a minimum of nursing atten-
tion makes it not only a necessity in most
tube feeding cases, but provides a wider
range of application of this preferred
method of patient feeding.
^urgfcai
supply co.
60 WEST COLUMBIA STREET - DETROIT 1, MICHIGAN
Ieptember, 1957
Say you saw it in the Journal of the Michigan State Medical Society
HEART BEATS
PREVENTION OF RHEUMATIC FEVER
AND BACTERIAL ENDOCARDITIS
(Continued from Page 1092)
even though the temperature returns to normal and the
patient is asymptomatic.
Penicillin
Children and adults — 200,000 to 250.000 units three
times a day for a full ten days.
Other Antibiotics. — Broad spectrum antibiotics
such as erythromycin and the tetracyclines are use-
ful in patients who are sensitive to penicillin. If
given for ten days, these antibiotics are probably
as effective as oral penicillin in the treatment of
streptococcal infections but are subject to the same
uncertainties of administration by the oral route.
The following therapy is not effective in pre-
venting rheumatic fever when used as treatment
for streptococcal infections: sulfonamide drugs;
penicillin troches or lozenges.
Prevention of Streptococcal Infections
In Rheumatic Individuals
Many streptococcal infections occur without
producing clinical manifestations. For this reason,
prevention of recurrent rheumatic fever must
depend on continuous prophylaxis rather than
solely on treatment of acute attacks of strepto-
coccal disease.
Recommendations for Prophylaxis
Who should be treated? — In general, all pa-
tients who have a well-documented history of
rheumatic fever or chorea or who show definite
evidence of rheumatic heart disease should be
given continuous prophylaxis. Although recurrent
attacks of rheumatic fever occur at any age, the
risk of recurrences decreases with the passage of
years. Some physicians may wish to make excep-
tions to instituting prophylaxis in certain of their
adult patients, particularly those without heart dis-
ease who have had no rheumatic attacks for many
years.
How long should prophylaxis be continued?- —
The risk of acquiring a streptococcal infection and
the possibility of rheumatic fever recurrences con-
tinue throughout life. It is, therefore, suggested
that the safest general procedure is to continue
prophylaxis indefinitely.
When should prophylactic treatment be initi-
iated? — For active rheumatic fever , treatment
should start as soon as the diagnosis of rheumatic
fever is made or any time thereafter when the pa-
tient is first seen. The streptococcus should be
eradicated with penicillin (See Treatment Sche-
dules), following which the prophylactic regimen
is instituted.
For inactive rheumatic fever, prophylaxis should
be instituted when the patient is first seen.
Should prophylaxis be continued during the
summer? — Yes, continuously. Streptococcal infec-
1098
tions can occur at any season although they are
more prevalent in the winter.
Prophylactic Methods — Oral and Intramuscular
Oral medication depends on patient co-opera-
tion. In most instances, failures of sulfonamide or
penicillin prophylaxis occur in patients who fail to
ingest the drug regularly. This can be avoided by
long-acting depot penicillin given intramuscularly
once a month.
Dosage — 1,200,000 units Benzathine Penicillin
G — intramuscularly, once a month.
Toxic reactions are the same types as with oral
penicillin (see below), but occur more frequently
and tend to be more severe. Some local discom-
fort usually is experienced.
Sulfadiazine Oral
Sulfadiazine oral has the advantage of being
easy to administer, inexpensive and effective.
(Other newer sulfonamides are probably as effec-
tive.) Although resistant streptococci have ap-
peared during mass prophylaxis in the armed
forces, this is rare in civilian populations.
Dosage — From 0.5 to 1.0 gm. once a day. The
smaller dose is to be used in children under sixty
pounds.
Toxic reactions are infrequent and usually
minor. In any patient being given sulfonamides,
consider all rashes and sore throats as possible
toxic reactions, especially if they occur in the first
eight weeks. In patients on this prophylactic re-
gimen it is hazardous to treat toxic reactions or
intercurrent infections with sulfonamides. The
chief toxic reactions are:
Skin Eruptions. — For morbilliform, continue
drug with caution. For urticaria or scarlatiniform
rash associated with sore throat or fever, discon-
tinue drug.
Leukopenia. — Discontinue if white blood count
falls below 4,000 and polynuclear neutrophiles be-
low 35 per cent because of possible agranulocy-
tosis, which is often associated with sore throat
and a rash. Because of these reactions, weekly
white blood counts are advisable for the first two
months of prophylaxis. The occurrence of ag-
ranulocytosis after eight weeks of continuous pro-
phylaxis with sulfonamides is extremely rare.
Penicillin — Oral
Penicillin has the desirable characteristics of be-
ing bactericidal for Group A streptoccoci and of
rarely producing serious toxic reactions. A careful
history of allergic reactions and previous response
to penicillin should be obtained.
Dosage — 200,000 to 250,000 units once or twice
a day. The latter is probably more effective.
Toxic reactions are urticaria and angioneurotic
edema. Reactions similar to scrum sickness in-
(Continued on Page 1100)
IMSMS
appetites
with.
INCREMI
LYSINE-VITAMIN SUPPLEMENT LED E RLE
Finicky eaters are headed for a fast nutritional
build-up with Incremin — tasty appetite stimulant.
Incremin offers 1-Lysine for improved protein utili-
zation, and essential vitamins for their stimulating
effect on appetite.
Tasty Incremin is available in either Drops or Tab-
lets. Caramel-flavoredTablets may be orally dissolved,
chewed or swallowed. Cherry-flavored Drops may be
mixed with milk, formula or other liquid. Tablets:
bottles of 30. Drops: plastic dropper-type bottle of
15 cc.
Each Incremin Tablet
or each cc. of Incremin Drops contains:
1-Lysine 300 mg. Pyridoxine (B„) 5 mg.
Vitamin Bi» 25 mcgm. (Incremin Drops con-
Thiamine(Bi) lOmg. tain 1% alcohol)
Dosage: only 1 Incremin Tablet or 10-20 Incremin Drops
daily.
*Reg. U.S. Pat. Off.
LEDERLE LABORATORIES DIVISION
AMERICAN CYANAMID COMPANY
PEARL RIVER, NEW YORK
September, 1957
Say you saw it in the Journal of the Michigan State Medical Society
1099
HEART BEATS
PREVENTION OF RHEUMATIC FEVER
AND BACTERIAL ENDOCARDITIS
(Continued from Page 1098)
elude fever and joint pains and may be mistaken
for rheumatic fever.
Although many individuals who have had re-
action to penicillin may subsequently be able to
tolerate the drug, it is safer not to use penicillin
if the reaction has been severe and particularly if
angioneurotic edema has occurred.
Protection of Rheumatic Fever
Patients in Hospital Wards
Patients with rheumatic fever or rheumatic
heart disease are often exposed to increased haz-
zards in hospital wards as the result of contact
with streptococcal carriers or patients with active
streptococcal infections. Protection of the
rheumatic patient is imperative because of the
high rate of recurrence of rheumatic fever follow-
ing streptococcal infection. In addition to the cus-
tomary precautions employed to prevent cross in-
fections, the following procedures are recom-
mended :
All hospital patients with streptococcal infec-
tions should be fully treated by one of the methods
outlined in “Recommended Treatment Sche-
dules,” in order to eliminate streptococci and
avoid the carrier state.
Patients admitted with acute rheumatic fever
should immediately receive a full course of anti-
biotic therapy, whether or not streptococci are is-
olated from the throat. (See “Recommended
Treatment Schedules,”) As soon as the therapeu-
tic course is completed, continuous streptococcal
prophylaxis should be instituted (See “Prophylac-
tic Methods, Oral and Intramuscular”)
Patients with inactive rheumatic fever or rheu-
matic heart disease should be placed on continu-
ous streptococcal prophylaxis on admission to the
hospital, or as soon thereafter as the diagnosis is
established. (See “Prophylactic Methods — Oral
and Intramuscular”)
Prophylaxis Against Bacterial Endocarditis
In individuals who have rheumatic or congeni-
tal heart disease, bacteria may lodge on the heart
valves or other parts of the endocardium, produc-
ing bacterial endocarditis. Transient bacteremia
which may lead to bacterial endocarditis is known
to occur following various surgical procedures, in-
cluding dental extractions and other dental mani-
pulations which disturb the gums, the removal of
tonsils and adenoids, the delivery of pregnant wo-
men, and operations on the gastrointestional or
urinary tracts. It is good medical and dental
practice to protect patients with rheumatic or con-
genital heart disease by prophylactic measures.
Recommended Prophylactic Methods
Penicillin is the drug of choice for administra-
tion to patients with rheumatic or congenital heart
disease undergoing dental manipulations or surgi-
cal procedures in the oral cavity.
Although the exact dosage and duration of
therapy are somewhat empirical, there is some evi-
dence that for effective prophylaxis reasonably
high concentrations of penicillin must be present
at the time of the dental procedure. The dosage
regimens employed for long-term prophylaxis of
rheumatic fever are inadequate for this purpose.
High levels of penicillin in the blood over a period
of several days are recommended to prevent or-
ganisms from lodging in the heart valves during
the period of transient bacteremia.
Not only should penicillin prophylaxis be de-
signed to afford maximum protection, but the
method must also be practical. In general, the
combined oral and parenteral route of administra-
tion is preferred. All patients should be instructed
to report to their physician or clinic should they
develop fever within a month following the opera-
tion.
First Choice — Intramuscular and Oral Penicil-
lin Combined. — For two days prior to surgery —
200,000 to 250,000 units by mouth four times a
day. On day of surgery — 200,000 to 250,000 units
by mouth four times a day, and 600,000 units
aqueous penicillin, with 600,000 units procaine
penicillin shortly before surgery. For two days
thereafter — 200,000 to 250,000 units by mouth
four times a day.
Second Choice (if infection is not feasible) Oral
Penicillin. — 200,000 to 250,000 units four times a
day, beginning two days prior to the surgical pro-
cedure and continued through the day of surgery
or dental procedure and two days thereafter.
Contraindications. — A history of sensitivity to
to penicillin.
Other Antibiotics. — Erythromycin or the broad
spectrum antibiotics should be employed as pro-
phylaxis in patients who are sensitive to penicillin.
In those who are undergoing surgery of the urin-
ary or lower gastrointestional tract, oxytetracycline
should be administered in full dosage for five days,
beginning treatment two days prior to the surgical
procedure.
Committee on Prevention of Rheumatic
Fever and Bacterial Endocarditis
Charles H. Rammelkamp, Jr., M.D.,
Chairman
Burtis B. Breese, M.D.
Harold I. Griffeath, M.D.
Harold B. Houser, M.D.
Melvin H. Kaplan, M.D.
Ann G. Kuttner, M.D.
Gene H. Stollerman, M.D.
Maclyn McCarthy, M.D.
Lewis W. Wannamaker, M.D.
1100
JMSMS
FOR THE ENTIRE RANGE OF RHEUMATIC-ARTHRITIC
DISORDERS — from the mildest
to the most severe
many patients with MILD involvement can be effectively
controlled with
HONE
many patients with MODERATELY SEVERE involvement
can be effectively controlled with
MEPROIONE
The only meprobamate-prednisolone therapy
the one antirheumatic, antiarthritic that
simultaneously relieves: (i) musclespasm
(2) joint inflammation (3) anxiety and
tension (4) discomfort and disability.
SUPPLIED: Multiple Compressed Tablets
in three formulas: ‘MEPROLONE’-5 —
5.0 mg. prednisolone, 400 mg. meproba-
mate and 200 mg. dried aluminum hy-
droxide gel. ‘MEPROLONE’-2 — 2.0 mg.
prednisolone, 200 mg. meprobamate and
200 mg. dried aluminum hydroxide
gel. ‘MEPROLONE’-i supplies 1.0 mg.
prednisolone in the same formula as
*MEPR0L0NE’-2.
MERCK SHARP & DOHME
DIVISION OF MERCK & CO.. INC.
PHILADELPHIA 1. PA.
*&S£PtlOLON£’ is a trademark of Merck & Co., lac.
September, 1957
Say you saw it in the Journal of the Michigan State Medical Society
1101
PR REPORT
QUESTIONNAIRES FLOOD
MSMS HEADQUARTERS
Enthusiastic support assures survey vitality.
Results of the Medical Insurance Opinion Study
in Michigan will be based upon the views of
more than 12,000 persons.
the formidable task of analyzing the mountain of statis-
tical information will begin.”
Results of the survey will not be known until
presentation of the full study report is made to
the MSMS House of Delegates and the public
generally on September 23.
In Lansing, J. K. Altland, M.D., President of the Michigan Health Council
(left) and Kenneth H. Johnson, M.D., Speaker of the MSMS House of Delegates,
look over the questionnaires returned by the public and doctors of medicine during
the multi-phase MSMS Medical Insurance Opinion Study in Michigan. More than
12,000 ballots were returned, processed, and tabulated. Analysis of the study
results will be presented to the House of Delegates and the public in Grand
Rapids on September 23. The Michigan Health Council co-operated with MSMS
in conducting the Survey of Consumer Opinion on Medical Insurance Protection —
a part of the over-all study.
The multi-phase study is sponsored by the Mich-
igan State Medical Society and the Michigan
Health Council. Included are separate surveys of
Medical Insurance Coverage and Related Costs;
Consumer Opinion on Medical Insurance Protec-
tion; a survey of Doctor Opinion on Michigan
Medical Service; and a study of Related Surveys
on Protection Against Medical Service Needs.
The 12.000 ballots submitted represent an
unusually high return for a study of this nature
and scope.
Commenting on the favorable public interest,
D. Bruce Wiley, M.D.. MSMS Survey Committee
Chairman, said:
“The excellent public and doctor response was due
principally to strong personal interest in the subject
matter. However, due credit must be accorded the
communications media of the state for their role in
publicizing the importance of the surveys.
“Transfer of information from questionnaire to IBM
punch cards will be completed by mid-August. Then
1102
National attention will be focused on Grand
Rapids during the formal presentation of the
Study Report to the assembled delegates by L.
Eernald Foster, M.D., MSMS Secretary.
Representatives of numerous state and national
medical organizations are expected to attend the
Grand Rapids meeting in order to obtain first-
hand information and details of the study.
A chronic cough is the most significant symptom in
the diagnosis of lung cancer.
* * *
Hematuria is a cancer warning.
* * *
Solution of the problem of gastric cancer lies in the
earlier recognition of those vague, confusing symptoms —
the same symptoms described by Avenzoar 800 years
ago.
* * *
Of all the sites of malignancy in the large bowel,
cancer of the rectum is the easiest to diagnose.
JMSMS
announcing...
a new practical
and effective method
for lowering blood
cholesterol levels...
Arcofac
Just one dose a day effectively
lowers elevated blood cholesterol
. . . while allowing the patient
to eat a balanced . . . nutritious .
and palatable diet
Each tablespoonful of emulsion contains:
Linoleic acid 6.8 Gm.
Vitamin B6 0.6 mg.
Mixed tocopherols (Vitamin E) 11.5 mg.
(sodium benzoate as preservative)
Arcofac is effective in small doses
and is reasonable in cost
to the patient
THE ARMOUR
LABORATORIES
A DIVISION OF ARMOUR AND COMPANY
KANKAKEE, ILLINOIS
Armour. ..Cholesterol Lowering . . . Factor
September, 1957
Say you saw it in the Journal of the Michigan State Medical Society
1105
AMA Washington Letter
THE MONTH IN WASHINGTON
If dangerous epidemics of Asian flu break out
in the country this fall and winter, the medical
profession will have its hands full. But the doctors
won’t be taken by surprise, nor will they lack
specific information on proper treatment.
While the attacks in the U.S. were still sporadic
and the death rate low — three fatalities in the
first 11,000 reported cases — a number of major,
nationwide efforts were under way to combat the
disease in the months when influenza rates gene-
rally are the highest.
1. Acting in co-ordination with U.S. Public
Health service, the American Medical Association
was pressing forward with its campaign to insure
that all physicians are informed of how to deal
with the disease.
2. In line with recommendations of the AMA
committee, a number of state medical societies by
mid-August had laid out complete emergency
plans, ready to be put in operation if needed.
3. U.S. Public Health Service epidemic intelli-
gence experts were scanning the country for out-
breaks that might be Asian influenza, and other
PHS officers were investigating acute respiratory
diseases. PHS also set up machinery to keep the
medical and health professions informed on na-
tionwide developments in the influenza picture.
4. Advising Surgeon General Burney was a
special committee, which included representatives
from AMA, American Academy of Pediatrics,
American Academy of General Practitioners and
the Association of State and Territorial Health
Officers.
5. Manufacturers of the vaccine, by running
their plants on two or three shifts and seven days
a week, were hoping to have produced 60.000,-
000 cc. by February 1.
There was, of course, the possibility that with
Congress in session through most of the summer
a vast federal program would be set up. with the
U.S. purchasing and allocating the vaccine. It
was heartening to the medical profession that this
possibility was pretty well eliminated in the early
stages when the Department of Health, Education,
and Welfare announced the following as {.official
policy :
“The Public Health Service, in co-operation with the
medical profession, will stimulate and promote a nation-
wide voluntary program of vaccination against the pre-
valent strain of influenza. It will not, however, request
federal funds for the purchase or administration of vac-
cine— except for its own legal beneficiaries. The State
and Territorial health officers- and the American Medical
1106
Association have jointly assured the Surgeon Gener;
that community resources, both public and private, wi
be mobilized to provide vaccinations for persons who ar
unable to pay for such protection.”
This policy was reaffirmed later by the Whit
House, when the President asked for a half a mil
lion dollars to finance the additional work fo
Public Health Service. The White House state
ment said flatly that it did not plan to have thi
federal government buy vaccine.
The AMA’s Board of Trustees selected as mem
bers of the special committee the same physician:
who make up the Civil Defense Committee, wit!
Dr. Harold C. Lueth as chairman. In addition tc
the work of this committee, special articles are
being published in the AMA Journal, mass cir-
culation media are being used to bring informa-
tion on Asian influenza to the lay public and the
AMA Council on Drugs is investigating and re-
porting to physicians on the use of antibiotics in
treatment of the disease.
NOTES: To wind up a long investigation of
the safety of chemical additives to foods, a House
committee called in a panel of scientists for two
days of discussion. In general they concluded : Be
careful about any mandatory federal controls.
Another hearing on weight-reducing prepara-
tions sold over-the-counter in drug stores heard a
parade of witnesses, all of whom had about the
same opinion : In themselves, the pills all are vir-
tually useless in inducing loss of weight, but their
other effects range from harmless to definitely
dangerous.
-x * #
Veterans Administration is increasing fees to
physicians under the hometown care program,
with the new schedules varying by states and
areas. During this fiscal year VA will pay out $8
million under this program.
* * *
A former AMA president, Dr. Elmer Hess, now
heads two government advisory committees, the
Health Resources Advisory Committee to Office of
Defense Mobilization and the Medical Advisory
Committee to Selective Service, membership of
which is the same. He succeeds Dr. Howard
Rusk.
Secretary Folsom is considering appointing a
committee of outsiders to investigate and evaluate
progress on medical research by the federal gov-
ernment.
JMSMS
For persons who overestimate their physical capacity
—as with this do-it-yourself dad— chronic fibrositis may
be a postscript to a weekend of accomplishment.
Sigmagen therapy is encouraged in the treatment of
chronic fibrositis to alleviate pain and prevent progres-
sion of the disorder to fibrosis and calcification.
Sigmagen provides doubly protective corticoid-salicyl-
ate therapy. Meticorten® (prednisone) and acetylsal-
icylic acid are combined to provide additive antirheu-
matic benefits and rapid analgesic effect. These dual
clinical values are enhanced by aluminum hydroxide to
counteract excess gastric acidity and by ascorbic acid
to help meet the increased need for this vitamin during
stress situations.
Therapy should be individualized. Acute conditions:
2 or 3 tablets 4 times daily. Following desired response,
gradually reduce daily dosage and discontinue. Sub-
acute or chronic conditions: Initially as above. After
satisfactory control is obtained, gradually reduce the
daily dosage to minimum effective maintenance level.
For best results administer after meals and at bedtime.
Precautions : Because Sigmagen contains prednisone,
the same precautions and contraindications observed
with this steroid apply also to the use of Sigmagen.
for patients who go beyond their physical capacity
protective corticoid-salicylate therapy
SlGMAGCN
corticoid-analgesic compound Tablets
Prednisone 0.75 mg. Aluminum hydroxide 75 mg.
Acetylsalicylic acid 325 mg. Ascorbic acid 20 mg.
SG-J»987
AMA News Notes
AMA PLANS SCHOOL HEALTH CONFERENCE
“A Decade of Progress in Fitness” will be the theme
of the sixth National Conference on Physicians and
Schools to be held October 30 to November 2, at the
Moraine-on-the-Lake Hotel, Highland Park, Illinois.
Sponsored by the AMA’s Bureau of Health Education,
this year’s program will emphasize a continuing interest
in the health and all around fitness of children and
youth.
More than sixty nationally recognized consultants
and resource persons have been selected from medicine,
education and public health to lead the discussion
groups. Topics to be considered include: the physi-
cian’s role in youth fitness ; community co-ordination :
mental and emotional aspects of fitness; dramatizing
basic fitness procedures; medical guidance in girls’
recreation programs; special health problems in ath-
letics; fitness of school personnel; optimum fitness for
youth with special health problems; home and family
relations; food factors in fitness.
As in previous conferences, state medical societies,
state health and education departments, and national
agencies concerned with school health and health edu-
cation have been invited to send representatives. State
societies should select their delegates and notify the
Bureau as soon as possible. In addition, medical as-
sociations should encourage state health and education
departments to send representatives so that a nucleus
of well-informed persons from several professions can
lend interprofessional leadership to school health activi-
ties within each state.
AMA JOINTLY SPONSORS
MEETING ON RADIO AND TV
Representatives of medical societies, radio and tele-
vision stations, voluntary health organizations, medical
schools and allied groups will be invited to attend a
national conference on “How to Use Local Television
and Radio in the Health Field,” November 7-8, at
Chicago’s Hotel Sheraton-Blackstone. The two-day con-
ference is being sponsored jointly by the American
Medical Association and the National Association of
Radio and Television Broadcasters.
Keynote speakers at the opening session will be
Dr. David B. Allman, AMA president, and Harold
E. Fellows, NARTB president, discussing the importance
of public interest broadcasting from the point of view
of the medical profession and the radio-television in-
dustry. Panel discussions will be held on “Mutual
Obligations in Public Interest Programing” and “The
Matter of Taste” — the need for keeping tab on material
presented over radio and television.
In addition, the group will split up into three
sections by size of community to consider such things
as the importance of good working relationships between
health groups and radio and TV stations; financing
of public interest presentations; programing of pub-
lic interest presentations (content, format, live shows,
film shows, visual aids) ; utilization of spot announce-
ments; working with news rooms; evaluation of pro-
gram impact; promotion; medical ethics involved in
public interest programing.
The program committee has announced that only a
limited number can be accommodated at the confer- ]
ence so advance registration is advisable Register by
writing the American Medical Association, 535 North
Dearborn, Chicago 10, Illinois. No fee for the conference
will be charged, but luncheon tickets will be sold.
AMEF SPEARHEADS FALL CAMPAIGN
The American Medical Education Foundation will
launch an intensive fall campaign for contributions to |
the nation’s medical schools. October and November I
have been selected as the months in which to appeal
to physicians for individual donations.
To assist local committees the AMEF has prepared
a new pocket portfolio with information cards and
pledge envelopes. A new folder entitled “So They \
May Serve” has also been produced for use in local
and state mailings. A new exhibit — first displayed at
the AMA convention in New York — is available from
the Foundation office for state meetings. Featuring
pictures of medical schools and gift checks to AMEF, I
this exhibit illustrates reasons why medical schools jl
should be privately supported.
In a progress report as of July 1, the AMEF an-
nounced that the six million dollar mark of contribu-
tions from the medical profession had been passed earlier
this year. The report also stated that so far in 1957
the AMEF income is 15 per cent higher than in the
same period last year.
Physicians are urged to contribute generously to the
Foundation during the remaining months of 1957.
AMA TO STAGE FALL RURAL
HEALTH MEETING
How to develop more effective rural health pro-
grams will be the chief topic of concern at the Ameri-
can Medical Association’s second study conference, Oc-
tober 4 and 5, for chairmen and members of state
rural health committees. Sponsored by the Council on
Rural Health, the conference again will be held at Pur-
due University.
The opening session will be devoted to a discussion
of organizational techniques of statewide rural health
committees. Another session will feature representatives
of leading farm organizations outlining their health
programs. Following this latter presentation will be a
discussion of ways that the medical profession and agri-
cultural groups can best work together in developing
better health programs. Registrants also will have an
opportunity to get together with others from their own
regions to discuss mutual problems.
Reservations for this conference should be sent di-
rectly to Students Union, Purdue University, Lafayette,
Indiana.
1112
IMSMS
HV JOURNAL
of the Michigan State Medical Society
Issued Monthly Under the Direction of the Council
VOLUME 56 SEPTEMBER, 1957 NUMBER 9
Are Your Patients Physically Qualified to Drive?
' I 1 HERE should be little need to begin this
-*■ article with a recital of impressive or dramatic
vital statistics relating to the “carnage on the
highways,” or repeat catch phrases which dra-
matize the appalling story of traffic death toll
and injury. The efforts of the American Safety
Council, lay press, and, more recently, medical
literature, have presented a continuous array of
facts, figures and safety slogans. So accustomed
are we to these presentations that we are in danger
of being lulled into a state of fatigued response.
However, dulled responsiveness does not deny the
fact, and perhaps a true realization of the physi-
cian’s real responsibility in this situation may serve
to jar us physician drivers out of any conditioned
apathy. Your Michigan State Medical Society
has been concerned enough to establish an active
committee to study the problem and ways and
means of attacking it.
In the tradition of conquest of disease, we pride
ourselves on neutralizing one hazard to longevity
after another in a progression from more effective
treatment to ultimate prevention. But mode of
living and modern man’s environment brings new
threats; and disease, as a cause of death, tends to
give place in frequency to accidental death. We
have learned continuously better ways of treating
trauma, salvaging function, and rehabilitating vic-
tims of accidents. But, are we adequately turning
our attention to prophylaxis in this area? Our
intimate involvement forces us to face this ques-
tion squarely.
A worldwide attention to the problem on the
By Harold E. DePree, M.D.
Kalamazoo, Michigan
part of law enforcement agencies, industrial and
insurance agencies, safety promoting agencies, and,
more recently, individual and institutional groups
of physicians, has yielded rather extensive study
and even more extensive literature on the sub-
ject. Automobile and highway design have come
under a great deal of consideration and this is
to be applauded. However, of particular interest
to us is the fact that much of this study has
been oriented in the direction of determining the
definable specific human factors in the causation
of automobile accidents. Much has been eluci-
dated and, in the words of the familiar phrase,
much yet needs to be learned. There is the hope
in the work of these agencies that a practicable and
relatively simple driver screening procedure may
evolve. Yet, again and again, these studies show
that the complexity of the human causative factors
in accidents, which are often of a temporary situ-
ational nature, makes the selection of safe drivers
by simple means extremely difficult. Most sig-
nificantly, those factors shown to be of definite
importance are of a nature which could only be
known and properly assessed by someone trained
and having an intimate knowledge of the physical
and emotional status of a prospective driver. This
“someone” must logically be the driver’s physician.
The discharge of our responsibility may follow
at least two main paths. One involves education
of our patients in the hazards which certain physi-
cal factors impose on driving, and, the other,
prohibition of driving by patients we know to be
bad risks on the highway. Too often the physician
September, 1957
1125
ARE YOUR PATIENTS PHYSICALLY QUALIFIED TO DRIVE?— DE PREE
TABLE I. ORGANIC FACTORS IN ACCIDENT
CAUSATIONt
Disorder
Recommend
re :
driving
Neurologic
Epilepsy
Opinion divided from complete
prohibition to qualified (5 years
free of seizure, adequate aura,
et cetera).
Neurologic disease involving
loss of function of extremity
or loss of coordinated move-
ment.
Opinion divided but consensus
states prohibition unless both
arms and one leg normal. (Also
individual consideration by physi-
cian.)
Neurologic disease involving Individual consideration by phy-
disturbances of alertness in sician.
consciousness.
Visual
Visual standards
Auditory
Minimal
Cardiovascular
Severe diminished cardiac re-
serve
Aortic Stenosis
Adams-Stokes Syndrome
Hypertension with Complica-
tions
Complete A-V Block
Cerebro-Vascular Disease
Uncontrolled paroxysmal au-
ricular fibrillation, flutter or
tachycardia.
Carotid Sinus Syndrome with
vertigo or syncope.
Aneurysm of any centrally lo-
cated vessel.
Congenital Heart Disease
Organic Valvular Disease
Coronary Artery Disease
Orthopedic
Head and Neck
Conditions which thru pain
or associated neuromuscular
deficit cause loss in rota-
tion to either side of more
than 75%
Thoracic
Severe kyphosis, scoliosis, lor-
dosis
Upper and Lower extremities
(minimal standards)
Drug and Chemical
Alcoholism
Anti-histamine
Anti-soporified
Sedatives
Diabetes Mellitus
Minimal standards —
Public transport drivers:
20/30 each eye (correctible to)
Form fields of 70° in horizontal
each eye and 140° both eyes.
Yearly exams.
Private car drivers:
Correctible to 20/40 in the better
eye. Form fields of 70° in hori-
zontal.
Meridian each eye or 140° in
horizontal meridian in one eye.
No requirements for color or
depth.
Spoken voice test. 50% of words
at 5 ft. in better ear.
Prohibited for private car, com-
mercial or transport drivers.
To be evaluated by individual
consideration.
Prohibited
Private car only
(individual consideration)
Normal upper and lower extremi-
ties for commercial transport.
Two good upper or one gooa up-
per and one good lower for pas-
senger car.
Obviously prohibited
Individual consideration and
warning by physician.
Individual consideration.
tModified from “Medical Aspects of Motor Vehicle Accidents/’
iq ^ State Journal of Medicine , Vol. 56: No. 24, December
shares in his patient’s sense of having his right-
ful prerogative of driving threatened. He may thus
become involved, thru a misguided sense of loyal-
ty to his patient’s welfare, in an effort to preserve
that prerogative, clouding good judgment of the
real public hazards involved. What then are
proven factors which we can recognize in our
patients as signs increasing accident likelihood?
This question has probably been applied most
extensively to the area of industrial transport driv-
ers. The most notable investigation and practical
application is found in the experience of the New
York Package Service. The physicians who
checked drivers for this service found they could
cut down their accident rate by paying attention
to physical conditions falling under certain sys-
temic categories. A recent symposium held in
New York to study just this problem outlined
important organic factors in accident causation
and classified them, generally, by these same
categories. With some slight modification for the
purpose of simplicity, these factors would then
appear as shown in Table I.
Table I is here presented as an attempt to
place in tabular form the recently expressed
opinion of experts in the field of accident pre-
vention. It is undoubtedly not complete, and is
not intended to serve as an authoritative reference
which should guide in the selection of safe drivers
nor prescribe the action of the physician in
handling the problem of the unsafe driver. These
physical conditions are felt to be reasonably im-
portant considerations when they involve someone
guiding a potentially destructive vehicle through
a traffic pattern at what are considered reasonable
speeds. This presentation, it is hoped, will serve
to emphasize to us as physicians, that patients
with these disease states, may also occupy the
driver’s seats of automobiles, trucks or buses
traveling our highways. A glance at the table
will serve immediately to point up the divergence
of opinions, the frequent importance of “indi-
vidual consideration” for each case, and, conse-
quently, again the importance of the physician
in the whole accident prevention effort.
Thus, although many with experience and
authority have frequently expressed the opinion
that there are now inadequate factual data to
determine accurately which specific organic factors
in accident causation are important, there is gen-
eral agreement that these factors do exist. Table
I shows some of the importantly considered ones.
If some selection of drivers for safety is to be
accomplished at all, and it cannot be done by
simple screening methods, it must follow that an
(Continued on Page 1164)
1126
TMSMS
Use of Chemical Tests for Intoxication
in Michigan Law Enforcement
A LTHOUGH the state of Michigan has a
worldwide reputation as the home of the
automobile, it lags definitely in highway safety.
Last year over 1700 citizens lost their lives on
Michigan’s highways. Only ten states (mostly
in the mountainous West) have higher death rates
from highway accidents.1 But this does not tell
the most tragic part of the story: the greatest
single cause of death in school-age children of
Michigan (ages five to nineteen years) is motor
vehicle accidents.2
To what extent does alcoholic liquor play a
part in producing this ghastly toll on our high-
ways? Where careful systematic studies have
been made, it has been shown that there is a
remarkable degree of correlation between alcohol
in the blood and death on the highway. Investi-
gation of 246 consecutive violent deaths in West-
chester County, New York3 showed that 46 per
cent of all deaths from automobile accidents in-
volved the drinking of alcoholic liquor. More re-
cent studies by the Delaware State Police4 have
shown that during 1956, 59 per cent of all fatal
highway accidents involved a driver or an adult
pedestrian who had been drinking. Similar values
were obtained in Maryland in a survey conducted
by the office of the State Medical Examiner.5
Over a long weekend — such as Memorial Day,
1957 (four days) — we can safely estimate that
twenty citizens will lose their lives on Michigan
highways and nine of these will involve a driver
or a pedestrian who has been indulging in
alcoholic liquor.
Now there is no statute making it unlawful
to drink and drive. One only is forbidden to
operate a motor vehicle on the public highway
while “under the influence” of intoxicating
liquor,* and by Supreme Court interpretation!
such a condition occurs as soon as the alcohol
Dr. Muehlberger is Toxicologist at the Division of
Laboratories, Michigan Department of Health, Lansing,
Michigan.
^Compiled Laws of Michigan, 1949, Section 256.303.
fPeople v. Townsend, 214 Mich. 267 (1921).
September, 1957
By C. W. Muehlberger, Ph. D.
Lansing, Michigan
“impairs the faculties of perception and judg-
ment.” This point is reached long before a per-
son becomes “drunk” in the lay interpretation of
the term. The Supreme Court of Arizona has
defined the term somewhat more explicitly:
The expression “under the influence of intoxicating
liquor” covers not only all the well-known and easily
recognized conditions and degrees of intoxication, but
any abnormal mental or physical condition which is
the result of indulging in any degree of intoxicating
liquors, and which tends to deprive him of that clear-
ness of intellect and control of himself which he would
otherwise possess. If the ability of the driver of an
automobile has been lessened in the slightest degree by
the use of intoxicating liquors, then the driver is deemed
to be under the influence of intoxicating liquor. The
mere fact that a driver has taken a drink does not
place him under the ban of the statute unless such drink
has some influence upon him, lessening in some degree
his ability to handle said automobile.**
As in any other type of criminal offense, it is
incumbent upon any law enforcement agency to
establish the guilt of a person charged with “driv-
ing while under the influence of intoxicants” be-
yond a reasonable doubt. In fact, one practically
requires that the law enforcement officers make
a medical diagnosis in order to establish the vali-
dity of their complaint. Merely to observe an
erratic or reckless driving pattern, smell the odor
of alcoholic liquor on the breath of the driver and
to note evidences of impaired muscular coordina-
tion as indicated by uncertainty of step, faulty
balance, slurred or blocked speech are not always
sufficient to provide convincing proof “beyond a
reasonable doubt.” Interrogation as to illness or
injury, disability, taking of medicines prescribed
by a physician, fatigue, etc. may assist in
establishing the validity of the officer’s complaint,
but there may still be left a doubt, which some
might consider to be a reasonable one.
For years, it has been recognized that, within
limits of human variability, the concentration of
alcohol which is circulating in a person’s blood
**Steffani v. State, 42 Pac. (2nd) 615 Arizona 1935.
1127
CHEMICAL TESTS FOR INTOXICATION— MUEHLBERGER
stream and which is furnishing alcohol to the
brain and other nerve centers, is a determining
factor in measuring the extent of intoxication.
Some years ago the American Medical Associa-
tion appointed a special Committee to Study Pro-
blems of Motor Vehicle Accidents. After con-
siderable study and investigation, this Committee
advocated the use of chemical tests for intoxica-
tion and stated:
“The committee, of course, reiterates its previous
statement that the percentage of alcohol in the blood is
a reliable index of the degree of intoxication, especially
when considered along with external symptoms of in-
toxication. There is listed in brief form the chemical
standards for the legal interpretation of “under the
influence of alcohol” in terms of the percentage of
alcohol in the blood or its equivalent in other body
materials:
1. Below 0.05 per cent alcohol in the blood: no in-
fluence by alcohol within the meaning of the law;
2. Between 0.05 and 0.15 per cent, a liberal, wide
zone: alcoholic influence usually is present, but
courts of law are advised to consider the behavior
of the individual and circumstances leading to the
arrest in making their decision;
3. 0.15 per cent: definite evidence of “under the in-
fluence,” since every individual with this concen-
tration would have lost to a measurable extent some
of that clearness of intellect and control of him-
self that he would normally possess.
These standards have proved themselves to be fair
and practical. The zone below 0.05 per cent vindicates
the nondrinking or temperate driver, the wide middle
zone considers tolerance and idiosyncrasy, and the highest
zone indicates alcoholic influence regardless of unusual
tolerance. The chemical tests can be performed with
remarkable accuracy and are the best means of proving
alcoholic influence. It is necessary, however, that care
be used in making the tests and that those who run
the analyses have sufficient experience and are able to
show that they can perform the test accurately.6
Thus biochemical analysis to determine the
amount of alcohol circulating in the blood stream
of an individual has come to serve as a very im-
portant objective guide to the law enforcement
officer in making certain that the behavior and
impairment which he observes is actually due to
alcohol and not to some other cause.
Since 1937, court cases involving chemical tests
for intoxication (analyses of blood, urine or
breath) have been accepted in the courts of at
least thirty states, and in over 200 instances7 con-
viction has been appealed to higher (appellate)
courts. To summarize these 200 cases reviewed by
the higher courts, I may say that in no instance
1128
has a conviction of driving while under the in-
fluence of intoxicants been reversed when the
following elements have been established:
1. The subject was in the custody of one who was
empowered to make an arrest or who did formally make
an arrest.
2. The subject submitted to the test without com-
pulsion of any kind.
3. The test performed was one which was generally
recognized as reliable.
4. The material analyzed was properly identified as
that obtained from the subject.
5. The test was made by a skilled and qualified per-
son employing chemicals and techniques which he knew
of his own knowledge to be accurate.
6. There was expert testimony to interpret the
significance of the results of chemical analysis in terms
of “alcohol influence.”
Our own State Supreme Court has ruled on
only one case involving chemical tests for intoxi-
cation.f In this case, a breath test employing the
Harger Drunkometer was administered to the de-
fendant. In reversing the conviction, our Supreme
Court stated : “There is no testimony in the record
that there is general acceptance by the medical
profession or general scientific recognition of the
results of a Harger Drunkometer test as accurate-
ly establishing the alcoholic content of a subject’s
blood and thus the extent of his intoxication”
(italics added). Since that time (1949) at least
twenty-three convictions in ten states have been
uniformly upheld when it was shown that the
Drunkometer breath test was properly made by
a qualified person and that expert testimony was
provided concerning the test’s reliability.
Ever since 1941 the results of chemical analyses
of blood specimens obtained from subjects who
submitted voluntarily have been admitted as evi-
dence in trials in Michigan involving driving while
under the influence of intoxicants, negligent homi-
cide or manslaughter. During the last ten years
the laboratory of the Michigan Department of
Health has made 6,800 such analyses of blood
for law enforcement agencies. There is no ques-
tion concerning admissibility of such evidence. The
argument that employing a person’s blood to
secure evidence which might be used against
him is violative of the Fifth Amendment that “no
person charged with a crime should be compelled
fPeople v. Morse, 325 Michigan 270 (1949).
.TMSMS
CHEMICAL TESTS FOR INTOXICATION— MUEHLBERGER
to be a witness against himself” has been shown
to be false.*
Blood tests present certain practical difficulties.
Some persons balk at the idea of having a needle
thrust into their vein. Arrests for so-called “drunk
driving” frequently occur late at night and in
sparsely settled areas. The problem of securing
the services of a willing physician, nurse or medi-
cal technologist who is skilled in taking blood
specimens is not simple. Furthermore, the taking
of a specimen may result in the requirement that
such a person might be served with a court sum-
mons to testify at a subsequent trial. After several
such experiences, only the most public-spirited
physician can be prevailed upon to take blood
specimens in cases involving suspected intoxica-
tion.
To obviate the difficulties attendant upon en-
gaging medical personnel, indirect methods for
estimating the blood alcohol concentration have
been resorted to. These involve the measurement
of the alcohol content of urine or breath.** They
are based upon the physiologic fact that the con-
centrations of alcohol in the urine and in the
alveolar breath are proportional to the concentra-
tion of alcohol in the blood which is being sup-
plied to the kidneys and lungs. Such tests are
only slightly less reliable than blood as an index
of alcohol intoxication and, for purposes of con-
firming (or denying) an opinion based upon
objective indications of intoxication, they are
amply accurate. One must remember that in a
factor such as alcohol influence which, in humans,
varies from .05 per cent to .15 per cent alcohol
content of blood, variations of .01 per cent or
.02 per cent are not of material clinical signifi-
cance. Breath tests certainly help differentiate
between the driver who actually had the prover-
bial “two beers” and the one who had two too
many.
*See U. S. Supreme Court ruling in unholding the
conviction in Breithaupt v. Abram (352 U.S. 432
(1957), abstracted in J.A.M.A. 164:406 (May 25)
1957. This position is also held by our own State
Supreme Court. See People v. Placido, 310 Mich. 404
(at page 409) (1945).
**To reliably indicate the blood alcohol concentra-
tion, breath specimens should not be taken until at
least fifteen minutes after the last drink. This insures
that any alcohol in the breath comes from the subject’s
lungs, and not from residual liquor which might remain
in the mouth and throat from the last drink. For recog-
nition of the reliability of breath tests, see editorial
“Chemical Tests and the Drunken Automobile Driver,”
J.A.M.A., 154:1279 (April 10) 1954.
September, 1957
In a number of Michigan’s cities, various
breath or urine testing procedures are being em-
ployed by law enforcement agencies. Detroit
police use the Drunkometer breath test8 as a
Fig. 1. Correlation oi blood alcohol lorols obtained by direct blood analyst*
and by breath analysis with the Intoximeter.
Fig. 1. Correlation of blood alcohol levels obtained
by direct blood analysis and by breath analysis with
the Intoximeter. From: “Evaluating Chemical Tests for
Intoxication,” National Safety Council, Chicago, 1953
(reprinted by permission).
screening procedure to weed out the temperate
drinkers from the more indulgent variety. Kala-
mazoo also uses the Drunkometer for screening
purposes and in persons who show .15 per cent
blood alcohol values, a urine specimen is obtained
and used for court testimony. Grand Rapids uses
a new breath testing device known as the “Breath-
alyser” for screening purposes. When a driver
flunks the Breathalyzer test (indicates a blood al-
cohol value of .15 per cent or more) he is asked
to submit to a blood test and this is employed in
the court hearing. Many other cities — Saginaw,
Battle Creek, Benton Harbor, Midland, Lincoln
Park, Niles, Owosso,, Grosse Pointe Shores, Hol-
land, River Rouge, and Birmingham — use a port-
able breath testing device known as the Intoxi-
meter.9'10 In this test, the law enforcement of-
ficer merely obtains the breath specimen which is
permitted to pass through the absorption tubes
of the test unit. The unit is then sealed, returned
to the laboratory and analyzed by a skilled chem-
ist. Simultaneous tests of both blood and breath
conducted at Michigan State University have
shown Intoximeter values to be remarkably ac-
1129
CHEMICAL TESTS FOR INTOXICATION— MUEHLBERGER
curate in establishing the blood alcohol level.
(Fig. 1.)
In court cases, the Intoximeter breath test has
been widely used in southwestern states (Cali-
fornia, Texas and Oklahoma). Of twenty con-
victions which were appealed to higher courts,
only one was reversed, and that because of failure
to properly identify the particular Intoximeter
unit employed in the test. Nearly 5,000 Intoxi-
meter units have been processed by the Crime
Detection Laboratory of the Michigan Depart-
ment of Health for law enforcement agencies
during the past ten years.
As with all new procedures, one will always
find a few skeptical and dissenting voices, even
among medical scientists. Early objections to the
Harger breath test ( “Drunkometer” ) which were
the cause for reversal in the Morse case stemmed
from erroneous values of the blood: breath dis-
tribution ratio of alcohol published by Yale Uni-
versity scientists. These have been retracted11
and it is now generally agreed that 2,000 volumes
of alveolar breath will contain the same quantity
of alcohol as will one volume of blood.
While many attorneys object to the use of
breath tests in establishing the degree of alcohol
influence, only one source of criticism arises from
the field of medical science in our state. A Sagi-
naw pathologist12 has been employed consistently
by a prominent defense attorney to attack the
validity of breath tests in general and the In-
toximeter procedure in particular. In court, such
criticism loses much of its weight when it is estab-
lished in cross examination that this particular
pathologist has never made a single test with the
Intoximeter and has reached his adverse con-
clusions only by his reading of some of the litera-
ture in scientific journals.
The use of modem methods of crime detection
has become almost imperative if we are to pre-
serve our basic government, which is founded
upon “liberty under law,” and chemical tests for
intoxication do serve to reduce the guesswork in
eliminating those who attempt to drive on our
highways while impaired by liquor. These tests
not only help to convict the driver who is under
the influence of intoxicants, but, what is more
important, they serve to exonerate the driver who
really has only taken two beers, who is unfor-
tunate enough to have been involved in an ac-
cident and whose breath smells of alcoholic liquor.
In upholding a sentence of involuntary man-
slaughter where a blood specimen was taken from
a defendant while semiconscious and which speci-
men, on subsequent analysis was found to have
.17 per cent alcohol, the U. S. Supreme Court
said (Breithaupt v. Abram) :
The test upheld here is not attacked on the ground
of any basic deficiency or of injudicious application, but
admittedly is a scientifically accurate method of detect-
ing alcoholic content in the blood, thus furnishing an
exact measure upon which to base a decision as to
intoxication. Modern community living requires modern
scientific methods of crime detection lest the public
go unprotected. The increasing slaughter on our high-
ways, most of which should be avoidable, now reaches
the astounding figures only heard of on the battlefield.
The States, through safety measures, modern scientific
methods, and strict enforcement of traffic laws, are us-
ing all reasonable means to make automobile driving less
dangerous.
As against the right of an individual that his person
be held inviolable, even against so slight an intrusion
as is involved in applying a blood test of the kind to
which millions of Americans submit as a matter of
course nearly every day, must be set the interests of
society in the scientific determination of intoxication,
one of the great causes of the mortal hazards of the
road. And the more so since the test likewise may
establish innocence, thus affording protection against the
treachery of judgment based on one or more of the
senses.
In a recent action,13 the American Medical
Association’s Committee on Medical Aspects of
Automobile Injuries and Deaths pointed out the
seriousness of the menace of drinking drivers and
has recommended that the blood alcohol ceiling
be lowered from 0.15 per cent to .05 per cent.
Until such time as our legislators can be convinced
that .15 per cent is too high, it seems questionable
if this stricter limit could be enforced. Perhaps
in the interest of saving 1,700 lives per year in
Michigan, we might be justified in taking more
drastic measures than are now 'being employed.
With the current trends toward the use of
pseudo-science in advertising all types of com-
modities, tooth pastes, beer, cigarets and arthritis
remedies, one is likely to look upon all scientific
solutions of our problems with a jaundiced eye.
Lawyers and judges are very properly skeptical
and conservative with respect to the uses of
science in the court room. In the interest of
removing the hazardous driver from our highways
(Continued on Page 1197)
1130
JMSMS
Drugs and Driving
By Seward E. Miller, M.D.
Ann Arbor, Michigan
/TOTOR vehicle accidents present acute medi-
-*-*-*- cal problems. Our present way of life is
impossible without motor vehicles in great num-
bers. Not only are large amounts of goods from
raw materials to finished products transported by
motor vehicles, but daily most individuals travel by
some form of motor vehicle transportation to
school, work, social activities, or to purchase nec-
essities.
Although much remains to be accomplished,
progress has been made in improved highway con-
struction. Motor vehicles, in addition to becoming
more numerous, have become more powerful and
more maneuverable. With expert or inept oper-
ation, they dart in and through congested traffic
areas with great ease. Rapid acceleration, deceler-
ation, sharp turning, and great ease of maneuver-
ability require increasing skill, judgment and
quick decision upon the part of drivers if acci-
dents are to be avoided. Increased driver train-
ing and public education have helped some to-
ward improving the quality of driving upon our
highways; however, there has been no structural
or functional improvements in the sensory and
reaction time mechanisms of man. In fact, with
split-second reaction time required for safe motor
vehicle driving, there is just cause for concern
over the factor of “human performance” in re-
lation to motor vehicle accidents. In this area
of “human performance,” physicians have a solid
responsibility and a real contribution to make
toward accident prevention.
The influence of drugs upon motor vehicle
driving abilities is a significant factor in the “hu-
man performance” element of motor vehicle acci-
dents. Physicians above all others best are able
properly to advise in this area. Numerous com-
mon drugs produce in some individuals various
reactions impairing their ability to drive a motor
vehicle. The degree of impairment varies tre-
mendously depending upon the severity and type
of reaction. Physicians administering drugs known
or likely to produce reactions impairing sensory,
Dr. Miller is Director, University of Michigan In-
stitute of Industrial Health.
mental or physical functions have a clear obliga-
tion fully to inform their patients concerning this
matter.
In addition, some patients experience unusual
reactions to drugs that ordinarily do not impair
driving ability in most individuals. Physicians ever
must be alert to this possibility and be on the
look-out for unusual reactions, allergic or other-
wise that impair sensory, mental or physical func-
tions making it unsafe to drive. Such patients
also must be firmly advised not to drive a motor
vehicle until the hampering symptoms have been
eliminated. The time required for recovery is
astonishingly long for many drugs. Some allegedly
“short acting” hypnotics may cause impairment as
long as twenty-four hours from a single dose.
Several groups of drugs rather universally im-
pair driving ability in one manner or another. The
more important of these drugs are discussed.
Central Nervous System Depressants
Analgesics (narcotics) . — The drowsiness in-
duced by analgesic drugs sufficiently damages sen-
sory functions and reaction time that patients so
afflicted should not drive a motor vehicle. In
addition, morphine, its derivatives and the syn-
thetic narcotics such as Demerol, cause varying
amounts of euphoria, inability to concentrate,
apathy, dimness of vision and rapid flow of un-
controlled thought. Patients under the influence
of these drugs should not drive a motor vehicle.
Individuals habituated to the use of narcotics
should not drive a commercial or passenger trans-
port vehicle. Ordinarily, these individuals are
not drowsy or euphoric, so unless experiencing
withdrawal symptoms may drive a private motor
vehicle.
Hypnotics and Sedatives. — These drugs not only
depress central nervous system activity, produc-
ing drowsiness and sleep, but also they may pro-
duce motor and sensory changes. No doubt small
doses of some of these drugs quieting a highly
excited and “jittery” patient actually temporarily
may improve his driving ability. However, this
September, 1957
1131
DRUGS AND DRIVING— MILLER
is not the usual circumstance, therefore it is best
to advise patients taking hynotic doses of these
drugs not to drive a motor vehicle. Of course, a
barbiturate addict is incapable of driving a motor
vehicle. Patients receiving regular mild sedation
who experience no drowsiness may drive a motor
vehicle. Patients receiving barbiturates and local
anesthetics for minor surgery should not be per-
mitted to drive a motor vehicle until fully re-
covered from the effects of such drugs.
Tran quili zing Drugs ( meprobamate , chlorpro-
mazine, reserpine, et cetera ).— During the initial
period of administration, some drowsiness fre-
quently is experienced. Also, from large doses,
the accompanying hypotension may occasionally
produce short episodes of faintness or giddiness.
Therefore, during the initial phase of dosage ad-
justment, patients should not drive a motor ve-
hicle. At all times, these patients should be care-
fully observed for symptoms of drowsiness or
faintness. Patients stablized on a maintenance
dosage of these drugs, who are without symptoms
of drowsiness or episodes of faintness, may drive
a private motor vehicle but not a commercial or
passenger transport vehicle.
Central Nervous System Stimulants
Benzedrine, et cetera. — Although these drugs
temporarily increase alertness and efficiency, large
doses in some individuals may produce headache,
agitation, irritability and a decreased ability to
concentrate. In all individuals, a period of fatigue
and depression follows the initial stimulation. An
individual may take one of these drugs to pro-
long the period of alert driving for a period of
two hours but not longer. After this two-hour
period, the patient should cease driving. The
dosage should not be more than 5 or 10 mgs. and
should not be repeated that day.
Antihistamines and Drugs Preventing
Motion Sickness
There is great individual difference in re-
action to these drugs with dizziness and/or drows-
iness occurring fairly frequently. Moreover, it is
unpredictable in which individuals or with which
preparations dizziness and/or drowsiness will oc-
cur. Patients under these medications should
not drive a motor vehicle until it has been estab-
lished by prior trial that they do not experience
dizziness or drowsiness to the specific preparation
administered.
Anti-infective Agents
Streptomycin- In full dosage, undesirable re-
actions of nausea, loss of sense of balance with
dizziness, ringing in the ears, and deafness may
occur. A patient developing such symptoms should
not drive a motor vehicle. Patients receiving over
1 gm. of streptomycin daily should be watched
carefully for the development of any of these ad-
verse symptoms.
Sulfa Drugs. — Patients receiving these drugs
should be warned that if they develop any
drowsiness or dizziness, they at once should cease
driving a motor vehicle.
Hallucinogens
Marijuana, et cetera. — These drugs have sing-
ular abilities for changing normal emotional re-
actions even causing individuals to become ob-
livious or indifferent to their surroundings. In-
dividuals under the influence of these drugs
should not drive a motor vehicle.
This brief review of the common types of drugs
impairing the ability of an individual to drive a
motor vehicle would not be complete without an-
other admonition. Frequently, individuals under
the influence of a drug may realize his driving
ability is impaired so he attempts to compensate
by driving slowly and unduly cautiously. This un-
usual behaviour frequently constitutes a significant
traffic danger. Therefore, physicians should not
attempt lightly to discharge their clear respon-
sibilities in this area by the mild admonition to
drive slowly or drive carefully. We must face the
situation squarely and firmly advise these pa-
tients under no circumstances to drive while un-
der the influence of drugs likely to impair their
sensory, mental or physical ability to drive a mo-
tor vehicle safely.
Bibliography
Brandaleone, Harold, et al. : Recommendations for med-
ical standards for motor vehicle drivers. Indus. Med.
& Surg.. 26:1, 25-32 (Jan.) 1957.
Leake, Chauncey D.: The amphetamines and the sleepy
driver.” Ohio State M. J., 53:176-178 (Feb.)
1957.
McFarland, R. A., et al.: Human Factors in Highway
Transport Safety. Boston: Harvard School of Pub-
lic Health, 1955.
(Continued on Page 1136)
1132
JMSMS
The Highway Accident Problem in Michigan
and What Has Been Done About It
T AST year, in Michigan, motor vehicles traveled
' more than 28 billion miles. Undoubtedly,
there was opportunity for millions of collisions
which did not occur. In spite of hazardous weath-
er, roadway and light conditions — oftentimes in
spite of poor intersection and open roadway design
and maintenance — thousands of potential conflicts
were avoided for every collision that occurred.
Perhaps we should conclude that Michigan
motorists are doing well, that we are beating the
laws of chance when only 300,000* * or so collisions
result. But long ago we learned that accidents are
avoidable. We have learned that accidents are not
necessary in spite of the great exposure traffic can
generate. Records of some drivers prove it is pos-
sible to travel the highways under adverse condi-
tions for years and still avoid being involved in an
accident.
Study of each accident reveals that it would
not have happened if a pedestrian or one or more
drivers had not failed to do the right thing. The
error most often involved is a violation of law.
Such repeated human failure brings about tragic
losses. In Michigan, during 1956, alone this meant
1,747 killed. This was a reduction from the hor-
rible toll in 1955 of 2,016 killed. Annually, more
than 60,000 are injured in Michigan traffic acci-
dents. The economic loss is conservatively esti-
mated to be in excess of $200 million a year.
This unnecessary traffic toll is all the more tragic
when we realize that many of those killed, those
injured, and those sustaining economic loss were
entirely free of blame. They were victims of an-
other’s negligence.
Statistics do not show the sad effect upon the
families of those who were killed or seriously
injured. The traffic accident toll includes heart-
aches and shattered family plans for the future.
Frequently, children are bereft of father or mother
Mr. Sheehe is Director of the Highway Traffic Safety
Center, Michigan State University, East Lansing.
*Slightly less than 200,000 traffic accidents were re-
ported but it is conservatively estimated another 100,000
occurred which were not reported.
September, 1957
By Gordon H. Sheehe
East Lansing, Michigan
love and guidance. Often, poverty results when
the family breadwinner is the victim.
Each of the drivers involved in this awful toll
did not expect to be in a traffic accident and did
not want to have one. Each was confident of his
driving ability and judgment. Yet each of Michi-
gan’s 300,000 crashes in 1956 was due in part to
either a pedestrian or driver (and in some cases
more than one driver) doing something definitely
unsafe and, in most cases, illegal.
Each became involved because of one or more
human weaknesses; inattention, impatience, weari-
ness or drugged senses, ignorance of the chances
of a collision, unawareness of the existence of a
hazard, and expectation that others will save the
situation for them by taking evasive action.
A false sense of security is developed in most
drivers who have not yet had a traffic accident
even though they repeatedly indulge in illegal
driving actions. They have “gotten away with”
bad driving long enough to become convinced that
it is not unsafe driving. Unfortunately, this false
sense of security isn’t always destroyed when an
accident does happen to the driver. Too often he
rationalizes the crash as the other fellow’s fault.
In fairness to drivers and pedestrians, it must be
admitted that the traffic stream in which they
must move contains many hazards which imperil
their safety. Michigan has more than 100,000 miles
of streets, and state and county highways. Many
miles of these have built-in hazards because they
were designed for traffic of a bygone day. Even
our improved highways, with but a few exceptional
miles, have countless intersections at grade at each
one of which conflicting traffic can collide. Every
private driveway or access to roadside business
adds to the potential danger of collisions. Pedes-
trians crossing streets and highways also add to
the exposure to conflict. To these millions of
friction points in our road network must be added
the oftentimes inadequate maintenance of road
surface and shoulders. And then still another
handicap is frequently added when rain and snow
make the surface more difficult to traverse with-
1133
HIGHWAY ACCIDENT PROBLEM— SHEEHE
out loss of vehicular control. On almost all of this
street and highway network, opposing streams of
fast moving traffic are separated by a foot or so of
“no man’s land,” sometimes marked by a center
line.
This is the facility upon which 3,500,000 Michi-
gan drivers operate the 3,000,000 vehicles regist-
ered in this state. Thousands of these vehicles
are in such defective condition that their drivers
and other motorists are jeopardized.
Engineering can make many present high acci-
dent locations safer. Limited access and divided
highways can lessen the chances of collision. Elimi-
nation of obstructions to view at intersections, more
street lighting, better maintenance, and improved
traffic control devices can help make streets and
highways safer. Better city and suburban planning
in conjunction with street and highway develop-
ment can prevent conflicts in the movement of
traffic.
But engineering improvements are far from the
total answer. Collisions still occur on the most
improved highways and at intersections where the
best present day engineering “know how” has
been applied.
In addition to engineering improvements, it re-
mains for all concerned to counteract the pedes-
trian and driver weaknesses mentioned earlier.
This involves two major undertakings: education
and discipline. When drivers and pedestrians will
not exercise self-discipline, the deterrent effect of
enforcement and driver license control must then
be used.
These conclusions are not new. Enforcement,
education, and driver license control have long
been acknowledged as necessary methods of stop-
ping the careless acts of pedestrians and drivers.
This is true whether the human failure is caused
by ignorance or willfulness.
Everyone will agree that present enforcement,
education, and driver license control activities are
somewhat effective. Without them the accident
toll would be much worse. But how many will
agree that present enforcement, education, and
driver license control methods are not achieving
anywhere near the maximum effect possible? If
presently known methods were utilized fully, ad-
ministered efficiently and with vigor, and if public
acceptance and support were fully developed, we
would see a one hundred per cent improvement in
driver and pedestrian behavior. Their increased
knowledge, skill, understanding, and acceptance of
regulations and discipline would be reflected in a
sharp decrease in accidents.
Responsibility for improvement in driver and
pedestrian knowledge, understanding and in their
acceptance of discipline, belongs to officials, poli-
ticians, educators, and lay group leaders. Yet
many of these responsible people evidence far too
much apathy or interest in other ends than acci-
dent prevention. They are irresolute and pliant.
They lack knowledge and fail to accept leadership
responsibility.
It is not enough to just decry the stupidity and
carelessness of the driver and pedestrian. They
need help, guidance and control which must come
from public information media, and from govern-
mental, educational and lay group leaders and
administrators.
Increase in application of known methods, ac-
ceptance of responsibility and improvement in
administration and leadership, however, will still
not be the complete answer. Better ways of edu-
cating and influencing drivers and pedestrians
must be found. More research and experimenta-
tion must be undertaken to improve present
methods. Some of the ablest traffic administrators
and educators are very concerned about the small
impact their best efforts produce.
Many enforcement leaders, for example, are
quite aware that, though the fatal accident rate
in their jurisdiction has been decreased, the total
accident rate has kept pace with the increase in
travel. Enforcement has not successfully dimin-
ished illegal driving and walking acts if the total
accident record is a fair index. These conscien-
tious people are asking how enforcement can be
improved so that it will achieve its objective of
obtaining greater driver and pedestrian compliance
with safety laws.
Driver education people want to know how to
improve driver education methods. It is true that
the accident rate of teen-agers who have taken
a driver education course is decidedly lower than
that of those who have not. Still many who have
taken such a course do have accidents subse-
quently. Driver educators believe better results
can be obtained when research develops better
methods of driver education.
Driver license administrators say they do not
know what to do for many problem drivers, those
who have accidents frequently or receive many
traffic tickets. Administrators report that suspen-
sion and revocation of license is not the answer
1134
TMSMS
HIGHWAY ACCIDENT PROBLEM— SHEEHE
in a majority of the cases. How to get at the
underlying causes of bad driving and how to
rehabilitate problem drivers is a major problem
today in preventing accidents.
So far, I have been discussing accidents, one of
the important manifestations of our traffic prob-
lem. But equally obvious manifestations of our
inability to properly administer street and highway
traffic are congestion and insufficient parking
facilities. These shortcomings cannot be blamed
upon the driver and pedestrian. But, as with most
accidents, the basic causes of traffic congestion and
inadequate parking are human failures. Eco-
nomics also play a part, admittedly. Off-street
parking facilities and street and highway construc-
tion cost a great deal.
Much congestion can be decreased, however, if
more efficient use is made of existing streets and
highways. Many effective means can be used to
improve vehicle traffic movement, such as: one-
way streets; elimination of curb parking, at least
at rush hours; elimination of turns; establishment
of by-passes and thru streets; lane markings; spe-
cial routes for truck traffic; proper timing and
synchronization of signal systems.
Why are these methods and devices not used
more extensively? In many cases those officials who
should propose the improvements do not do so
because they are unaware of what could be done.
They have no training in traffic flow planning and
operations, nor is a trained traffic engineer em-
ployed in their city or county. In other places
proposed changes designed to better traffic move-
ment are opposed and effectively stymied, some-
times by a single individual, more often by a
group. This opposition is often due as much to
shortsighted, selfish motives as to ignorance of
the benefits to be derived from the change.
Correction of all these causes of unsafe and
inefficient traffic movement is a huge task of pub-
lic administration on the one hand and human
relations on the other. Basically the problem is
one of education, politics and economics.
Before much improvement can be expected,
drivers and pedestrians must be educated in what
is safe and unsafe behavior. Since education of all
is undoubtedly impossible, at least to the degree
necessary, some form of regulation and control
must be exercised. This requires the consent of the
governed, the enlightened understanding of the
majority of voters, the resolute action of legislators,
the activity of regulatory agencies, et cetera. Edu-
cation, regulation, road building, and other per-
tinent matters cost money and involve public
policy — introducing the elements of economics,
politics, public and official understanding. These
in turn require public information and education,
as well as training of official agencies’ personnel.
To say that traffic improvement is largely a
matter of human relations, finance and effective
public administration is not enough. To prevent
traffic accidents:
1. We need to train more career people for traffic
administration. Safety is a by-product of good street and
highway administration.
2. We need to improve the traffic knowledge of many
existing officials and traffic workers. This includes
mayors, city managers, county supervisors, police, sheriffs,
school teachers and many others.
3. We need to improve the individual driver’s and
pedestrian’s understanding of traffic hazards. They must
know how to recognize hazards in time and how to keep
out of trouble.
4. We need to develop greater respect for laws and
regulations, to engender more self-discipline in our
people, especially when they are driving.
5. We need to build public support for firm, impartial
enforcement and driver license administration. The pub-
lic must desire more stringent enforcement methods
rather than oppose the apprehension and conviction of
violators.
6. We need to encourage more selfless, co-operative
group action to get the teamwork necessary, especially
at the local levels of government.
7. We need to obtain facts as a basis for plans and
action.
8. We need to discover and develop better methods
of driver education, enforcement, problem driver rehabi-
litation, etc., through research.
9. We need to have traffic engineering science used on
all our highways, not just on the truck line system, and
in all our cities.
10. To do these and many other things which will
be required, we must more completely inform all Michi-
gan people about traffic problems, about what is needed
to solve them, and about what they can do to help. In
the final analysis, the people as voters, taxpayers, pres-
sure groups, or jury members control the rate of progress
we shall make. An informed, interested public will see
that the needed remedies will be found and financed.
Definite progress has been made in Michigan
during the past two years. In the summer of 1955,
Governor Williams provided the leadership for an
all-out traffic accident prevention program. The
Legislature, in its November, 1955, special session,
aided tremendously by appropriating funds for
200 additional state police, enacting the state sub-
sidized universal driver education law requiring
those under eighteen years of age to pass a driver
September, 1957
1135
HIGHWAY ACCIDENT PROBLEM— SHEEHE
education course before obtaining a driving license,
establishing the Highway Traffic Safety Center at
Michigan State University, and passing a maxi-
mum speed limit for rural areas.
In subsequent sessions, the Legislature has ap-
propriated funds for 150 additional state police
officers, and enacted legislation providing for
county traffic safety schools for problem drivers
and others who wish to attend them.
Enforcement by all the police agencies and
courts of the state has increased substantially. The
Central Driver Record Files of the Division of
Driver and Vehicle Services of the Secretary of
State’s office have been improved substantially.
The driver improvement activity of that Division
has increased 100 per cent.
Driver Education is now being taught in all the
high schools of the state. Hundreds of teachers
needed for this program have taken the initial
qualifying Driver Education Teacher Course.
Newspapers, radio and television stations have
provided more public safety information than ever
before.
The Highway Department’s road building pro-
gram has been increased substantially following
the passage of the 1956 Federal Highway Act.
The Highway Traffic Safety Center at Michi-
gan State University has assembled a large com-
petent staff and is bringing the entire resources
of the University to bear upon the traffic problem.
The five-fold activity program of the Center in-
cludes:
1. Educating career people for Highway Traffic Ad-
ministration in undergraduate and graduate courses.
Driver Education teachers, highway and traffic engineers,
safety organization managers, traffic police administrators
are being educated.
2. Training those now holding responsible positions in
highway traffic administration. Scores of short courses
and conferences have been held for many different
groups, such as, engineers, police, judges, womens’
groups, teachers, and school bus drivers.
3. Research on many traffic problems for which new
or better solutions are needed. Faculty members of
many schools and departments of the University are
engaged in individual and group research.
4. Field assistance in response to requests of local
officials and citizen groups. Qualified resource people
from many of the University’s schools and departments
are aiding cities and counties in solving their traffic
problems.
5. Information and materials service. The “You Are
The Jury” radio program is broadcast weekly on forty
Michigan radio stations. A traffic film loan library
comprising 130 different motion picture films is being
used by groups throughout the state. A monthly news-
letter has been started to provide up-to-date information.
Speakers on many traffic subjects respond to requests of
many different groups.
These are some of the steps Michigan has taken
to decrease the terrible annual traffic toll. Many
groups not mentioned in this resume are con-
tributing staff, time and money to the State’s
accident prevention program.
The total effort is succeeding. There were 269
fewer people killed in 1956 on Michigan highways
than in 1955, and in the first seven months of
1957 there have been 155 fewer deaths than in
1956, in spite of increased travel.
Though this progress is encouraging, much
more needs to be done. The number injured in
traffic accidents has been decreased only slightly.
The steadily increasing amount of travel in Michi-
gan is constantly increasing exposure to accidents.
The accident rate per 100 million vehicle miles
must be decreased another 33 per cent, if Michi-
gan is to keep from killing 2.000 in the year 1970.
DRUGS AND DRIVING
(Continued from Page 1132)
McFarland, R. A.; Moore, R. C.; and Warren, A. B.:
Human variables in motor vehicle accidents: A re-
view of the literature. Boston: Harvard School of
Public Health, 1955.
Medical Aspects of Motor Vehicle Accident Prevention.
Symposium by New York University — -Bellevue
Medical Center and the Center for Safety Educa-
tion, New York University. New York State J.
Med., 56:3853-3882, 1956.
Meprobamate and other agents used in mental disturb-
ances: Ann. New York Acad. Sc., 67:671-894,
1957.
Health, Medical and Drug Factors in Highway Safety.
Conference Proceedings, Second Highway Safety
Research Correlation Conference, April 5-6, 1954.
National Academy of Sciences, National Research
Council, Washington, D. C. Publication No. 328.
Traffic Safety. Hearing Before a Subcommittee of the
Committee on Interstate and Foreign Commerce,
House of Representatives, 84th Congress, Second
Session on Investigation of Highway Traffic Acci-
dents. U. S. Government Printing Office, Washing-
ton, 1956.
1136
TMSMS
Automotive Crash Injury Research
in Michigan
/''"NN April 17, 1957, the Executive Committee of
^-'HThe Council of the Michigan State Medical
Society endorsed an automobile crash injury re-
search program sponsored by Cornell University
Medical College, in co-operation with the Michi-
gan Department of Health and the Michigan
State Police. In this new study which was initiated
on June 1, Michigan represents the thirteenth state
to collaborate in an interstate data-collecting
system.
The purpose of this program is to obtain
reliable data on the frequency, nature and specific
causes of injury to occupants in passenger cars
involved in automobile accidents. In addition,
these studies are producing medical statistics
which promise to implement treatment of auto
crash victims through more definitive knowledge
of the nature and scope of the problem. Data
from other co-operating states have formed a basis
by which automobile manufacturers have made
important design changes in many 1956 and 1957
passenger cars which are specifically engineered to
provide occupant protection during accidents.
Reliable information being obtained on the degree
of protection offered by these items, which include
the seat belts, springproof door latches, energy-
absorbing steering wheels, padding, et cetera, is
most encouraging.
The interstate research effort differs from pre-
vious highway accident studies in that it is seek-
ing information on causes of injury rather than
causes of the accident itself. Trauma produced
in highway accidents is regarded as the mass dis-
ease which is as characteristic of our times as were
bubonic plague, typhoid fever, and malaria in
previous years. In studying this “disease,” an
epidemiologic approach has been utilized with the
co-operation of medical societies, State Depart-
ments of Public Health and State Police groups of
Indiana, North Carolina, Virginia, Maryland,
Georgia, Connecticut, New York, Vermont, Pen-
nsylvania Minnesota, Texas, Colorado, Arizona,
Mr. Tracy is Supervisor, Field Operations, Cornell
University Medical College.
September, 1957
By Robert M. Tracy
New York, New York
California and Oregon. With carefully designed
standardized data-gathering forms, the enforce-
ment officers and the medical profession are con-
tributing data from this “laboratory of the high-
ways” to the Automotive Crash Injury Research
group at Cornell, where a standard technique of
evaluation and analysis is employed to identify
the characteristics of the environment which pro-
duces trauma.
With the introduction by automobile manu-
facturers of new door lock designs, energy-absorb-
ing steering wheels, specially designed energy-
absorbing padding on the instrument panels and
forward overhead structure, as well as safety belts,
the epidemiologic approach can now also be used
as an objective measuring device to determine the
degree of reduction in both the frequency and
severity of injury that these changes are providing.
Studies of post- 1955 automobiles involved in ac-
cidents already indicate, for example, that oc-
cupants of these cars are experiencing a 29 per
cent reduction in risk of dangerous through fatal
grade injury. A preliminary evaluation of im-
proved door locks designed to decrease the inci-
dence of ejection (commonest cause of injury in
accidents) shows that, in the injury-producing
accident study, post- 1955 models experienced ap-
proximately 27 per cent less incidence of front
doors opening during accidents than did pre-1956
models. A direct result was an approximate 50
per cent cut in the frequency of occupant ejection.
Occupants of these newer model automobiles have
been found to sustain nearly 30 per cent less
dangerous through fatal grade of injury.
It has been demonstrated, also, that properly
engineered and installed seat belts can provide a
remarkable degree of protection. The most
marked improvement was seen in the prevention
of ejection and its associated injury risks. Although
continuing studies are expected to increase the
knowledge of the precise degree of added protec-
tion the seat belt may be expected to afford,
present findings show that their use can reduce
1137
AUTOMOTIVE CRASH INJURY RESEARCH— TRACY
injury rates somewhere within the range between
30 per cent and 60 per cent (depending on the
type of accident and other factors).
Studies in Michigan are expected to represent
Fig. 1. Michigan Sampling Plan, First Period.
an important addition to the interstate program
in its continued effort to evaluate safety design
changes and to produce data which can be useful
as a basis for planning further safety design im-
provements. Standard statistical sampling tech-
niques are employed involving the investigation of
all injury-producing accidents in selected sampling
areas. Individual areas are studied for periods of
six months each and the Michigan study is sched-
uled for a tenure of at least two years. The ac-
companying illustration shows the areas currently
under study. Mechanics of the program require
that state police investigators fill out special re-
ports for all injury-producing accidents in the
shaded areas. In the larger sections, labeled “5”
and “6”, studies are confined to investigations of
1956 and 1957 model automobiles only. Following
his investigation of the accident, the state police-
man notifies the doctor or hospital having charge
of accident victims that these cases come within
the scope of the study. All physicians in these
areas have been appraised of the study through
letters from Dr. Arch Walls, President, Michigan
State Medical Society. Hospital administrators
and their staffs have received further instructions
from Cornell field personnel.
Medical forms are brief and do not require
much of the physician’s time. Upon completion
they are mailed to the Michigan State Department
of Public Health to be matched with related police
reports and special photographs illustrating car
damage details and injury causes before forward-
ing to Cornell for analysis and statistical use.
Earnest participation of the medical profession in
this effort, which is aimed at solving one of the
nation’s foremost epidemiologic problems, is ur-
gently requested. Unless the injuries of each per-
son hurt or killed in the passenger car accident
within the sampling areas is carefully recorded, the
effectiveness of this study and the value of the
subsequent data obtained may be seriously re-
duced.
These studies are sponsored by the Armed
Forces Epidemiological Board through its Com-
mission on Accidental Trauma, with funds sup-
plied by the Surgeon General of the Army, by
the Division of Research Grants of the United
States Public Health Service and by grants of
unrestricted funds by the Ford Motor Company
and the Chrysler Corporation.
By collaborating with Automotive Crash In-
jury Research, the physician will be furnishing the
basic medical data necessary to combat this epi-
demic problem. Only with valid medical data
can this mass disease be successfully attacked.
Gastroscopy should be employed: (1) where routine
studies fail to reveal a positive diagnosis of gastric dis-
eases; (2) as a supplementary aid to x-ray diagnosis;
(3) to follow the course of certain benign conditions
which may become malignant.
The asymptomatic period in esophageal and gastric
cancer is much longer than has been supposed. There
is reasonable evidence indicating that gastric lesions, at
least, are probably one and a half years old or even older
when symptoms first appear.
1138
IMSMS
Traffic Accidents and Safety
Transportation of the Injured
nr HE AUTOMOBILE, like the atomic bomb,
must be controlled. Trauma rates high as
a killer. The automobile kills about 40,000 yearly
and injures 1,300,000. It is the greatest cause of
death in children up to the age of fourteen. The
medical profession can unquestionably make a
great contribution to traffic safety as a logical
element of its work in the field of preventive
medicine. This is a significant extension of the
profession’s more obvious and direct concern with
the care of persons injured in traffic accidents.
Public officials, professional traffic safety authori-
ties, the automobile industry and other interested
groups welcome the increasing participation of
medical men in this field in all appropriate ways.
Few would deny that some of the most bril-
liant achievements of modern medicine lie in the
field of preventive medicine. The medical aspect
of traffic safety is in this category. There may
come a time when the issuance of a driver’s li-
cense will include a more detailed appraisal of
the physical defects of the applicant.
The one and one-third million persons injured
in traffic accidents become the direct responsi-
bility of the medical profession. This responsi-
bility is closely divided into phases. It must be
emphasized, however, that the care of the in-
jured person is basically a continuous process,
from the time of sustaining the injury, to dis-
charge, following rehabilitation.
Healing of tissue following an injury begins
the first minute. Good immediate care and safe
expeditious transportation of the injured become
the first and very important phase in the care of
these victims. The fate of the person and his
injuries is often decided during this time. The
quality of handling and transportation may be
the deciding factor in whether a person with a
relatively simple injury makes a full early re-
covery, or whether this simple injury is converted
into a complex situation resulting in a long re-
Dr. Curry is a member and past chairman, Subcomit-
tee on Transportation of the Injured, Committee on
Trauma, American College of Surgeons.
September, 1957
By George J. Curry, M.D., F.A.C.S.
Flint, Michigan
covery period with permanent disability or even
death.
A survey of the quality of transportation of the
injured was made covering the years 1949-1953.
Sixty-two cities, large and small were thus in-
vestigated. Fair to poor handling was found in
25 to 28 per cent. This information has been
previously reported in published articles.
During the past five years there has been in-
creasing interest directed toward improvement in
transportation of the injured. Subcommittees on
transportation of the injured have been active
at all levels, national, state and local. These are
part of the objectives of an educational program
projected by the American College of Surgeons
through its Committee on Trauma.
The immediate care and transportation of the
injured is in the hands of the ambulance attend-
ant. It seems logical, therefore, that concentrated
attention should be in this direction. His educa-
tion should be an important objective of any medi-
cal group. It is obvious that he should first be
selected on the basis of good character and de-
pendability. Special instruction can be easily ar-
ranged through the Red Cross courses anywhere.
If this is not possible, special organized lecture
and demonstration courses may be given by hos-
pital house staffs and other medical groups. To
maintain his interest and enthusiasm, regularly
scheduled meetings should be held where definite
transportation problems are reviewed. City ord-
inances requiring proficiency certification of am-
bulance attendants are increasing in number
throughout the country. At present, there are
fifteen in operation, with ten under planning.
The Flint Ordinance has been in continuous
operation since 1949, first obtained in 1942, but
discontinued during World War II because of
help shortage. Marked improvement in the qual-
ity of transportation of the injured has resulted.
A record of 27,000 ambulance transportation cases
to the Emergency Receiving Department, Hurley
Hospital, showed only seventy infractions. Flint
(Continued on Page 1141)
1139
The Speeding Ambulance
By George J. Curry, M.D., F.A.C.S., and
Sydney N. Lyttle, M.D., F.A.C.S.
Flint, Michigan
"TX URING the past few years considerable
criticism has been directed toward the speed-
ing ambulance. Panic by the uninformed is be-
hind the widely held fallacy that speed in getting
an accident victim to the hospital is important.
Prompt immediate care may be vital, but speed
merely increases the injury and accident hazard.
Dr. Basil C. MacLean, New York City Commis-
sioner of Hospitals, has been quoted, “The average
patient would get there soon enough by parcel
post.”
Since 1941, Flint, Michigan, has had an am-
bulance ordinance requiring ambulance atten-
dants to be certified as to their proficiency in im-
mediate care and transportation of the injured.
However, even under the ordinance speeding was
permitted whenever the drivers thought it neces-
sary. This resulted in several ambulances racing
to the scene of the accident. The last one to ar-
rive usually left empty-handed.
During the summer of 1949, an ambulance ran
a red light and collided with a convertible coupe
killing the twenty-four-year-old ambulance at-
tendant. Three weeks later an ambulance driver
for the same company, traveling at an estimated
seventy miles per hour, ran a red light and
crashed into a tank truck. The driver was also
killed.
A new program incorporating the following was
then put into effect.
1. A central dispatching system under control
of the police department assigns ambulances on
all emergency calls.
2. The independent ambulance companies are
assigned to specific zones. The morticians’ am-
bulances serve as a second line of defense.
3. The ambulances are limited to a top speed
of thirty-five miles per hour.
Opinions have been expressed by various groups
regarding the necessity of speed in transporting
the injured. The general impression among lay
people is that speed is necessary in saving lives.
The opposite view is expressed by some of the
From the Section for the Surgery of Trauma, Hurley
Hospital, Flint, Michigan.
members of the medical profession who feel that
the sirens should be removed from the ambu-
lances, and all traffic and speed regulations should
be obeyed even to the point of waiting for red
lights.
An ambulance averaging thirty miles per hour
would require ten minutes to travel five miles.
To save five minutes, sixty miles per hour would
be necessary. In 2,500 consecutive ambulance
runs this time interval would not have influenced
the course of a single injury.
Time trials under different traffic conditions
were carried out over a 4.4 mile stretch of a
usual ambulance route. An ambulance with the
right of way should be able to travel this distance
in less than ten minutes without speeding. The
shortest trial, obeying all traffic laws, was thirteen
minutes; the longest twenty-eight minutes. When
this delay is added to that necessary for the am-
bulance to reach the accident scene, the travel
time becomes significant.
A four-year-old child was apparently injured
by the gear shift lever and sustained an open
wound of the neck associated with bilateral pneu-
mothoraces, and fractures of the thyroid cartilage,
cricoid cartilage, and upper two trachial rings.
The child was cyanotic upon admission to the
emergency receiving department. Prompt mea-
sures restored the patient’s airway, and she sur-
vived. The total elapse of time between the dis-
patch of the ambulance by the police department
and the patient’s arrival at Hurley Hospital was
twelve minutes. The accident occurred a little
over a mile from the hospital, and transportation
was accomplished without excessive speed. Had
the transportation time been increased by many
minutes, it is probable that this child would not
have survived. This is the only case in this series
where a moderate delay could have resulted in
death.
Of these 2,500 cases, twenty-seven persons were
dead on arrival. Five of these died of fracture
dislocations of the cervical spine with complete
transection of the cord above the 4th cervical
1140
JMSMS
THE SPEEDING AMBULANCE— CURRY AND LYTTLE
vertebra. Twenty died of severe craniocerebral,
chest, and internal injuries. There was one
strangulation by hanging and one drowning. None
of these could have been saved by a speeding am-
bulance.
Thirteen persons expired in the emergency re-
ceiving department. These apparently died from
head and chest injuries, although other multiple
injuries were present.
Postmortem examinations performed on those
who died of severe chest injuries revealed com-
binations of rupture of the diaphragm, fractures
of the liver and spleen, lacerations of the aorta,
inferior vena cava, and the heart. Those not
autopsied presented external evidence of severe
injury.
It is believed that none of these victims, who
were dead on arrival or who expired in the re-
ceiving department, would have survived had
their injuries occurred on the hospital door step.
In only forty-five persons was the time interval
between that of the accident and the arrival at
the hospital considered to be significant as far as
the course of the injuries was concerned. In these
cases, expeditious handling of the victims was de-
sirable, but the speeding ambulance considered
unnecessary. In nine of these accident victims a
wild, weaving, siren-screeching ride to the hospital
might have produced death or permanent invali-
dism. These included seven cases of multiple rib
fractures associated with unstable rib cages and
pneumothoraces, and two fracture dislocations of
the cervical spine.
The other thirty-six victims were in severe
states of shock at the time of their arrival at the
hospital. The shock was produced by fractures
of the liver and spleen in five cases, and multiple
fractures of the skeletal system in eighteen, super-
ficial lacerations in eight, and penetrating wounds
of the abdomen and chest in four, and one burn.
The degree of shock in any of these cases may
have been increased by a rough ride in an am-
bulance.
In this series of 2,500 consecutive ambulance
runs, haste in transporting the injured was un-
necessary in 98.2 percent. There would have been
no difference in the outcome of 2,455 patients
had they been transported according to standard
traffic regulations.
In 1.8 percent expeditious handling was consi-
dered necessary, but a speeding ambulance could
have increased the severity of the injuries.
It is recommended that:
1. Ambulances in transporting the injured per-
son should observe the local speed laws of the
vicinity in which they are traveling.
2. They should retain the use of their sirens.
3. They should have the right of way in traffic.
The patient deserves a safe, expeditious ride
to the hospital.
TRAFFIC ACCIDENTS AND SAFETY
(Continued from Page 1139)
ambulance attendants are required to carry cards
indicating proficiency certification, at all times.
They expire in one year and are reviewed follow-
ing the annual meeting of all ambulance attendants,
held in December. In addition, windshield stick-
ers bearing the co-sponsors, American College of
Surgeons and Flint Committee on Trauma, Amer-
ican College of Surgeons, are presented to attend-
ants having a good record.
A chart bearing patient’s name, age, sex, diag-
nosis, quality of transportation and ambulance
attendant’s name is kept in the Emergency Receiv-
ing Department, at Hurley Hospital. Three re-
peated infractions disqualify the attendant. Rein-
statement occurs after re-examination and inves-
tigation. Ambulance inspection, for proper equip-
ment, takes place at regular intervals, throughout
the year, by the special instructor for ambulance
attendants through the American Red Cross.
Recommendations :
1. Organized educational programs for am-
bulance attendants.
2. City ordinances requiring certificates of pro-
ficiency for ambulance attendants.
3. Hospital receiving department charts indi-
cating the quality of transportation of each case.
4. Continuous interest in this important phase
of the care of the injured person.
September, 1957
1 141
Whiplash Injuries
By Frank H. Mayfield, M.D.
Cincinnati, Ohio
TT 7E DISLIKE the term “whiplash injury,” for
^ * it has come in many circles to imply knowl-
edge of anatomic and physiologic disorders of the
human neck that are not known. It is not unusual
in semantics for words to undergo mutation; for
example, the word “pituitary,” which literally
means “slime,” has come to identify the master
gland. And now “whiplash,” which was intro-
duced to describe the forces to which the neck is
vulnerable, is in a sense becoming a master hoax.
Diagnostically, it is no more definitive than is
“headache” or “bellyache.” Yet it occurs fre-
quently in medical histories, particularly in con-
nection with traffic accidents, and is quoted quite
commonly in the courtroom. There seems to be a
popular trend to catalogue under this title all
unexplained symptoms which follow cervical
trauma.
In our opinion, the term is used improperly if
it does more than describe the nature of the force
to which the patient is exposed. We would not
infer, however, that patients whose necks are
wrenched by whiplash or direct blow may not
suffer disabling injuries. Indeed, we hope to pre-
sent evidence that is quite to the contrary, for we
share the view of Sir Edward Appleton, the noted
physicist, who said in Cincinnati recently: “There
must be something the matter with the man who
goes to the doctor when there is nothing the
matter with him.” We would add that there is
probably little the matter with the man who goes
to his lawyer when there is something the matter
with him — unless perhaps he has “legal mortis,”
an apt phrase employed in a recent issue of the
Virginia State Medical Journal. We are not alone
in realizing the extent to which “whiplash” is
misused; yet this stock phrase has caught on so
widely, that we cannot hope to abolish it from
our vocabulary. The best we can do, probably, is
to bend our efforts to restoring proper meaning to
the term by defining some of the underlying dis-
orders responsible for the symptom complexes it is
used to describe. With this in mind, we would
draw attention to certain features of the anatomy
Jack C. Griffith, M.D,
Battle Creek, Michigan
of the cervical spine that render this area more
vulnerable to trauma than other parts.
Trauma to the cervical spine may be of suffi-
cient severity that disabling symptoms are notice-
able at the moment of impact. These symptoms
may persist. They may arise from fracture, rup-
tured disc or torn ligaments and seldom constitute
a difficult diagnostic problem. Experience is suffi-
cient in cases of this type to indicate a definite line
of therapy and also to form a prognostic estimate
with reasonable accuracy. It is the patient who
suffers what appears to be a mild injury, but who
then becomes progressively disabled with head-
ache, neck pain and/or arm and shoulder pain,
and emotional instability that tests one’s clinical
judgment. It is this type of trauma, with delayed
development of symptoms, that requires the most
careful analysis, lest tissue changes that might
respond to therapy be overlooked or lest the
examiner by evincing concern either add to the
anxiety of the injured or be duped into document-
ing the false claim of the malingerer.
Our general concept of pain transmission can
be summed up very briefly: If a major noxious
stimulus is applied to a sensory nerve, the pain is
felt in the dermatome or segments supplied by
that nerve. This is the case, for instance, with
ruptured disc or fracture. But if a nerve receives
repeated small stimuli (such as massage), each
stimulus may not register clinically. After many
such stimuli, however, the nerve becomes sen-
sitized and mass response is initiated. This reac-
tion results from the summation effect of subclini-
cal stimuli. It is the chronic bombardment of peri-
pheral nerve trunks due to mild massage that
would appear to account for the pain referred into
the head, neck and/or arm; vasomotor changes
that are noted in the eyes, nose and ears; and the
many subjective symptoms that appear to be
referable to the brain.
In 1949, one of us (FHM) and C. R. Hunter
presented the data from eleven patients who had
undergone section of the sensory root of the second
cervical nerve or who had had the greater occi-
1142
TMSMS
WHIPLASH INJURIES — MAYFIELD AND GRIFFITH
pital nerve avulsed for hemicranial pain. These
patients, for the most part, had been well until
sustaining an injury in which the neck was forci-
bly wrenched. They gave a history of more or
less constant discomfort post-traumatically in the
suboccipital region on the side involved which
they had come, over the months or the years, to
accept as their normal lot. But upon this chronic
discomfort, severe paroxysms of hemicranial pain
were superimposed. Usually, the bouts of severe
pain involved one side of the head, and always
the same side. Occasionally, when an attack was
most severe, the pain might spread to involve the
entire head. Ordinarily initiating in the subocci-
pital region, the pain would radiate to the vertex,
the temporal area and to the area about the eyes.
The attacks tended to be sudden in onset, often
occurring at night, and were associated with tear-
ing of the eyes, flushing of the face, alteration of
sweat, and (at times) occlusion of the nasal
passage on the side involved. Some patients
showed constriction of the pupil on the painful
side. A few had lancinating pain in the face
associated with these bouts. Most patients were
conscious of numbness and tingling of the parieto-
occipital area of the scalp. Some of them com-
plained of vertigo and a sense of dizziness during
severe paroxysms.
Our investigation of these operative cases was
based upon certain unusual features of the ana-
tomy of the upper neck. The first and second
cervical nerve roots emerge behind the lateral
articular masses. Posteriorly, the roots are not
protected by pedicles and facets which elsewhere
in the vertebral column complete the root canal.
There is relatively little range of motion between
the atlas and the occipital bone. And since the
sensory component of C 1 is so rarely present,
it is unlikely that this root often plays a part in
the production of symptoms. The joint between
the atlas and axis, however, is highly movable and
the anterior primary ramus of C 2, even under
normal circumstances, is subject to unusual stress.
The posterior primary ramus of C 2 which con-
tinues into the scalp as the greater occipital nerve
emerges between bony surfaces and is capable of
being crushed or traumatized by any movement
of the head which would tend to approximate
these surfaces. Within the normal range of mo-
tion of the neck, the second cervical nerve prob-
ably is not vulnerable to trauma. It would
appear, however, that if added force were applied
to the neck when it was already at its limit of
normal range, such as occurs with the usual
whiplash injury, damage to this structure could
occur. It appeared reasonable to assume that once
traumatized, structural changes in the nerve suffi-
cient to render it painful under otherwise normal
circumstances might occur. Plausibility was added
to this assumption by the fact that our observa-
tions following section of the root indicate that the
area of supply of the second cervical nerve is
greater than the textbooks record. Accordingly,
when one considers this peculiar vulnerability of
the second cervical nerve root to trauma, in con-
nection with the fact that the second cervical nerve
supplies sensation to the major portions of the
scalp and overlaps considerably into the face
area, it seems reasonable to assume that this struc-
ture may be responsible in certain instances for
unilateral head and/or face pain.
The original study reported eight cases in which
symptoms were initiated by trauma; these patients
were relieved by surgical treatment and (as far as
can be determined) have remained well. The
three patients whose symptoms were not pre-
cipitated by trauma were not benefited.; indeed,
it must be acknowledged that their situation may
have been aggravated by the surgery. At the pres-
ent time, 108 patients have undergone section of
the sensory root of the second cervical nerve; and
thirty-six patients have had the greater occipital
nerve avulsed. Some of these subsequently have
had root section. Sixty of the 108 treated with
section of the second cervical nerve are totally
relieved and approximately one half of those
treated by avulsion of the greater occipital nerve
have been afforded temporary relief for a period
of months. In certain instances, intraspinal section
of the nerve root has also been necessary. Our
overall experience with such patients has dimin-
ished the hope which we held at the outset that
interruption of this nerve pathway might resolve
the problem of the majority of patients who suffer
with this syndrome. On the other hand, we are
convinced that this is the source of pain in some
patients who suffer with intractable unilateral
head pain after trauma. It is our belief that
rection of the second cervical nerve root or avul-
sion of the greater occipital nerve can be under-
taken with reasonable confidence that relief will
follow in the patient disabled with post-traumatic
intractable suboccipital and hemicranial pain, pro-
vided that prior to injury he was symptomless and
September, 1957
1143
WHIPLASH INJURIES— MAYFIELD AND GRIFFITH
provided too that the following circumstances pre-
vail : ( 1 ) pain and tenderness in the region of the
second cervical nerve root and the greater occi-
pital nerve, upon which are superimposed dis-
abling bouts of severe pain, perhaps exaggerated
by movements of the neck (particularly on look-
ing upward) or by sleeping posture, and perhaps
increased by emotional tension; (2) substantial
reduction in pain sensation, as demonstrated by
pinprick, over the area of supply of the second
cervical nerve; (3) aggravation of symptoms by
passive movements of the neck which tend to
approximate the lamina of the first and second
cervical vertebrae.
Naturally, the patient who is emotionally un-
stable before trauma is not immune to this syn-
drome; and consideration must also be given to
the problem of the patient with a secondary
anxiety state triggered perhaps by pain or hos-
tility toward the employer or the driver of the
second car involved in the accident in which he
was exposed to injury. Such individuals, con-
ceivably, might be motivated by a selfish desire
for financial gain. It is not our intent to mini-
mize or ignore their suffering. It is simply that no
ready formula exists for dealing with them. That
stanza from the Rubaiyat , “Which is the potter,
pray, and which is the pot?” voices the dilemna,
and it is not lack of sympathy or compassion for
them that causes the clinician to leave such pa-
tients to their unhappy lot.
Evidence used to confirm our observations in
reference to this syndrome is chiefly clinical. In
only four patients in the series have x-ray studies
of the atlanto-axial joint revealed any abnormali-
ties. We have been able, however, to reproduce
the symptoms listed above during operation per-
formed under local anesthesia by stimlulation or
traction upon the greater occipital nerve (if avul-
sion were being done). In our early cases, an
attempt was made to gain information by stimu-
lating the nerve root intraspinally while operating
under local anesthesia. When the second cervical
nerve was stimulated, pain was referred to the
vertex and to the region behind the eye. When the
third cervical nerve was stimulated, the pain was
referred to the region about the ear and along
the lower jaw. Pathological sections of the avulsed
fragments of the greater occipital nerve usually
have shown some fragmentation of the myelin and
in one or two there has been fusiform enlargement
of the nerve. Sections of the sensory root have
not demonstrated sufficient organic change to be
convincing.
When doubt is present as to the syndrome,
avulsion of the greater occipital nerve is carried
©ut rather than intraspinal section. It is our prac-
tice to follow the nerve deeply into the neck and
then to pull it with the hope that the sensory fibers
will be pulled out of the cord or at least out of
the ganglion. This procedure also interrupts the
motor fibers and leads to mild atrophy of the sub-
occipital muscles. Aside from this, however, no
untoward effects need to be expected. Exceptions
to the rule do exist; there have been occasional
reports of paraplegia following this procedure.
Perhaps this is a risk that must be run and it is
debatable whether such isolated instances should
deter the surgeon from performing avulsion. In
cases where the patient has been relieved tem-
porarily and subsequently the return of sensation
causes the renewal of pain, we have then attacked
it intraspinally.
It is not our practice, however, to operate upon
all patients who present the findings described
above. Fortunately, the symptoms of most pa-
tients in this group subside spontaneously or after
reassurance, rest and head halter traction. It is
possible that the newer tranquilizing agents may
enable one to control the superimposed anxiety
symptoms to the extent that we can make a more
accurate appraisal in the future. We reserve sur-
gical treatment for those patients whose symptoms
do not respond to conservative measures. Avul-
sion is then resorted to, since it is not unlikely that
most post-traumatic head pain may be trans-
mitted in part at least through these nerves. It is
no less likely that the head pain of the tension
states also is transmitted through these structures.
In the hope of determining more accurately the
role of this root in all forms of hemicranial pain,
we have operated upon some thirty patients with
various types of pain involving one side of the
head and/or face. With rare exceptions, surgery
has been ineffective. Results have not been sig-
nificantly different in the industrial group as com-
pared to those patients whose injury could not
possibly represent a source of financial gain to
them.
Case Reports
Case 1. — M. L., a white woman, aged seventy-seven,
was first admitted December 3, 1951, with a history of
pain in the left mastoid region with radiation into the
left jaw and forehead. Physical examination was com-
1144
JMSMS
WHIPLASH INJURIES
MAYFIELD AND GRIFFITH
patible with the second cervical nerve syndrome. On
December 4, the left greater occipital nerve was avulsed.
The postoperative course was uneventful, and she was
discharged on December 1 1 asymptomatic.
She remained asymptomatic until December, 1956,
when following a fall in which she received a mild head
injury, she had a recurrence of her pain. Again the pain
began in the left mastoid region with radiation to the
forehead. The pain was mild at the onset, but with
time became progressively more severe. She was re-
admitted on March 7, 1957.
Physical examination, on admission, showed the left
posterior neck and scalp to be tender to touch with
marked tenderness over the greater occipital nerve. The
scalp distribution of the greater occipital nerve showed
hypalgesia to pinprick and there was the scar from pre-
vious surgery. On March 8, the greater occipital nerve
which had regenerated was again avulse. The post-
operative course again was uneventful and she was dis-
charged on March 12, 1957, asymptomatic, and has
remained so.
Case 2. — A. W., a young white woman, aged twenty-
six, was admitted on May 2, 1957, with a history of
being in an automobile accident eight or nine years
ago. She did not remember whether or not she received
a neck injury at this time.
She was asymptomatic until two years prior to the
present admission, when she developed a dull ache at the
base of her skull. This ache persisted and one year prior
to admission the ache became more severe and radiated
to the top of her head. The pain was relatively con-
stant but the intensity varied and the severity increased
up to the time of admission.
Physical examination showed tenderness over both
greater occipital nerves and hypesthesia in the G 2 dis-
tribution bilaterally. On May 7 a cervical laminectomy
was performed and the posterior roots of the second
cervical nerve were cut bilaterally.
The postoperative course was uneventful, and she was
discharged free of headache on May 15, 1957, and has
remained so.
Case 3. — L. R., a white woman, aged sixty-three, was
admitted on March 9, 1957, with a history of being in
an automobile accident in September, 1955. In this
accident, she sustained a mild injury to the left side of
her head and neck. Following this she developed pain
located at the base of the skull and the left posterior
half of her head. The pain remained constant for three
months, then subsided for a few days, only to recur.
The pain then persisted until the time of admission.
Physical examination showed tenderness over the left
greater occipital nerve and hypalgesia in its distribution.
On March 12, a second cervical posterior rooh rhizotomy
on the left was performed. The postoperative course
was uneventful and she was discharged asymptomatic
and has remained so.
The above case histories involved injury to the
second cervical nerve. The lower cervical joints
differ substantially from other joints in the spine
in that, instead of three joints — two facets and
one intervertebral joint — there are five. In addi-
tion, two are synovial joints that in part surround
the disc, paticularly in the area of the root canals.
They are spoken of as the lateral vertebral joints
of Luschka. These are not present elsewhere in
the spine. They are subject to inflammatory and
traumatic reactions, as is any synovial joint, and
when inflamed or traumatized, they heal by cal-
cium deposits within the synovia; and these cal-
cium deposits narrow the root canals through
which the cervical nerves emerge. When the canals
are narrowed, the nerve root is subject to massage
with each movement of the neck.
We are now in the process of reviewing the
histories of patients who have been operated upon
for removal of cervical disc for the purpose of
determining the incidence of head pain associated
with this disorder and the incidence of relief
following removal of the lesion. The statistical
analysis has not been completed; but it is our
impression that the coincidence of headache with
these lesions and the relief of pain following their
surgical removal is substantial. We are unable at
this time to define with confidence methods of
diagnosing this disorder or of clarifying the paths
of transmission, except to recount possible path-
ways which may play a role. There are communi-
cating branches from the cervical plexus to the
vagus and hypoglosseal nerves from both C 1 and
C 2. The superior cervical sympathetic ganglion
has direct communications with cervical roots one
to four.
Corbin and Hinsey have shown by degeneration
experiments in cats that the ascending sensory
branches of the upper four cervical nerves ascend
dorsomedial to the substantia gelatinosa of the
upper cervical cord and in a similar position with
relation to the spinal tract of the fifth nerve in the
medulla, terminating at the level of exit of the
glossopharyngeal nerve. Connections are made
along the way with the intermediate nucleus of the
medulla and with the cuneatenuclei, the fasciculus
solitarius and the descending vestibular nucleus
and tract. Foerster has demonstrated that stimu-
lation of the distal cut end of a dorsal root pro-
duces vasodilatation in the dermatome. Bridges
recently has confirmed this for the cervical roots.
There are intimate communications between the
sympathetic chain of the neck and the roots and
September, 1957
1145
WHIPLASH INJURIES— MAYFIELD AND GRIFFITH
it is not unreasonable to presume that bombard-
ment of these structures with painful stimuli is
sufficient to induce secondary autonomic changes
in the head and face, such as reddening of the eyes
and edema of the nasal mucous membrane.
Inasmuch as the synovial joints of Luschka
surround a lage part of the discs in the cervical
area, the discs are necessarily smaller than the
other parts of the spine and do not extend to the
lateral margin of the vertebrae. Hence, extrusion
of the disc is less frequent, the posterior margin
of the joint space in the cervical area is more nar-
row than the anterior, which further lessens the
likelihood of disc extrusion. Disc extrusions do
occur, however; and when they do, they are apt
to induce symptoms immediately after trauma,
which may of course subside with rest, traction,
and immobilization; but usually they produce a
characteristic clinical picture of pain in the neck,
shoulder and arm, along with certain areas of
sensory, motor and reflex defects in the painful
extremity. They may in addition induce chronic
head and neck pain, but this is not necessarily so.
In contrast to this, the gradually increasing cal-
cium deposits in the joints of Luschka subject the
patient to pain long before definite root phenom-
ena are demonstrated, for usually these signs do
not appear until the circulation of the roots is
interfered with.
Case Reports
Case 4. — N. M., a white woman, aged forty-three,
was admitted on September 21, 1956, with a history
of being in an automobile accident in June, 1955. In
this accident, she received a whiplash type of injury to
her neck. Following the accident, she developed pain
in her right neck and shoulder and a right-sided head-
ache. These symptoms persisted, varying in intensity,
but showing a progressive increase in severity. She had
been hospitalized elsewhere in October, 1955, and June,
1956, and had received conservative therapy without
significant improvement.
Physical examination showed the upper extremity to
be subjectively weak in all muscle groups. Neck motion
was restricted and painful. Myelogram showed a defect
in the oil column at C 5-6 level on the right (Fig. 1).
On October 2, a cervical laminectomy was per-
formed and a calcified mass removed from the inter-
space between the fifth and sixth cervical vertebrae on
the right. The postoperative course was uneventful and
she was discharged asymptomatic and has remained so.
Case 5. — M. H., a white woman, aged fifty-one, was
admitted on February 12, 1957, with a history of pain
in the left face of twenty-five years’ duration. This
had been intermittent, lasting hours to days.
In 1952, she developed pain in the left shoulder and
neck. This was treated by traction with improvement of
the neck and shoulder pain. The face pain, however,
became worse and remained constant up to the time of
admission. During this time, she had consulted many
doctors and had received many kinds of therapy includ-
ing alcohol injection of the nerve supplying the face.
(Continued on Page 1161)
1146
JMSMS
Emotional Problems in Driving
By John M. Dorsey, M.D.
Detroit, Michigan
During the year I have emphasized three vital subjects: the personal touch in medicine, the necessity for freedom
in medical practice, and professional unity. . . . The cold, brisk, and impersonal attitude toward patients is on its
way out, and I say good riddance.
Dwight H. Murray, M.D.* *
“and the drivers are stupefied. They are in confusion
in the ways the chariots jostle one against another in
the streets: their looks are like torches, like lightning
running to and fro.”**
TN PRODUCING and assembling my views on
this topic of motion and emotion, I reminded
myself again and again of the necessity to main-
tain a good-natured attitude in such tooling up,
the number of traffic fatalities occurring on a holi-
day week-end giving my imagination many a
gloomy detour.f It occurred to me that a most
appropriate patron saint of the motorist might be
one who was tortured on the wheel, a kind of
martyr to the cause. My countiy’s rolling economy
has its awfully wonderful aspect. The traffic scene
in the United States is such an enormous one that
it can be comprehended only in a piecemeal way,
such as: some seventy-million drivers, some sixty-
million motor cars, some three and one-half million
miles of roadway.ff
To recover my proper medical balance of one-
ness, hope, and cheer, I acknowledged my deep
appreciation for my trusty car and my increasing
devotion to safe and sane automobile living. A
gratifying experience which, in every instance of
it, serves to give me a new lease on life, is to ob-
From Wayne State University College of Medicine,
Detroit, Michigan.
*From presidential address before the House of Dele-
gates: AM A Journal, 164: No. 8, June 2, 1957.
**Prophecy from the Book of Nahum, II, 3-4, 600
B.C.
t“During the past year, over 35,000 individuals were
killed, and almost a million injured in motor vehicle ac-
cidents in the United States. In the armed forces alone,
1,610 persons were killed and another 10,360 injured
in off-duty driving accidents. The economic cost of
accidents through property damage, injury and lost time
is staggering. In 1954, estimates for the country as a
whole ranged as high as 4.5 billion in direct costs, and
another 15.5 billion in indirect costs. The armed forces
have computed that the average fatal accident of a
serviceman costs the government $43,000.” — John J.
Conger, Ph.D., et al: Personal and Interpersonal Factors
in Motor Accidents. The American Journal of Psychiatry,
113: No. 12, June, 1957.
ffA most helpful book prepared under the leadership
of Edward W. Pepyne, Driver Education Consultant:
Man and the Motor Car, Fifth edition. New York:
Prentice-Hall, Inc., 1954.
September, 1957
serve myself extending my study and practice of
civilized living to include my riding a curve, mak-
ing a light, or “putting the show on the road” gen-
erally. It is truly a sight for sore eyes to observe a
driver whose interest in the love that passes under-
standing transcends his infatuation with the car
that passes others.
Every physician is a physician basically by virtue
of the value he places upon human life. From the
time of Hippocrates, medical orientation has recog-
nized that human life implies human individuality.
It is an established fact that, up through the ages,
human leadership in every other educational
direction has been beholden to medical lead-
ership, specifically to the physician’s fidelity to
the individual variant as the vantage point of his
study and practice. Now again in the diagnosis
and treatment of his traffic ills, the physician is
foremost in seeing clearly that every traffic problem
is necessarily a problem to a given individual.
Of all of the many ways in which traffic emo-
tional problems might be presented, I choose this
personal way of considering each one of them as
entirely my own, for I regard it as the ideal medi-
cal scientific “method of choice.”
Since traffic violations number well over ten mil-
lion a year, since well over one million Americans
have now been killed in automobile accidents in-
volving chiefly collision and car out of control,
since this distressing emotional picture of traffic
toll of human life follows regularly its grim pattern
year in and year out, and since traffic safety cam-
paigns have always proved effective in evolving
new methods, therefore may it be now just the
ideal moment for every physician to point out, and
keep pointing out , that responsibility cannot be
lived in any way whatsoever except in a single
solitary human individual!**
**The cry, “Get a horse,” is no solution. The driven
horse was a far greater killer than the automobile. See
Reginald M. Cleveland, and S. T. Williamson: The
Road Is Yours, New York: The Greystone Press, 1951.
A fascinating account of the “men of stout heart whose
vision and courage set America awheel.”
1147
EMOTIONAL PROBLEMS IN DRIVING— DORSEY
Every motorist and pedestrian needs to grow in
himself what corresponds, in the illusional and un-
tenable language of “intercommunication,” to a
thorough “public-relations selling job” on the
head of fixing responsibility where it is to be
found, within himself. If, and when, responsibility
is thus lived sanely, all insane guilt or blame is
renounced.
Perspective
When a man dies, it means that a part has worn
out. — Henry Ford.
It is desirable that every mind cultivate an ap-
preciation of how and why scientific method is
both an issue of, and a way to, progressive life.
Modern scientific living bases itself upon observa-
tion. The views of automotive living expressed
here are intentionally individualistic, purposefully
selfish, professionally personal. I might as well
hide myself in Latin or Greek as in a vocabulary
of “elseness” or “otherness” or “externality” which
appears to rule me out. Calling any part of my
own living “not mine”, is a self-evident instance of
being unable to call that part of my soul my own.
As a culmination of my thirty-two years of work
as a medical educator, I find my sources of greatest
emotional helpfulness to lie in my insights, my ob-
servations which I am able to recognize as taking
place in my own mind. Every kind of living which
passes for mental disorder, including emotional
instability, is traceable to insight deficiency, to
living myself inside out, without realizing that
what I call “outside” is lived only inside of me.f
Every kind of living which I sense as representing
mental health and strength is traceable to insight
sufficiency. However, as Shaw said, “I dislike
feeling at home when I am abroad.” Neither my
likes nor dislikes, about any traffic necessity of
mine can alter the reality of it to the slightest
degree.
It is but natural, therefore, that I attempt the
treatment of any and every kind of problem in
my world from the standpoint of exposing it to
the intimate view afforded only by my personal
living of it. My every thought has emotional prop-
erty and, in that basic sense, any and every traffic
problem of mine may be conceived as an emotion-
al one. My world is as my mind creates it and
views it. In this sense it may be described most
accurately as a psychological world. The world of
myself, my world which has any and all meaning
tjohn M. Dorsey, M.D., Living Education. Michigan
Educational Journal, April and May issues, 1957.
for me, may be considered as observable by my
mind’s eye. From the vantage point of literal med-
ical pyrrhonism, I will proceed to “have a look”
at certain of the emotional aspects of motoring,
specifically with an eye for: What difference does
it make if I see my world traffic problem as my
own or not? How can I make sure that I con-
tribute to my world’s peaceful driving?
Since thick traffic, especially, is a mob scene,
having in it all of the potential disorder of mob
living of each driver, self-conscious living is clear-
ly the specific antidote for everyone to employ, if
he will spare himself the insanities of a mobster.
This is a hard saying, to myself, but I find my driv-
ing much harder without the courage for this emo-
tional and intellectual honesty. Furthermore, to
maintain the driving improvement which this in-
sight affords me, I must practice the exercise of
it, as in this writing: earnestly, faithfully, syste-
matically. Any of my alleged science which dis-
regards the only basis for its being, self observa-
tion, for me, is true quackery.
Accidents as well as sicknesses will happen. It
is impossible for any accident or sickness to occur
unless every force necessitating it is present and
working. The term “accident,” as well as “sick-
ness,” may be seen as a costly misnomer. It is
healthful to be able to view every accident or sick-
ness kindly, in the sense that it reveals life-saving
insights. I have found it helpful to renounce my
attitudes of “fighting” accident or disease in favor
of peacefully studying it, so that I may profit
from the life-preserving lesson which the careful
and caring investigation of it provides.
As a physician, renouncing extraordinary pro-
fessional driving privileges, I may not well overlook
the study of my, including my patient’s, whole con-
dition for driving. An awakening to this kind of
safety consciousness is part of the reward for every
doctor’s self-contained scientific interest in, and
reverence for, the majesty of man.
“Physicians ride the highways daily, and few groups
exceed them in the frequency of use of motor vehicles.
Therefore, they know at first hand that physiologic and
psychologic factors determine the fitness of drivers, their
reflex movements, the adequacy of their training, and,
perhaps most important, their awareness of their own
health limitations, including factors relating to mental
health.”*
*Irving Graef, M.D.: Physicians and Automobile Ac-
cidents. See helpful reprint on Symposium, Medical
Aspects of Motor Vehicle Accident Prevention, New
York State Journal of Medicine, 56: No. 24, Dec. 15,
1956.
1148
JMSMS
EMOTIONAL PROBLEMS IN DRIVING— DORSEY
The study of my mind is always good medicine
when it seem to be too narrow, and an excellent
antidote for any philosophizing about any life
which is not clearly my own. All automotive liv-
ing is in every instance nothing but the emotional
living of an individual human being.
“To understand both the healthy and the malignant
emotional patterns, how they operate, in whom, when,
and to incorporate the findings within a logical over-
all theory of accident phenomena will be a great ac-
complishment indeed. It is hardly necessary to add
that such an accomplishment will not come about over-
night. The answers, as most of the answers involving
human behavior, will come slowly and piecemeal.”**
Temper Is Too Valuable To Lose
The fact is this: the lonely man, who is also the tragic
man, is invariably the man who loves life dearly — which
is to say, the joyful man. — Thomas Wolfe.f
Much, as well as little, is known about emo-
tionality; “much,” in that every bit of it is of
vital importance, “little,” in that there evidently
remains far, far, more to be discovered. This
much, however, is already clear: an emotional
block is always a potential traffic block; an emo-
tional attack, or blowout, is always a potential
traffic accident: impoverished emotionally, so-
called “bloodless” living, favoring indifference and
carelessness, is always a potential fatality; a rich,
ranging, resilient emotional person, capable of
living self-composedly each of his feelings in all
of its quantities, is the potential ideal motorist.
Pain of any kind or degree is a life-saving sign
that I am endangering my existence. Unhappy
emotions are forms of self hurt. Each of my
painful emotions may be reviewed as being a
signal to me that I am not living enough of
myself sufficiently consciously. Thus, fear always
involves my regarding my somebody, or some-
thing, else as not mine, and hence as potentially
destructive; hate always signalizes the same kind
of dissociation — my hating, or being hated by,
“another”; guilt is a form of self hate deriving
from my feeling unworthy before my “other one” ;
envy is my effort to compensate for my ignorance
that my superior other one is lived entirely by
me; jealousy is a sign that I have dispossessed
myself of love; shame is my sense of embarrassed
self, a compensation for my lack of insight that
**John Maclver, M.D., and William P. Shepard,
M.D.: Human Factors in Accidents. Ibid.
fThe Anatomy of Loneliness.
all exposure is self-exposure; disgust is my feeling
of revulsion unconsciously conecting me with a
part of my repudiated self which I would expel;
distrust, doubt, suspicion, superstition, — each is
clearly a feeling signalizing my repudiation of my
own self power.
Human living is emotional living. Whatever
exists in me, exists emotionally. Whether or not
I am able to be aware of my emotionality does
not affect its existence. It is greatly to my ad-
vantage to be able to be aware that I am an
emotional person, however. Otherwise, I may
habitually live wrathfully, vengefully, fearfully,
and so on, without realizing it, and, hence, with-
out being able to feel how I am thereby hurting
myself. For instance, entirely unsuspected as such,
my facial pallor may be an expression of my
habit of mind of living in despair, or constant
fear; or my flush, an unrealized sign of my habit
of mind of feeling constantly ashamed, or out-
raged; and so on and on.
Emotional “sobriety” is a matter of my feeling
my emotions as my own. “Soberness” does not
mean “unemotional”; it does mean: not drunk
with my emotion, but able to enjoy it in a self-
contained way. My driving without being able
to sense my emotions as mine and only about me
is a form of drunk driving. An autoist cannot
well afford to live himself as an absentee auto-
crat, lacking an evident accessible self-starter and
self-stopper. Driving a car calls for all of the
presence of mind which the emotional sanity of
self-realization, the height of human helpfulness,
alone can provide.
My long suffering reader here cries out:
“Hold on there! Unless you want me to put this
down as all stuff and nonsense, let me point out to you
a few things. I always realized that my emotions related
me to my fellowman, beginning with my mother and
father. Now you claim that what I used to help myself
with, in building up my human relationships, is a source
of mental disorder for me! In fact, you claim that I
keep myself immoderate, extreme, and generally uneco-
nomical, by not seeing that all of my ‘elseness’ and
‘otherness’ is really mine, by not seeing that all of my
so-called ‘relatedness’ is entirely my own inside living.
According to you, my jealousy of my unfaithful mate
would all subside and I would again be able to feel
loving if I could see clearly that my mate is all and
lovably only mine, and that I can love her truly only
as ‘unfaithful’ to herself and therefore needing to cure
herself of this self-cruelty! According to you, my feel-
ing of persecution would give way to natural loving
September, 1957
1149
EMOTIONAL PROBLEMS IN DRIVING— DORSEY
kindness, if I could see that I am living all of my own
persecutor and hence could see that he can only be
attacking himself by calling his own victim “not his”!
You claim that what you live consciously of yourself
can never be used for cancer formation, or life dissocia-
tion of any kind! Now, what I want to know is this,
How does all of that super-duper selfishness differ from
egomania, from megalomania? I saw a fellow once who
thought he was Napoleon, and another one who thought
he was the son of God, and each one was diagnosed
as suffering from delusions of grandeur. Now you claim
to be your own everything! But you'll say my despair is
just the painful sign that I’m looking for outside help!”
Yes, my every emotion is lived by me, but is
not about all of me. My love is all and only
about love, my hate is all and only about hate,
my fear all and only about itself, and so on.
Yes, living my mind in a way which works
smoothly and harmoniously does necessitate ac-
curate self-accounting. I may not confuse one
part with all of myself, or the converse.
Yes, I am my own everything and feel grand
about it, but I also see my “you” as your own
everything, and also see that you cannot feel
grand about it until you see yourself in that ac-
curate, full, measure.
And, also, yes, my desperation is always trace-
able to my dogged determination to seek for
help where it cannot be found, in the nowhere of
not-I. My emotional hopelessness is ever a pain-
ful sign that I am not living myself in a hope-
ful way, that is, with the clear, sober, appreciation
of my all comprehending human individuality.
Otherwise, I would see that while there is life,
there is hope.
To be specific, once I fail to see my fellow
autoist as my own, I prepare myself thereby to
suffer any and every painful feeling, without
realizing that I am bringing it upon myself
through this failure. I may become enraged or
uncaring, fearful or reckless, accusatory or ir-
responsible, envious or scornful, and so on, and
thus continue to hurt myself by living my enemy,
or my stranger, as “not mine at all.”
The efficacious treatment of each one of my
emotional problems lies in my appreciation and
continuous development of the extent of my self-
possession and. hence, of my necessity for self-
reliance. “God helps him who helps himself,”
is a view which encompasses the truth of the all-
ness of individuality. This observation of self-
consciousness as being the only possible ground
of honest self-knowledge, the equating of self-
consciousness with divinity, is reminiscent of my
St. Augustine’s consciousness of his self living, of
my Descarte’s self-consciousness, of my Male-
branche’s self appreciation, and of my psycho-
analyst’s view that making self a conscious self
is a healthful procedure. Of my fellowman I can
only observe, with holy writ: “Ye are gods.”
After all, is there any possible feeling of certainty,
apart from self-consciousness? What is not a
personal problem is no problem at all. “I am
speaking of, and for, myself,” must be my funda-
mental view in my attempt to treat my traffic
syndrome. The free feeling of “my living me” is
the central principle of my life. Each one of my
sensations and perceptions is a primary form of
the activity of my personality and, as such, rep-
resents my growing individuality.
Whenever my distressing emotion fails as a
signal of mine which I can use for saving my-
self from the risks of self anesthesia, it must ap-
pear to me to “take over,” to take up my self-
awareness, so that I feel myself “in a panic” of
this specific emotional distress. I may then pro-
ceed to try to make the best of a disabling cir-
cumstance, to suffer the “knock” of my mental
motor as signs that its cylinders are missing.
As Helen Keller observes in beginning the
story of her life, it is with a kind of fear, “a
superstitious hesitation,” that I publish my
views upon my emotional problems in my traffic
living. All I can ask, and that I do ask, is that
my reader consider the author of this report as
his patient, as one who recognizes that he is both
mentally ill and weak, hence needing to heal and
strengthen his mind. Again with Helen Keller,
I do feel that “the higher truths relating to every-
day life” do “embarrass most people as much as
the company of great men.” Self-blind as I am,
to the extent that I am unconscious of myself,
I too exclaim:
“What if a ray of light should flash through the
darkened chambers of my soul? What would happen,
I ask many and many a time. Would the bow-and-
string tension of life snap? Would the heart, over-
weighted with sudden joy, stop beating for very excess
of happiness?”*
Emotion in every kind and degree is a sign
of life and a precious source of vitality. Any
and every emotional problem is therefore not
*Helen Keller: The Story of My Life. New York:
Grosset and Dunlap, 1905.
1150
JMSMS
EMOTIONAL PROBLEMS IN DRIVING— DORSEY
truly a problem inherent in the emotion itself,
but one inherent in the particularly difficult way
in which the emotion, simple clear and precious
in itself, is experienced. It is fully well to be
able to be conscious of every human feeling, or
emotion, with composure. It is not so well to be
intolerant of any human feeling, or emotion, with
or without composure.
Driving a car tests the extent to which I have
developed my ability to live emotionally with
self-composure. A precious safety measure is
the insight: My driving always involves excit-
ing emotional living. Preparedness for my own
“internal combustion” helps to prevent my over-
whelming myself with various strong drives neces-
sarily associated with my traffic driving. Both
intense pleasures and severe pains, such as annoy-
ance, anger, righteous indignation, envy, rivalry,
guilt, fear, distrust, embarrassment, shame and
so on are dangerously distracting driving distresses.
It is up to me to grow able to live any such
feeling with self-control, in order to have my
car under control.**
There is no worse form of illness than ill man-
ners. A test of my readiness to live myself in
a good-natured, well-mannered way is adminis-
tered every time I drive my car. I am indeed
fortunate when I am sufficiently rested and self-
contained to live the highway statesmanship of
my fellow motorist really as mine, observing my
pedestrian really as mine, recognizing all of my
automobile world as really mine. The easier it
seems for me to live myself as if I could be
transported “out of my mind,” as in times of
loud exasperation or quiet despair, the less able
am I to concentrate on the exigencies of my real
motor transportation. The height of good man-
ners is: minding my own business. Wilbur Shaw
sagely observed about the “mortal sin” of inat-
tentive driving: “A good driver is invariably a
veiy poor riding companion, because he always
has his mind on his work not on his entertain-
ment.”!
A “self-contained person” is one who is aware
that he contains all of his pleasant and painful
**John M. Dorsey, M.D., Psychological Medicine.
The Journal of the Michigan State Medical Society (to
be published).
fAlso according to Shaw, the President of the In-
dianapolis Speedway Corporation, “In my opinion, the
most courteous — or sportsmanlike — people on the road
are the much maligned women drivers.” See Paul W.
Kearney; How to Drive Better and Avoid Accidents.
New York: Thomas Y. Crowell Company, 1953.
September, 1957
human feelings, one who is continent in that
his emotions do not “spill over.” The emotional
component of my traffic living is ever great,
often enormous, always contingent upon innumer-
able unpredictable events, and constantly a source
of possible fatal interference with my driving ef-
ficiency.
As a motorist I help myself emotionally exclu-
sively by realizing that my world, including my
traffic is the creation of my own self, a produc-
tion of my very own activity. With my Novalis
I may say, “Why need we traverse the difficult
roads through physical nature? The better and
purer road lies within our own mind.” Thus I
may see the true expansion of my selfhood, finding
my own individuality behind the veil I draw of
“external world,” recognizing my “externality”
as my own product, as nothing but a wonderful
means of mine for carrying on my individuality
most happily. What living of mine I cannot
identify as entirely an existence of my own is an
illusion of mine, a reality of me which I cannot
observe as such. When my Herbart recognized the
study of mind as a legitimate self-interest he,
thereby, introduced the importance of renouncing
all other study. “I am my own ‘ancients,’ ‘tradi-
tion,’ ‘authority,’ ‘history,’ ‘impersonal,’ and any
other psychologism,” — is the finding and founding
of myself indispensable for my self-conscious liv-
ing.
Another one of my readers resists this view:
“Doctor, when I have been indulging the habit of
mind, you would say, of not even questioning the ex-
istence of an external world entirely outside of me,
what harm can there be to my driving if I just go on
living in the same way that some three billion of my
fellowmen live. In fact, wouldn’t it annoy me, so
that I’d better draw over to the side of the road and
stop, to be constantly owning up, as you would describe
it, to all of my traffic living? Can’t I live a more serene
emotional life by believing ( 1 ) somebody else can help
me, and (2) I can help somebody else, than by seeing
that ( 1 ) my somebody else can only help himself and
(2) I can only help myself?”
As I ask myself each of these questions, I see
clearly that my self-reliance, sense of self-posses-
sion, self-confidence, and self-esteem, in fact,
every self element of mine, benefits from my
living the truth of my oneness, and that the emo-
tional gain of an accurate self-estimate is of life-
saving driving help for me. Also, the habit of
mind of owning up to my living is to be attained
1151
EMOTIONAL PROBLEMS IN DRIVING— DORSEY
gradually and simply by practice. And, lastly, my
appreciation of my self-helpfulness is my very most
cherished one, which I enjoy most happily in its
corresponding expression in my fellowman.
Human life is nothing except the life of each
separate individual human being, and it is nowhere
else to be found. My taedium vitae is the direct
outcome of ignored sources of liveliness in myself.
I need naturally to see myself in every part of my
world, not just in its front side or rear view mir-
rors, in order to clear my senses to revere my in-
dividuality. With each new model of car and ex-
pressway, for safety’s sake, must go a new model of
driver equipped with the virtue of how to use
them: Self-insight. My tranquilizing drug may
appear to “quiet my nerves,” but it requires the
growth of my self-consciousness to bring my seren-
ity of spirit, stamina of soul, strength of sincerity.
After all, “traffic” is exactly what each one
makes it out to be. Apart from its meaning for and
in each individual, it can have no other meaning.
As I live myself emotionally, so do I drive emotion-
ally. As one of my friends keenly observed:
“Any Detroit traffic condition depends largely upon
which side of the bed I get out on each morning. When
I feel up to it, the ‘traffic’ goes along smoothly and I
marvel at the few snarls and ‘ham’ drivers. I can even
enjoy seeing how each driver expresses his individuality
as best he can in his driving. On other mornings,
though, nothing seems to go well in traffic, nothing!
Then everybody, everyone that I see anyway, looks like
a hit-and-run driver, as if he shouldn’t have a driver’s
license. He’s asleep at the wheel, hogging the road,
speeding, or stalled, or something that he oughtn’t be.
That’s just the day I shouldn’t drive on, — trouble
everywhere, how can I keep out of it.”
Defensive Driving
To any serious observer the basic flaw in our ap-
proach to the traffic problem has been our universal
misconception of the driver’s license and what it means.
- — Paul W. Kearney.
An essential qualification for every driver,
which is becoming more and more appreciated
as a life-saving attribute, is that of his capacity
to develop defensive driving* Density of traffic
now requires that I grow myself as a defensive
driver, if I would avoid remaining an offensive
one.
Defensive driving may be loosely defined as
*See Charlotte Montgomery: Handbook for the
Woman Driver. New York: The Vanguard Press, 1955.
This author kindly prefers the term “Wide-span driving,”
a wording which renounces violence and introduces the
high man-powered meaning: Attention!
“driving for the other fellow,” but it means ob-
serving that my “other fellow” is driving for him-
self, that he is living his immediate necessities
in terms of the way he conducts his life generally.
At first sight this view, “recognizing my responsi-
bility for taking into account my fellow driver’s
inexpertness,” may seem beyond my understand-
ing. How helpful it is for me to acknowledge
that every bit of progress in my development has
been made up against that some ominous force,
the Un-understandable! To see myself with this
great souled enlightened selfishness in as much of
my living as possible is the finest possible discipline
of my sense of value, of my feeling of worth, of
my appreciation of my life itself.
There are some two million new drivers be-
ginning each year. Nothing can possibly reach
the masses of traffickers except through each in-
dividual driver. My review of automotive mean-
ings for the preparation of this study has definitely
improved me as a defensive driver. The finest
physician is the one who sees he is a self-made
physician ; the best driver is the one who sees
he is a self-made careful driver. It is the mere
feeling for my life which provides me with the
effective motivation for caring for my fellow
driver as mine. Nothing else can. What I live
consciously is what I cherish consciously.
My highway truck driver has succeeded in
“making a fine name for himself” as a decent
fellow citizen of the road largely through his
kind defensive driving. The more my emotional
life harmonizes with my sense of self-possession,
the greater is my capacity to become a defensive
driver. Every really new slant on my growing
up more helpfully is first viewed as repugnant to
my habit of mind. For instance, the view, “Diag-
nose and treat my traffic violator as myself,” will
always blind me until I feel emotionally that I
really help myself with it.
In all kinds of behavior where good taste based
upon self-interest does not motivate my driving
etiquette, for my wide-span driving I must call
upon the next best source of self-care, namely
superficial politeness. When I do not, and cannot,
feel emotionally my well-mannered or ill-man-
nered fellow motorist as mine, I may compensate
helpfully for this “case of mistaken identity”
within me, bv shallow civility, by pretending
equality.
As I invest my living attention in my fellow
driver, I thereby test my ability to live myself
1152
TMSMS
EMOTIONAL PROBLEMS IN PRIVING— DORSEY
kindly in that particular identification. The great-
er my ability to tolerate kindly the inexpert driv-
ing of my fellow driver, the greater my readiness
for my traffic living, — and the converse.
Quite as I tend to arrogate to myself greater
mental health and strength than I really have,
so particularly do I tend to consider myself a
safer driver than I really am. This specific self-
deception that I am more expert in traffic living
than the facts warrant alone accounts for my
contribution to the density of traffic. Mechanical
devices unquestionably making my driving easier
and safer, in every instance also may make it
more difficult and dangerous, in that they greatly
favor my illusion, “I am not now taking so many
chances even if I am not the best of drivers.”
The “newest thing” in a revolver makes it no
safer for Russian roulette.
What difference does it make to me if I call
my fellow driver mine, if he happens to be in-
toxicated and drives his car in such a way that
I cannot avoid a collision injuring myself severely?
It makes all the difference in my being able to be
kind to myself following my accident, in my es-
caping the narrow-minded view that two wrongs
(to myself) can make a right, in my avoiding
constantly torturing myself with feelings of bit-
terness and obsessing myself with derogatory
ideas. By viewing the whole painful experience
as my own I can help myself directly the most,
and my intoxicated fellowman can help himself
most. This self-kindness is the most economic
force of all for guaranteeing my every kind of
recovery, healthfully and wealthfully. With kind-
ness, distributive justice proceeds best, amends
being made as reparations, not as terrors. With
kindness my healing process enjoys the most fa-
vorable course — synergic intentions, not cross-pur-
poses.
Anterior to my traffic safety’s shaky three E’s
(Education, Engineering, and Enforcement) is
always its solid I. The deep and wide-span driving
which enables me to see my mind in myself and
keep myself in mind is a hidden critical factor
in good driving. By concentrating upon myself
as my world, I accumulate mileage on the right
side of the right road leading in the right direc-
tion. 1
The indomitable force of the feeling of kindness
is all too rarely appreciated, all on account of the
fact that kindness is all too rarely recognized for
what it always is: Self-kindness. All unkindness
likewise is self-unkindness, and motoring unkind-
ness may be suicidal. To the three R’s for safety’s
sake, now is being added a fourth: Riding. A
basic text for driving school, “Watch everything,
far and near,”* highlights the necessity for the
protective use of my mind’s eye also.
I, including all of my fellowmen, have grown
too rapidly as a motorist to be able to stabilize
myself sanely on that level. Jokes have been made
over the fact that our national flower is the golden
rod even though ours is a car-nation. My young
American male now regards his readiness to
drive an automobile as a kind of maturity test.
His steering and maneuvering a car have some-
thing . of the significance for him which aiming
and deftness with a gun had for his pioneer
ancestors. Some grisly traffic humor proposes
that the driver put a notch on his steering wheel
for every pedestrian he runs down. Much car
advertising appeal now is essentially that which
attracts the emotions of the precious child in
my nature. It appears to be leveled at that won-
derful stage of my development which was ac-
curately high and mighty, but which did not in-
clude my equally precious fellow driver in my
comprehension of myself.
Perhaps the most misleading view of my auto-
mobile living, corrected somewhat in my con-
vertible with the top down, is the illusion that it
is a private life which does not include my public
welfare. The illusion that I am “inside looking
out” may take over to such an extent that my
realization of living my “outside” within me may
be correspondingly dim. The key to a happy full
life is to be able to see clearly all that is in that
life. I cannot consider myself with anything like
a full view without having a happy sense of self-
fulfillment.
Traffic Sanity
“Now in building of chaises, I tell you what,
There is always somewhere a weakest spot.” — Holmes
The public health significance of mind con-
sciousness, of living my self consciously, is no
where illustrated more clearly than in driving.
Thus, it is sometimes strikingly evident that, as a
motorist, I hide myself behind a feeling of anony-
mity. This lack of a sense, or feeling, of personal
identity is what characterizes every bit of my
“wild” behavior in every kind of mob action.
**Frank Williams: How to Drive and Stay Alive.
Greenlawn, New York: Harian Publications, 1954.
September, 1957
1153
EMOTIONAL PROBLEMS IN DRIVING— DORSEY
Hence, having my traffic officer ask for my name
and address accomplishes most for bringing myself
to my senses. It has occurred to me that the
simple method of having my name conspicuously
appearing on the outside of my automobile would
greatly favor my peaceful driving. A sane driver
is a self-oriented one.
On the other hand, I can sense my need to
identify myself with my automobile, even to the
extent of driving it as if it were a continuation
of my own body. It does seem natural to expect
and demand that my driver identity, as an ego-
mobile, lend itself to much greater use in my
seeing to it that my ipsomobilet is in good driv-
ing condition, and that I, including my fellow
driver and fellow pedestrian, escape harm. Van-
nevar Bush said it well, “The doctor, above all
professional men, needs to be a full man.” No-
where is this qualification more applicable than
to the doctor of traffic complaints. Certainly
every sufficiently experienced physician has ob-
served the personal resemblance of complaint and
complainer, as of accused and accuser.
No matter whether I express my emotional
disorders in speeding, lane-straddling, disregard-
ing traffic signals, or losing my basic sense of
selfness in concentrating upon “the other fellow’s”
poor driving, my fundamental difficulty is the
same one, namely, my attention is not vigilantly
devoted to my driving. Thus my chronic or acute,
mild or severe, emotional panics disable me for
this all-important purposeful focusing of myself
as a driver.
My incontinent emotions may disable me as a
driver in two chief ways : (1)1 may be so greatly
“upset” with inordinate anger, grief, jealousy, or
any other extreme feeling, that I disqualify my-
self as a safe driver; or (2) I may live my emo-
tional qualities under such disregard, so “feeling-
lessly,” that I drive carelessly or uncaringly. It
is particularly this forged “calmness” covering up
my humane feelings, which can account for my
reckless driving. As a cold, dispassionate, disin-
terested, impersonal driver, I lack humanizing
kindness and a tender sense of identity with my
fellow driver.
Each and every emotional problem, in or out
of a car, resolves itself into a problem of my
self-rejection, necessarily accompanied by a con-
striction of my self-esteem. Once I see nothing
tThis name was once proposed as the official one for
“the horseless carriage.”
but my own identity in my living, I immediately
recover my mental equilibrium. Moreover, until
I do succeed in seeing wherein I am living my
own fellowman, my distressing feelings signalize
that human failing.
Driving offers innumerable opportunities for
autohypnosis besides all degrees of actually falling
asleep at the wheel. Easiest of all, I can lull my-
self into a sense of false security, simply by con-
centrating on such shiny truths as, “Nothing harm-
ful has happened so far,” “The fears I have when
I ‘imagine’ traffic, are the worst,” and so on.
“On parade” I may enjoy my deepest and most
satisfying illusion of being seen and heard from.
The swiftly changing scenery can distract my at-
tention from the dangerous operation for which
I am responsible. Driving is a full-time risky as-
signment, and one which is not safely combined
with other seemingly uncomplicated activities, not
to mention courting, daydreaming, or drinking.
As more and more of my fellow citizens ex-
pect to be able to secure an automobile license,
I certainly expect to find a much greater number
of inexpert drivers. A similar kind of situation
is occurring in my school living. As more and
more citizens have demanded education rights, an
illusion has been created to the effect that my
educator appears to be lowering his educational
standards, such not at all being the case. As far
as respecting the dignity of the individual citizen
is concerned, health is to be gained by having
him educate himself as much as he can. If I
take the position that it is good citizenship for
me to have only those of my fellow citizens edu-
cate themselves who are capable of attaining
highest educational standards, I find myself in an
untenable position. Some similar American con-
sideration of the most careful kind may be given
to the inexpert driver. The true source of Ameri-
can vitality is American consciousness of the dig-
nity and sufficientness of the individual man.
“Team play” in which every player sees his team
as his own — that is uniquely the American way.
There is no emotional traffic tie-up which this
clear mindedness cannot clear up.
Every person’s traffic jam, or clearance, ex-
ists in him — he cannot exist in it. The traffic
was made for man, not man for the traffic, little
appreciated as this realistic view may be. The
degree to which my traffic becomes appreciated
as mine is the only safe criterion for my measuring
the achievement of humane traffic management.
1154
TMSMS
EMOTIONAL PROBLEMS IN DRIVING— DORSEY
I cannot make traffic safe for somebody else, or
make somebody else a safe driver. Each one of
us must do that for himself.
Perhaps this constant concentration upon the
inclusiveness and exclusiveness of oneness, of in-
dividuality, is not clearly comprehensible for one
of its readers. I am most thankful of all (to my-
self) for the awakening of my conscious interest
in the arrest of my development inherent in the
view: “Whatever seems incomprehensible to me
is not a source of helpfulness for me and I can
safely assume that it, itself, cannot be under-
stood, and that I need not regard myself as un-
clear, unenlightened or undeveloped on its ac-
count.” I am grateful to myself here and now
for my ability to scrutinize my traffic views with
less obscurantism, less occultism, less superstition,
than I must feel if I do not see them entirely and
only as my own.
The designation of a person as “a big wheel”
is more humorous than humane. Man’s uncon-
scious identification with his car can be an in-
stance of his “losing his mind” — not a conscious
finding of his mind in his very own creations.
Thus he may allude to himself with or without
insight as “clutching up,” needing a “tuning up,”
a “brake job,” “new spark plugs,” or “a complete
overhauling.” All of the machinery of his world,
all of his universe exists in each man. Take from
any one of his world interests the life which he
gives to it and what remains of it? Nothing*
I can hear one of my readers exclaim,
“That’s going too far! For instance, how may a
driver’s school profit from this comprehensive view of
self-activity? What good does it do the pupil to pay
more attention to the purely subjective, human, nature
of all of his automotive living? Will not ‘all people
agree,’ does not plain ‘common sense’ show, that every
student driver needs to forget about himself and con-
centrate on his driving lesson? Is it not an ordinary
observation which any student can make for himself, as
you seem to like to say it, that he is surrounded by
*"*“Joe does not know that he is the victim of a
mechanized and materialistic culture. His environment
from the beginning has been so largely made up of
gadgets and machines that without their benign pres-
ence Joe feels lost, as if he has been dropped suddenly
into the middle of an Alley-Oop type of primitivism.
Joe’s life began with a deception. On his third day,
he began sucking on a rubber or plastic nipple instead
of at his mother’s breast. He was brought up on a
formula with certain additives to insure his motor
against carbon deposits.” — E. C. Coleman, I. Clark
Davis, and E. G. Lentz: Shall Joe’s Car Go to College?
American Association of University Professors (Summer
Issue): 43: No. 2, June, 1957.
September, 1957
his environment, not that his environment is surrounded
by him? Does ‘Look Where You’re Growing!’ strike you
as a better road sign than ‘Look Where You’re Going?’
Is it your idea of safe driving technique to imagine
your pedestrian, or fellow driver, as nothing but a
sense perception, or an insight, of yours? Are you
really ‘so far gone’ on your subject that you think
psychology can correct traffic wrongs? How much of a
deterrent is it to a careless driver to be mindful that
he is only hurting himself by his carelessness? Oh,
I could go on and on shooting holes in your individu-
ality theory! When you see me next time on the
highway, please see me as real and my car as real,
not just perceptions of yours! Do you think for one
minute that my seeing the road sign as my road sign,
the ignition as my ignition, the steering wheel as my
steering wheel, the accelerator as my accelerator, the
brake as my brake, the traffic officer as my traffic of-
ficer, the traffic ordinances as my traffic ordinances, will
improve my driving! Doctor, please, were you retarded
in school, or do you just enjoy writing startling inani-
ties? Put on your headlights, you’re driving in the
dark.”
Treatment
“The man who knows not that he knows not aught
He is a fool, no light shall ever reach him.
Who knows he knows not and would fain be taught
He is but simple, take thou him and teach him.
But whoso knowing, knows not that he knows,
He is asleep, go thou to him and wake him.
The truly wise both knows and knows he knows,
Cleave thou to him, and never more forsake him.”
From the Arabic
Who is a poor driver? One answer is an easy
one for me. Some other impulsive, hot-headed,
stupid motorist! However, a comprehensive view
of the traffic problem in my world will not allow
me to drive far in that kind of fog. To the
extent that I do so, I top the myth of the head-
less horseman with the stark reality of the head-
less driver. What is the sovereign remedy, the
panacea, the specific treatment for “the inexpert
driver?” I know of no way of raising the level
of automobile driving in my world except the
sure one of making a better driver of myself.
Nevertheless, it often seems practical to me to
try to get everyone else in my world to drive more
kindly (expertly). In fact this illusion of “mak-
ing somebody else a better driver” is so tempting
that, at times, it seems I might find it both “face
saving” and comforting to develop this writing as
based upon it. However, in the long run the
medical principle of self-help shows up this il-
lusion as being too unhealthy for indulgence. Dis-
covering for myself that my fellow driver is only
as dense or as clear as I am, finding out for my-
self that my expecting more carefulness than is
1155
EMOTIONAL PROBLEMS IN DRIVING— DORSEY
immediately possible, can only increase my driving
hazards, — such open-eyed insight has contributed
immeasurably to my safer and saner automobile
living.
Automobile accident prevention confronts every
American citizen with one of his most severe
tests of his ability to respect the dignity and com-
prehensiveness of his human individuality. The
January 26, 1957 issue of the Journal of the
American Medical Association is devoted to orig-
inal articles bearing upon traffic safety. Every-
one of these articles stresses the importance of
studying each participant in a traffic problem as
a unique individual. Fully esteemed human in-
dividuality is the health basis for all proper ac-
cident prevention programming.** It is becoming
increasingly evident that an application for an
automobile license requires for its completion a
thorough medical examination, and that con-
tinued driving requires continuing, follow-up,
medical clearance. For instance, as an individual
who is “accident prone,” I must deprive myself
of driving privileges for my own good, pending
my study and treatment and cure of myself as an
accident repeater.
My need to be able to suffer myself “through
thick and thin,” to endure the growth of my
hardiness as well as heartiness, accounts for the
growing pains attending my progressive develop-
ment as a world citizen. As long as my capacity
for feeling hurt is applied toward my culturing
myself in the ways of tolerance and magnaminity,
it is all to the good. However, it is also possible
for me to develop the habit of hurting myself
less profitably, indulging a need for vindictive
punishment, “asking for it,” “leading with my
solar plexis.” Thus, “a glutton for punishment,”
I may be really anxious to have my accident for
**“It is submitted that the prevention of motor-
vehicle accident falls within the scope of preventive
medicine because of the epidemic nature of accidental
deaths and injuries and because of the outstanding role
of host factors in causing accidents. The physician, be-
cause of his background in the biological sciences, has
an unusual opportunity to understand the human causes
of accidents and to combine treatment with education
and safety.’- Ross A. McFarland, Ph.D.: Psychological
and Psychiatric Aspects of Highway Safety. Journal
of the A.M.A., January 26, 1957.
Also see, Murray E. Gibbens, William V. Smith,
M.D., Ward B. Studt, M.D.: The Doctor and the
Automobile Accident. Journal of the A.M.A., January
26, 1957. This article incorporates sixteen driving rules
entitled the “Good Driver’s Code.” Every one of these
rules embodies an appreciation of the healthfulness of
self-esteem, and the healthlessness of self disesteem. As
the medical authors indicate, it would be well to have
a code such as this adopted by state licensing boards.
the week, or month, and get it over with. A
nonshatter windshield is a great help, but it may
not keep me from “flying to pieces.” A safety belt
is a wise precaution, but it may not help me
to “hang on to myself.”
Automotive inventions certainly help to make
driving easier. But it is a grievous error to con-
sider driving of any kind to be easy. My car is
a truly marvelous instrument but. like every other
means of expressing power, its use as a benefaction
can be only the issue of the wisdom and care with
which it is employed. When I attempt to account
for there being as few accidents as actually oc-
cur, the best solution that I can come up with is
that this outcome is itself accidental. This view
may not be seen entirely as a gloomy one if the
meaning of the word accident itself is carefully
explored. “Accident” means: the forces neces-
sitating the event are not sufficiently taken into ac-
count. It is a happy view which sees many un-
conscious forces not taken into account which
necessarily reduce the number of collisions of
every kind. As Kearney firmly observes, nobody
will ever know how many “perfect driving rec-
ords” have been made on the law of averages.
Is there any possible way of holding human
life dear, not “cheap,” except by revering human
individuality? Does the soporific habit of mind
addicting nearly everyone, “I live in my world,
my world does not live in me,” necessarily make
for careless and reckless driving? Does all “traf-
fic management” unrecognizable as self-develop-
ment and self-control, tend to defeat its purpose:
the preservation of human life? Does “automotive
industry” have any significance whatsoever except
insofar as each given individual contributes his
own vitality to making it a meaningful concept?
If I take my living away from “automobile,” or
from “traffic,” what remains for me? Is it not
thus with every single one of my fellowmen? Does
this insight carry much weight in my world?
Until this true dignity of man is clearly the moti-
vation for safe driving, can there be wholehearted
devotion to traffic safety?
Oh, yes, I can pass traffic ordinances in increas-
ing numbers, as well as increasing traffic fines
correspondingly; in other words, symptomatic
treatment in the form of law enforcement helps.
Even if present driving license requirements were
enforced, it would help particularly in presenting
the extreme necessity for driving proficiency in
the right light. However, north, south, east, and
1156
TMSMS
EMOTIONAL PROBLEMS IN DRIVING— DORSEY
west of the traffic officer, the law of the six
cylinder, or eight cylinder prevails, where govern-
ment is not lived consciously as self-govemment.t
Thoreau saw this truth brightly, “That govern-
ment is best which governs not at all,” and, “For
government is an expedient by which men would
fain succeed in letting one another alone and, as
has been said, when it is most expedient, the
governed are most let alone by it.” The story
goes that Sergeant Alvin York accounted for his
single-handed capture of many enemy soldiers by,
“I surrounded them.”
Poceedings involving traffic offenses create
unique problems of legislation and of law enforce-
ment with regard to the issue of human individ-
uality. Of local traffic courts, Alfred T. Vander-
bilt recorded a profound observation:
“Traffic violations present peculiar problems which
emphasize the shortcomings of many of these local courts.
People whose sense of respect for law and order would
preclude their attempting to tamper with the adminis-
tration of justice in other courts, do not hesitate to do
so in evading punishment for traffic offenses. While
outstanding records have been made in traffic courts
here and there, such courts unfortunately are the ex-
ception and not the rule. Yet because most people will
never appear in any other court, there is no other
place where they can learn the true meaning of justice,
of respect for law, and their significance for good citizen-
ship. The field is one which cannot be neglected without
grave risk to the future of the body politic."* *
Necessary to say, all of my humanity, mankind,
is entirely mine! The general traffic safety of
mankind is only, and nothing but, a matter of
each separate individual’s safety. The driver with
the most insight is the sanest, hence safest. May
my insight show me that my intention to improve
upon myself as a driver includes my living myself
in such a way that my fellow driver may similarly
improve himself. Seeing all sources of helpfulness
as useful in “traffic management,” is no exception
to seeing my traffic control as an extension of my
self-control.
f“A psychiatric examination in the Detroit Traffic
Clinic was ordered for a commercial driver who had
been ticketed on over two hundred occasions. His oper-
ator’s license had been suspended, he had been fined,
placed on probation, but he continued to drive without
a license and was arrested.” — Alan Canty: Problem
Drivers and Criminal Offenders: A Diagnostic Com-
parison. Reprinted from Canadian Services Medical
Journal, 12:136-143, February, 1956.
*George Warren: Traffic Courts. (Judicial Adminis-
tration Series.) Boston: Little, Brown and Company,
1942.
For seeing my automobile as the wheel of for-
tune, which it truly is, I, too. may well have it
speak up for itself as follows:
I’m just a motor car — a ship of the highway — and
you're my captain.
Behind my steering wheel you're the lord and master
of a miracle.
You can make me take the kids to school;
You can drive me down the sunny road toward the
country;
With me you can carry your goods from the market
place . . . you can rush the sick to be healed . . . you
can go in minutes to places otherwise hours away.
You can do magic!
Yet, in the blink of an eye, in one tick of your
watch, I can turn deadly killer!
I can snuff out the life of a boy or girl still full of
life ... I can twist a smile into tears ... I can wreck
and cripple and destroy.
I can deal out death like the plague!
And I’m no respecter of persons ... a child, a
grandmother, or even you, my friend . . . it’s all the
same to me.
I’m sensitive. I respond instantly to the commands
you give me.
If you guide me with steady hands and feet, clear
eyes, and an alert brain — all responding to good at-
titudes, trained habits, and cool judgment — then I’m
your friend.
But if I’m guided with unsteady hands and feet, dull
eyes, or a sluggish brain ... if I’m directed by un-
sportsmanlike attitudes, bad habits, or poor judgment
. . . then I’m your enemy ... a menace to the life,
the happiness, the future of every person riding, walking,
or playing.
I was made for pleasure and usefulness.
Keep me that way.
I’m in your hands.
I’m just a motor car, and you’re my captain.
Behind my steering wheel you’re the lord and master
of a miracle or ... a tragedy.
It’s up to you!*
In order to feel deeply, grow emotional, about
my traffic problem, I must observe it as personally
mine. I can have no one else tell me what I
only can find out, namely, that it’s up to me to
care kindly for myself, in my traffic as in any other
living. I may be able to observe, however, that
my neighbor is living himself with increasing
gentleness and decent consideration in the way
he drives his car — and such a self-observation of
mine can further my stopping, looking, and listen-
ing. In this growth of my sane emotional traffic
living there is no suggestion of that totally im-
**Man and the Motor Car. Fifth edition. The Cen-
ter for Safety Education New York University. New
York: Prentice-Hall, Inc.
September, 1957
1157
EMOTIONAL PROBLEMS IN DRIVING— DORSEY
possible mental feat of “learning by example.”
I can learn by my living only. Each of my emo-
tions which I can see has only to do with my own
living, is soberly lived. Every other emotion is
intoxicating me, even though it be a kind of in-
toxication which my fellow physician’st most help-
ful Drunkometer cannot measure. My properly
dreaded police classifications HBD (Had Been
Drinking) and DWI (Driving While Intoxicated)
may well be extended to cover my trying to drive
and be inebriated emotionally at the same time.
After all of this one-way traffic of words, again
I seem to hear my patient reader remonstrate:
“That this product of human activity called motor
transportation is a psychological, hence human individual,
one ; that every meaning of traffic exists only in each
separate mind; that individual independence is the pro-
ducer of all that stands for civil and uncivil whole,
hence the producer of the idea that whole humanity
is nothing but a collection of single minds; that it is
only his consciousness of his greater self, not his con-
sciousness of his dependence upon a so-called ‘external
world’ which he could not have produced, which makes
man see his world as his own; that ‘family,’ ‘state,’
‘religion,’ and all such personifications are products of
man which grow only with his growth, and that he is
not educated or in any way influenced by any of them
as ‘externals’ ; that self-created, and so consciously
realized, sense perception (the same as insight) sees
the truth; that whatever is wrong in a human being
requires his mind to fix it; that any and every matter
of any and every meaning presupposes one mind as its
sole and whole creator; and that devotion to this kind
of self-orientation is necessary in order that self-esteem
(the specific feeling that heals and strengthens and
satisfies), may be fully measured and fully dispensed,
— all of that, I say, I can go along with, if in no other
sense than as wild claims that you make for the study
and practice of yourself in medicine with self-conscious-
ness. What I would like to be able to see clearly is,
How in the world of Dorsey, do you intend, or even
expect, to have your seventy million worlds,* * and that
number is just your fellow American drivers, benefit from
these technical introversions which you say yourself
you have worked thirty-two years to cultivate? You can
see for yourself what is needed now, not that it won’t
be needed thirty-two years from now, maybe more.
Come down from your ivory tower and try crossing the
Edsel Ford Expressway at the rush hour on those psycho-
logical feet of yours!”
fDr. R. N. Harger, Professor of Biochemistry and
Toxicology, Indiana School of Medicine.
*Agnes A. Sharp, Ph.D.: Forty Million Worlds. Pub-
lic Safety, p. 16, June, 1939.
To all of which, and the like, I give careful
heed. Once more may I point out that I am in
favor of every way in which anyone in my world
is helping himself, and here, specifically, solving
his every kind of traffic problem. My view of
helpfulness is in no way subtractive, only additive.
From personal experience I find that I can and do
help myself, whether I do it self-consciously or
not. When I do it self-consciously I help myself
more than otherwise, that is all.
May my discontented reader have the last
words :
“Oh, yeah! Tell it to the judge! But according to
you, all living is self-activity, so have your judge have
some external observations on traffic by means of intro-
spection!
“Or better still, next time he has me up for a
traffic violation make sure that he sees me as his
traffic violator, especially when he slaps on that fine.
“According to you, Doctor, there will always be a
lot of labor-management unkindness, until the laborer
can see his manager as his very own, and the manager
can see his laborer as his very own. Are you expecting
the millenium this year? Sure, if every employe of
Ford Motor Company could live his Company, each of
its personnel, as his own, he would thereby see himself
as high above and far beyond attacking himself and
calling his injured selfness ‘the boss,’ or ‘somebody else.’
I imagine that you wrote these minutes of yours in the
quiet peace of your study, far from the noisy annoyances
of the assembly line. There are a lot of bugs in your
magnanimous ‘broad selfishness’ theory that need iron-
ing out. If you don’t believe me, try them out on a
traffic violator who just came from a dressing down by
his wife, is on his tardy way to an irate foreman, and
is now confronting an indignant traffic officer!
“But seriously, Doctor, you remind me of the ancients
in the way you would solve the traffic problem. They
denied entirely the existence of any motion whatsoever,
observing, ‘A thing cannot move to where it is, since
it is there already; and of course cannot move to where
it is not; hence it cannot move at all!’ Come to think
of it, for me always and everywhere are ever the same,
now and here! I am going to stop all of this or first
thing I know I’ll be saying, ‘Maybe you’ve got some-
thing there. Maybe the only real development of
driving-school is each pupil’s heart culture.’ I am in-
terested in your claims for conscious self-possession and
self-reliance though, and, as Kettering once said before
the Automobile Old Timers, ‘The desire to know is in-
finitely more important than knowing how.’ If I am
unconsciously arresting my own development, I want
to wake up to that rut I’m in.”
1158
JMSMS
Function of an Amputee Clinic
By Frederic B. House, M.D.
Ann Arbor Michigan
N PLANNING for rehabilitation at St.
Joseph Mercy Hospital, we try to keep our
eyes on the objective and allow ourselves to be
somewhat flexible in devising plans for reaching
the objective. In the case of amputees, the ob-
jective is clearly the rehabilitation of the indivi-
dual patient. To accomplish this, a team is re-
quired since no single doctor or social agency can
accomplish this task unaided. We have brought
such a team together and we call it a Lower
Limb Amputee Clinic. It is important to note
that the team may differ from case to case as the
individual patient’s needs are found. Further-
more, it may differ depending on the role the
surgeon cares to play. He is encouraged to stay
with the patient and prescribe for him from be-
ginning to end. He may. however, transfer re-
sponsibility as soon as the leg has been removed.
If the surgeon does not stay with the case, medi-
cal responsibility is transferred to the physiatrist.
The clinic assembles once each week. We count
among our members the surgeon, physiatrist, phy-
sical therapist and social service from our own
hospital. From the outside we bring in the re-
presentative from the Office of Vocational
Rehabilitation and the prosthetist. When needed,
we can draw from any of the medical specialists
in the hospital to assist with particular problems
that may arise in a specific case.
The functions that the clinic performs can be
described under six headings:
(1) Presentation of the case by the surgeon;
(2) physical therapy: (3) evaluation and plan-
ning; (4) preparing the prosthesis; (5) gait
training and (6) vocational adjustment.
Presentation of the case by the surgeons: — Ideal-
ly, the surgeon will present to the clinic a patient
whose limb has been removed for just cause, at
an optimum level, in which proper muscle attach-
ments have taken place, skin healed and contrac-
tures eliminated. The time necessary for these
things to take place is frequently unpredictable
Presented before the Michigan Chapter of the Amer-
ican College of Surgeons, Ann Arbor, March 12, 1957.
and a varying amount of assistance from others in
the clinic may be brought to 'bear on the problem
during the postoperative period. Because of this,
we encourage bringing the case to the clinic soon
after amputation has been done.
Physical therapy: — At the direction of the sur-
geon or the physiatrist, physical therapy may be
used with benefit in the following ways : as means
of general conditioning by the use of massage and
exercises for the uninvolved limbs, for teaching
crutch walking (a prerequisite to proper use of a
prosthesis, since it demonstrates the patient’s will
to learn and ability to gain balance), for pre-
venting contractures and building muscle strength
necessary to the proper use of a prosthesis, for
providing such agents as whirlpool, ultra violet
light, ultra sound, bandaging and others for the
proper healing and shrinking of the stump. The
therapist has another role frequently forgotten — -
intelligently to encourage the patient in working
toward his objective. She may make the difference
between success and failure in this one activity
alone.
Evaluation and planning: — With the informa-
tion so far accumulated and the patient at hand,
the clinic evaluates the case to determine three
things. First, what degree of rehabilitation can be
expected, second, how this can be accomplished,
and, third, who will pay the bill.
It is well understood that no prosthesis will re-
store to an amputee the same degree of function
he would have had with the intact leg. One may
call the maximum possible degree of rehabilitation
80 per cent of normal and call 20 per cent that
degree of proficiency required to permit the am-
putee not only to walk but also improve his
ability to preform the activities of daily living
over one confined to a wheel chair. With this
scale in mind, the clinic can estimate the point
in between those limits that a particular indivi-
dual patient may expect to reach. Although, as
a trick, a patient might be able to walk a few
steps on a prosthesis, if he is not going to reach
September, 1957
1159
FUNCTION OF AN AMPUTEE CLINIC— HOUSE
the twenty per cent level or above, he would pro-
bably not use the prosthesis and a great deal of
expense would be wasted if one was made for him.
Therefore, if such is the finding of the clinic, no
Fig. 1. Above the knee amputee, mid-
way in his gait training. The leg is still
in the rough and will not be finished
until a perfect fit has been obtained.
prosthesis would be recommended and the patient
would be instructed in the use of a wheel chair.
If the clinic can see that a degree of proficiency
could foe obtained to allow the patient to do more
than care for the activities of daily living but
also allow him to be gainfully employed, then
certain opportunities are available to him through
the Office of Vocational Rehabilitation, including
money for medical care, prosthesis and vocational
adjustment.
The problem of cost must be fairly faced. In
cases which are not of interest to the Office of
Vocational Rehabilitation, other means of financ-
ing must be found. Social service may help find
ways. The patient himself, with the help of his
family, may be able to pay the bills. It can always
be said that if the outlook for rehabilitation is
over the 20 per cent level the care of the patient
in the future will foe minimized by the use of a
prosthesis, provided proper training and fitting are
done.
Preparing the prosthesis: — The prosthetist can
do remarkable things with a block of wood. With
ancient zeal and a fe\y modern tools he seems to
almost duplicate the lost limb. However, as we
have said, one doesn’t expect 100 per cent func-
tional recovery. The leg is made to the doctor’s
Fig. 2. Below the knee amputee, able
to stand alone after many months of
disabling vascular disease in the left leg
and foot. He will return to gainful em-
ployment.
prescription for a patient who the clinic thinks
will learn to use it. All the individuality of the
patient’s problem is built into the prosthesis.
Many steps go into the production of a prosthesis
which we will not discuss here. However, it can
be said that with the clinic approach to the am-
putee problem the patient does not obtain a
finished limb until he can walk on it and it fits
well.
Gait training: — This process takes several
weeks and is carried out by the physical therapist.
The patient is required to come to the physical
therapy department at frequent intervals. He is
trained with the leg in the rough, using it only a
few hours each week at first. In the intervals at
home he continues the care of the stump and
especially his exercise program mentioned at the
beginning of this discussion. He is finally allowed
to take the rough leg home for added practice
when he is able to wear it with comfort for over
an hour at a time.
Vocational adjustment: — The ideal result of
our efforts is a worker back on the job. Many
1160
TMSMS
FUNCTION OF AN AMPUTEE CLINIC— HOUSE
opportunities exist for the proper candidate
through the services of the Office of Vocational
Rehabilitation. If the candidate is not able to
learn to contribute to his own financial support,
then social service and his family must help him
make the adjustment to living without gainful
employment.
Case Reports
Case 1. — This man had the onset of vascular disease
many years ago. On October 3, 1956, he underwent an
above the knee amputation of the left leg. Since our
clinic was not functioning at that time, he was re-
ferred to a limbmaker who measured him for a leg.
We saw him first on January 8, when the stump was
well healed, but the patient was completely frustrated by
difficulties in getting his leg and instructions in its use.
The clinic evaluation showed an expected 40 to 60
per cent functional recovery according to our scale. The
rough leg already made was obtained from the prosthet-
ist. It was no trouble getting the patient to come in
for training three to five times a week even though he
had to drive from his home sixty miles away. On Feb-
ruary 1, he was walking unaided for short periods. On
February 12 he was allowed to take the leg home for
use a few hours each day. On February 26, the leg was
sent in for finishing. He was seen again March 12,
the limb was checked out and follow-up arangements
were made.
Case 2. (Fig. 2). — This man is very happy with his
prosthesis and the prospect of walking again. His first
operation was a left lumbar sympathectomy on July 9,
1956. Resection of a popliteal aneurysm was done on
July 18, at which time occlusion of the distal popliteal
artery was demonstrated. After a period of some im-
provement he came in for below the knee amputation,
which was done on October 29, 1956. He was seen by
the clinic on November 13 and started on physical
therapy for the stump and for crutch walking. In the
evaluation we could foresee employment and, therefore,
his case has been carried by the Office of Vocational
Rehabilitation. The leg was fitted on Januay 8. Ad-
justments have been made during the period of gait
training. He took his rough leg home on February 12.
On February 26, the leg was sent in for finishing, and
it was checked out on March 12. Gait training will be
continued as needed.
In summary, then, the function of an amputee
clinic is to provide the services necessary for the
rehabilitation of the amputee. This requires the
use of a team which can be made up from agencies
already existing in communities where hospital
facilities are available. Furthermore, this team
can function so as not to disturb the valuable
patient-doctor relationships found in open staff
community hospitals.
WHIPLASH INJURIES
( Continued from Page 1146)
Physical examination, on admission, showed limited
ability to open or close the mouth (related to injections)
but was otherwise negative. X-rays of the cervical spine
showed marginal spurring of the vertebral bodies with
narrowing of the intervertebral spaces at C 4-5, C 5-6,
and C 6-7, with a reversal of the normal curve at C 4
level.
On February 26, 1957. a cervical laminectomy was
performed and calcified spurs were removed at C 4-5
and C 5-6 on the left. The postoperative course was
uneventful and she was discharged free of pain, but
carried a mild weakness of the deltoid muscle on the
left. She has remained free of pain and the strength
of the deltoid muscle has improved.
Conclusion
The entire subject of trauma to the cervical
spine and particularly that of persistent and late
symptoms, requires cautious and detailed investi-
gation before any conclusions or standardized
method of treatment can be established. It is
imperative that the subject be investigated, for we
know of no disorder that tests one’s clinical judg-
ment more severely than that of deciding which
of a patient’s symptoms results from structural
changes or nerve pathways, and which result from
functional disorders, constitutional or acquired.
The ability of a physician to judge correctly these
factors from the onset of symptoms until rehabi-
litation is complete will determine (as Alex Aitken
has stated) the number whose records are closed
with the sum of money they spend and the dis-
ability which they keep.
Summary
Attention has been called to certain unusual
features of the anatomy and physiology of the
cervical spine believed to account for certain of
the delayed and prolonged symptoms that arise
after cervical trauma.
September, 1957
1161
Asian Influenza
A Revie u) of Available Information
By Michigan Department of Health
Lansing, Michigan
T NFLUENZA was reported as being epidemic in
•*-Hong Kong during the first week of April, 1957.
It apparently had its origin on the China main-
land some time previously. The attack rate in
Hong Kong was estimated at 15 to 20 per cent.
The epidemic there subsided in mid-May. Virus
studies showed it to be due to a Type A influenza
of a strain not previously identified. Since its dis-
covery in Hong Kong, this strain has spread to the
various continents of the world. Travelers and
ships from the Far East have brought the strain
to the United States. Confirmed cases of the dis-
ease have now been found in a number of states
with particular prevalence in relation to points of
entry from the Orient.
The important factors in the Far East outbreaks
have been poverty and crowding. Climatic and
geographic factors do not seem to be operative.
The incidence in the United States has been great-
est where groups of young people from various
places have come together with cases or contacts
of the disease, as in barracks, on shipboard, in
dormitories, and in camps. While cases and con-
tacts of cases have now been widely spread in the
United States for several months, no epidemics
have been reported in the general population.
Although the Asian strain of influenza is highly
contagious, and spreads rapidly, the disease itself
has been mild, recovery has been quick and com-
plications rare. Younger people seem to be in-
volved much more than older people. This could
indicate some previous experience with the parti-
cular strain or some immune factor present in the
older age group which is not present in the
younger.
The disease has been usually characterized in
the United States by sudden onset, high fever,
prostration, chills or chilling, sweating, frontal
headache, general malaise, muscle pains, some
cough, and frequently a sore throat. Nausea,
vomiting, epistaxis, and abominal pain have been
infrequent. Diarrhea has been rare, as has been
neck stiffness.
Prepared August, 1957.
The physical findings have ordinarily not been
marked. Dull injection of the pharynx may be
present. About half the cases have shown non-
tender swelling of the cervical and submaxillary
lymph nodes. In rare instances, rales are heard
in the chest. X-ray of the chest may show in-
creased bronchial markings.
While blood counts have commonly been nor-
mal with a normal differential; although in some
instances moderate increase in the total white
count has been noted with some polymorphonu-
clear predominance.
Prompt recovery in twenty-four to seventy-two
hours is usual. Treatment to give relief from pain,
rest and ample fluids is ordinarily sufficient. Neith-
er sulfa drugs nor antibiotics are effective against
the influenza virus, but may be effective should
complications, which have been infrequent, occur.
Since a number of conditions may simulate in-
fluenza, it seems desirable to have some sampling
of local outbreaks to determine the presence or
absence of the Asian strain. Laboratory deter-
mination of the disease is made from throat wash-
ings and paired (acute and convalescent) blood
specimens.
Throat washings to be of diagnostic value
should be obtained during the first three days of
illness, and while the patient is still febrile. Throat
washings are obtained by having the patient gargle
repeatedly with 10 to 15 cc. of plain bacteriologi-
cal broth, or boiled skimmed milk. Saline solu-
tions should not be used for this purpose. It may
be helpful to have the patient cough, thereby
bringing infected material from the trachea into
the pharynx before gargling. Washings should be
transferred to a closed tube for transportation to
the laboratory. If a delay of a few hours is neces-
sary, the fluid should be kept chilled at refrigera-
tor temperatures. Specimens should be iced with
ordinary ice for transfer to the laboratory. Unless
the specimen can be tightly sealed, dry ice should
not be used. If a longer period of storage is un-
avoidable, the washing should be frozen and
(Continued on Page 1164)
1162
TMSMS
Detroit Surgical Association
MEETINGS OF MARCH 25 AND APRIL 22, 1957
Meeting of March 25, 1957
CANCER OF THE STOMACH
By Cameron Morrison, R. Lehman,
A. Rutner, and G. S. Wilson
An evaluation of 637 cases of cancer of the
stomach was made over a ten-year period at the
Detroit Receiving, the Dearborn Veterans and the
Grace Hospitals. It was found that the absolute
survival rate was 9 per cent, with a 21 per cent
five-year survival of those resected for cure. The
survival rate was the highest at the Veterans Hos-
pital, lowest at the City Hospital, with the private
institution occupying an intermediate position.
This study showed that the differences in survival
depends upon the condition of the patient and the
extent of the disease rather than the variation in
technique and ability.
Meeting of April 22, 1957
REGIONAL ENTERITIS: TREATMENT
AND FOLLOW-UP ON 100 CASES
By Solomon G. Meyers, M.D., Paul E. Ruble,
M.D., and L. Byron Ashley, M.D.
The prognosis was somewhat better in 100 cases
of regional enteritis seen at a large private hospital
than that reported from the large centers where
the more seriously ill patients gravitate. The diag-
nosis in this group was established by tissue study
in 64 per cent and by gross inspection at laparo-
tomy in an additional 21 per cent.
Some of the patients presented with fever of
undetermined origin, sprue syndrome, infantilism,
and obstruction due to foreign body. Four pa-
tients had gross bowel hemorrhage. Six developed
ulcerative colitis. Two patients developed cirrhosis
six and eight years after ileitis was diagnosed.
A study of the follow-up data on 89 per cent of
these patients revealed that only 20 per cent of
the group had spontaneous or medical improve-
ment and the remainder required surgical treat-
ment. Surgery is indicated in intestinal obstruc-
tion, fistula formation, and intractable disease. The
operation preferred in this area is resection of the
disease rather than short-circuiting with transec-
tion.
Follow-up data is available in fifty-nine of the
sixty-two resected cases. Arrest of the disease or
long periods of palliation occurred in 81 per cent
of these. Eleven cases or 19 per cent had recur-
rence. Of the eleven cases with poor surgical
results, seven had subsequent resections with good
September, 1957
results in about half the cases. There was no
operative mortality in the resected group. Thus,
the surgical treatment of regional enteritis deserves
a more optimistic prognosis than is generally re-
ported from the large centers with a 40 to 60 per
cent recurrence.
EXPERIENCES WITH SURGICAL CORREC-
TION OF VENTRICULAR SEPTAL DEFECTS
UTILIZING CARDIAC ARREST INDUCED
BY ACETYLCHOLINE
By Thomas Gahagan, M.D., Charles Sergeant,
M.D., and C. R. Lam, M.D.
From the Division of Thoracic Surgery , Henry
Ford Hospital, Detroit, Michigan
Fifty-one patients having interventricular septal
defect have been operated upon with the use of the
DeWall-Lillehei type of pump-oxygenator with the
adjunct of cardiac arrest induced by injection of
acetylcholine. This allows the heart to be com-
pletely isolated, with the systemic circulation main-
tained by the pump oxygenator, and the pulmo-
nary and coronary circuits completely inactive.
This allows the heart to be entered and the defect
closed in a field which is quiet and free of blood.
Three situations have been encountered in which
the ideal intracardiac exposure may be compro-
mised. The presence of an unrecognized patent
ductus arteriosus allows blood from the arterial
side of the pump to enter the lungs, resulting in
blood loss from the pumping system and bleeding
into the heart via the pulmonary veins. An un-
recognized left superior vena cava (persistent left
common cardinal vein) allows leakage of pump
blood into the right side of the heart via the coro-
nary sinus, also resulting in blood loss and loss of
exposure of the defect. The third situation is fre-
quently encountered, in which the septal leaflet of
the tricuspid valve covers the defect, as a curtain
covers a window.
We have dealt with these situations in the fol-
lowing manner. Prior to starting the pump, a test
is made for the presence of the ductus by proximal
occlusion of the pulmonary artery. If a thrill per-
sists distally, the ductus is patent and must be di-
vided before the pump run. A search is made for
the left superior vena cava. If present, it must be
occluded during the perfusion by snaring it intra-
pericardially. When the septal leaflet of the tri-
cuspid valve hides the defect, the chordae tendi-
neae of the valve are severed and the leaflet is
retracted upward to expose the defect. After clos-
ing the defect, the divided chordae are repaired.
1163
DETROIT SURGICAL ASSOCIATION
The total mortality rate in the series is 34 per
cent. Most of the fatalities have occurred in the
group of desperately ill infants under the age of
two years. In twenty-one operations performed on
children three years of age or older, only one pa-
tient has been lost, a mortality rate of 4.8 per cent.
DUPUYTREN’S CONTRACTURE WITH
SPECIAL REFERENCE TO THE
PATHOLOGY INVOLVED
By Robert D. Larsen, M.D., and
Joseph L. Posch, M.D.
From the Department of Surgery, Wayne State
University College of Medicine, The University
Surgical Service of the Grace Hospital and the
Surgical Service of the City of Detroit Receiving
Hospital, Detroit, Michigan
Dupuytren’s contracture, one hundred and
twenty-five years after it was described by Dupuy-
tren, remains a disease of unknown etiology. His-
tologic study of the specimens removed from sixty-
one patients was undertaken. On the basis of these
studies we have concluded that Dupuytren’s con-
tracture is a fibrous tissue proliferation which
arises within the palmar fascia in intimate asso-
ciation with thick walled vessels and an increase in
capillary vascularity. This tissue undergoes the
well known stages of maturation of fibrous tissue
until the stage of a firm, relatively avascular, con-
tracted scar is reached. The pathological changes
do not suggest to us that the lesion is due to
inflammation or neoplasm. The significance of
iron pigment in the early lesions needs further
study. Surgery is the only form of treatment which
will produce any lasting benefit in this disease,
although administration of tocopherols and irra-
diation may produce some temporary improve-
ment. The operation must be fitted to the indi-
vidual patient. Complete excision of the fascia will
be indicated in most cases; however, partial exci-
sion of the fascia and fasciotomy have their place
in selected cases. With proper choice of operation
and careful attention to operative details excellent
or good results can be expected in between 80 and
90 per cent of the operated patients.
ARE YOUR PATIENTS PHYSICALLY
QUALIFIED TO DRIVE?
( Continued from Page 1126)
important role in controlling the operation of
these factors along our death ridden highways
be played by the individual physician. He is in
a position to judge the true nature of a particular
case and prohibit driving. He, also, can educate
his patients as to the importance of safe driving
and the hazards involved when organic disease
factors impair or threaten adequate function.
With the advantage of his position of intimate
knowledge and influence, he must then appreciate
his public responsibility and join his efforts with
those of others who fight to reduce the toll of
this largely preventable disease of society.
Bibliography
1. Larson, J. A.: Drivers, psychiatry and the driver;
all types of vehicles. Michigan M. Soc., 49:1288
(Nov.) 1955.
2. Webb, J.: Standards of fitness among drivers of
commercial vehicles; a socio-medical investigation
based on wartime records of civilian medical boards.
Brit. M. J., 1:515 (Feb. 26) 1955.
3. Lebensohn, Jas. E.: The seeing factors in traffic
safety. Sight Saving Rev., 19:191, 1949.
4. Newquist, N. Melvin: The aging, ailing truck driv-
er. Indust. Med. & Surg., 26:109 (March) 1956.
5. Brandaleone, H.. and Friedman, G. J. : Physical
Standards for vehicle operators: Indust. Med. &
Surg., 26:17 (Jan.) 1956.
6. Editorial: Traffic accidents are preventable,
J.A.M.A., 156:1255 (Nov. 27) 1954.
7. Woodward, F. D., and Moore, C. N. : Methods for
prevention of auto accidents, Modern Med., 23:64,
(Sept. 15) 1955.
8. Woodward, F. D.: Medical criticism of modern
automotive engineering. J.A.M.A., 138:627 (Oct.
30) 1948.
9. Editorial: Should the health officer look at the
auto? Am. J. Pub. Health, 46:91.
10. Symposium: Medical aspects of motor vehicle ac-
cidents. New York State J. Med., 56: December
15, 1956.
11. McFarland, Ross A., and Moore, Roland C.: Hu-
man factors in highway Safety: A review and evalu-
ation, New England f. Med., 256:792 (April 25)
1957.
ASIAN INFLUENZA
(Continued from Page 1162)
stored briefly near minus 70° C. Blood should also
be taken for serum samples: one during the time
of acute illness, and a second, two to four weeks
later. Specimens of 10 to 20 cc. Each is de-
sirable if specimens can be obtained. Throat wash-
ings, and blood samples should be sent to: Dr.
Thomas Francis, School of Public Health, Univ-
ersity of Michigan, Ann Arbor, Michigan.
Pharmaceutical houses are presently in a posi-
tion to provide vaccine within the next several
weeks, which should be effective against the
Asian strain of influenza. It is of lessened value
if not given a week or more before exposure. Just
now there is little indication as to how epidemic
this disease will become among the general poula-
tion.
1164
JMSMS
Doctor— To Serve Society Better
The past State Medical Society year has run swiftly as
a mountain current. Like a cascading stream, it has dashed
against giant boulders and gently splashed between green
meadows. My metaphor refers simply to the problems and
the accomplishments of our Society during the past 365
days. Never has there been a more exciting year and very
few periods with such extraordinary accomplishments.
But as I write, the current still rushes and the boulders
seem to become larger — so great in fact, that it is necessary
to find out more about them — as some must be blasted out
of the path of progress or dams must be erected to protect
the fields of medicine. Again, my metaphor refers to the
MSMS Market Opinion Survey, created to find out just
what you, Doctor, and also what the people of Michigan
want in medical care. Our monumental study — the largest
ever undertaken by any state medical society — will chart our
future course — will give us a pattern so our great resources
may be used to the best advantage of the public.
As President, my last admonition to you is to study well
the findings of this epic survey and to heed the direction sig-
nals which the report indicates. The practice of medicine,
like a stream, may alter its course from time to time, but the
principles behind Medicine always must be the same: to
give to the people the best medical service available.
* * *
I come to the end of my tenure as your President with
gratitude to all for allowing me this greatest honor of my
life. I pledge a continuation of my zeal and labor for the
altruistic purpose of the Michigan State Medical Society,
which in essence is to equip each member of the medical
profession to serve society better.
President, Michigan State Medical Society
September, 1957
1 165
Editorial
TRAFFIC SAFETY NUMBER
The September number of The Journal of the
Michigan State Medical Society, following a pre-
cedent of emphasizing diversified interests estab-
lished many years ago, is devoting this issue to
Traffic Safety. We are pleased to acknowledge
the assistance of John B. Roger, M.D., of Bellaire,
who helped to assemble the papers and advised in
selecting the material published.
THE PHYSICIAN AND TRAFFIC SAFETY
You and I as physicians can do much to reduce
the carnage on the highways. We cannot do it
all, for there is no one simple remedy. Any sig-
nificant reduction in highway accidents will be the
result of a variety of efforts on the part of many
groups of people: more careful methods of driver
licensing, meeting the problem of the drinking
driver, better car design, more and better driver
education, better law enforcement, safer highways.
Improvement depends on efforts in all these areas,
not just in one or two.
Viewing the traffic safety problem in epidemio-
logical terms, it is reassuring to observe that much
progress has been made. While the totals each
year remain distressingly alike, we must not forget
that when traffic fatalities are reported on the
basis of units of 100 million vehicle miles, it is
two and one half times as safe to be on the high-
ways now as it was in 1934 and 1935, the two worst
years rate-wise that we have ever had. We killed
38,000 on the highways in 1955, but at the 1935
rate this figure would have been 95,000! We
want to remember this improvement of the past
when we are tempted to despair of our efforts of
the present.
While it is reassuring to look at the past with
the eye of the epidemiologist, it is frightening to
look into the future with that same eye! The
experts tell us that in the next ten or fifteen years
we can expect a rise of 45 per cent in vehicle-
mileage. If this is true, in the same period of
time, we shall have to reduce the accident rate by
nearly 50 per cent from what it is now in order
even to just stand still!
There are a number of articles in this issue of
The Journal which point up some of our respon-
sibilities as physicians in the prevention aspect of
this problem. In these areas which are uniquely
medical, only the physician can guide. Much of
this guidance will have to be given to patients
individually, depending on the health problem
involved. Some will be given corporately in the
form of suggested educational approaches, licen-
sing standards, et cetera. Not always will such
guidance be appreciated or understood, for too
many Americans think of their role as drivers as
a constitutional right rather than as a privilege
granted them by the State. But such guidance
must be given, tactfully and persuasively.
This year, at the request of our State Medical
Society, a bill was introduced into the Michigan
Senate which, if adopted, would have done much
to screen physically unfit drivers, and to make
others with less serious defects into safer drivers.
Yet this bill died in committee. This bill, or some
modification of it, should be introduced again and
again until it finally is adopted, even as Michigan’s
excellent student driver training bill had to be
introduced a second year to get it out of com-
mittee and adopted by the Legislature.
We physicians must not forget that we also are
citizens, and should be the spark-plugs of local
community efforts towards safe driving. Our mem-
berships in luncheon clubs and other community
organizations give us unique opportunities to be
catalysts for safety.
In addition we should not let the occasional
necessity to hurry in an emergency become the
pattern for all of our driving. The physician should
set an example to his patients and neighbors for
sober, careful and considerate conduct on the
highways.
You and I have a unique opportunity to make
the highways safer for our patients and ourselves.
Let’s use it!
John R. Rodger, M.D.
Chairman, MSMS Committee
on Study of Prevention of
Highway Accidents
1166
TMSMS
EDITORIAL
DO DOCTORS CHARGE TOO MUCH?
Dr. Frank G. Dickenson, head of the economics
department of the American Medical Association,
and Medical Economics , the magazine, have pub-
lished material tending to prove that, in general,
charges made by doctors are not excessive. They
have demonstrated that hourly charges, as worked
out by hours of duty — as compared to plumber’s
charges, for instance — actually bring a lesser re-
turn in terms of dollars. In spite of all the evi-
dence, it is constantly asserted by pressure group
leaders that “doctors’ charges” are too high. Of
course, all medical care and hospital services are
included, but not stated.
An authentic exposition from an entirely new
and unbiased angle is welcome. The U. S. News
and World Report on its cover for July 5, 1957,
in half inch high letters, black and red, asked,
“DO DOCTORS CHARGE TOO MUCH OR
NOT ENOUGH? What Government Figures
Show.” Sketches showing health cost values for
the period 1936 to 1957 are most impressive:
Accepting doctor’s fees, cost of living and hospital
bills for 1936 as 100, the diagram shows that hos-
pital rates have increased to 387. Cost of living has
gone up to over 205, doctors’ bills on the same
average have gone up to 178, and dental costs
averaged just more than the medical profession,
185.
Eight pages are devoted to this study, with a
mass of tables, rates and averages — all from gov-
ernment sources. The reason for the constant rise
is still a question. Hospital rates are commented
upon with the marked growing costs reaching over
$6,000,000,000 a year. Some hospitals are govern-
ment-supported, federal, state or local, while oth-
ers are voluntary or private. But all are in finan-
cial trouble.
It is very evident that all the people must learn
to budget their health costs and accept a greater
percentage of costs. This is primarily due to hos-
pital costs which have almost quadrupled in the
twenty years under study. The article in U. S.
News and World Report stated specifically that
doctors’ charges have really followed far behind
the cost of living, and no blame is justifiably im-
posed on the professional people involved in health
services. Hospitals must accept their responsi-
bility and the “why” is carefully avoided.
THE “WHY”
Many times, in these pages, attention has been
invited to some of the basic reasons for hospital
increased costs. Hospital labor, nurses, cooks,
maids, all employes have always been woefully
underpaid. For several years that condition has
been on the remedy column. Wages and salaries
constituted varying amounts of hospital costs de-
pending on the reports and local conditions, but
they are from seventy to eighty per cent of all
costs of operating a hospital. These wages and
salaries are still below equivalents in industry. A
second item is that more services are used and
needed by the increased and modem methods of
care and attention all patients now receive.
Another question asked by U. S. News and
World Report for June 14, and July 12, 1957,
gives some more information. Place the value of
the dollar of 1935 to 1940 at 100 cents of actual
purchasing power and we find that the dollar of
1952 to 1956 is worth only 49.7 cents and is de-
creasing. It now takes over two dollars to buy as
much work as one did. The same is true of sup-
plies and everything else.
THE VALUE OF OUR MONEY
The invested dollar is earning less than the cost
of living increase. In other words, the dollar and
its interest earnings for the past ten years has
actually depreciated. The two together are worth
less. Something is wrong with our money control.
It may be that the medical profession should take
a hint from labor, and tie into our charges such
items as our prepayment premiums and our retire-
ment provisions with the cost of living. Labor
was five years ahead of us in adjusting wages to
cost of living and has profited much. Now labor
is suggesting that social security and retirement
annuities also be tied to the same varying value
of the dollar, otherwise called “cost of living.”
Tax expenditures by state governments, part of
the cost of living, in the short space of eight years
(1950-1957) have gone from $12.3 billions to
$20.6 billions, and the appropriations for 1958
are $22.5 billions.
Labor took particular pains to provide retire-
ment funds through employers. Fixed rates were
established to be paid in the far future after the
working man should have passed sixty-five. Chang-
ing values have made those retirement monies
September, 1957
1167
EDITORIAL
worth about one half the amount of anticipation.
The same is true of social security payments which
have also been increased. Labor leaders have
recently proposed a tie-in of “cost of living.” The
workers realize their old age pensions, allowances
or insurance are dwindling.
The self-employed citizen or professional man,
who wishes equality with labor and who wishes
ultimately to retire with the living $5,000 a year
would have provided in 1925, would have to
invest in industrial stocks or corporate bonds for
these years as follows:
Industrial stocks Corporate bonds
1925
$105,260
1925
$ 91,410
1949
$ 76,760
1940
$114,590
1950
$201,220
1955
$251,170
1957
$206,820
1957
$213,610
This gives a glimpse of values being asked to
be set aside to guarantee a stable, non-decreasing
income by the one unit of our society having the
power to dictate.
IS MEDICAL PRACTICE CHANGING?
Those who have been in the profession a score
or more of years know the practice of medicine is
undergoing great changes. They have seen revolu-
tionary changes in pharmacology with new drugs,
appliances and methods. Fully 85 per cent of the
methods and materials now used in medical prac-
tice were unknown a short score of years ago.
Much of our exact scientific medical knowledge
is also new. Surgery has made fantastic strides.
The modern operator has at his command methods
of anesthesia, methods of by-passing the heart,
the kidneys, of entering those organs for elabor-
ate procedures. No cavity of the body is now
barred to curative procedures.
This short time has seen far more exciting and
promising developments of skills and methods of
healing than the whole preceding period. From a
scientific and professional consideration, the medi-
cal world has and still is far outstripping all
recorded history. But the welfare of our people
who need advice and counsel involves much more
than diagnosis and treatment of their ills. The
idealism of our pioneers in economic and socio-
medical problems have made just as rapid and just
as rewarding contributions. They saw the need to
assure the benefits of our vastly increasing medical
know-how when only a small portion of our public
were financially able to obtain the services. The
medical dreamers were faced with demands for
government to dispense medical care on a com-
pulsory “insurance” basis. Private study, research,
trial and error, spurred on by the knowledge that
no matter how skillful or successful our services
might be, has shown that even if no one could
pay for them, there was still a need. Those in-
spired and devoted dreamers knew that a helping
hand in the form of methods of paying which
were much less painful, would be a boon to the
patients and their families. Criticism and dis-
couragement failed to stop the spontaneous grass
roots movement which changed the time worn
and unhappy methods to a budgeting and prepay-
ment success. This, the medical profession gave
our people.
We are now in another era of need with more
demands and more problems, and again there is
a demand for someone else than the profession
to administer and “run the show.” Again it will
take the concerted and continuous administrative
ability of an understanding group — the doctors
themselves — and not just a few of them but such
an overwhelming percentage that no question may
arise.
THE PROGRAM
The socio-economic problems are an extension
of those of a decade or two ago. They can and
will be solved — and by the same kind of devotion
and dedication that was so successful before. The
profession must work together, or we shall work
separately under orders, and not as efficiently.
Labor unions and the government are pressing,
they would like the opportunity to put the profes-
sional man on an hourly schedule whose work
hours might well be far from their own projected
thirty-six hours a week. Few doctors are now
working less than about sixty, but they are their
own task masters.
The growth of voluntary health plans has
changed the picture of unpaid medical accounts
from one of being left unpaid, to one where
prompt payment of the account in almost its
entirety can be anticipated. Let us preserve the
concept responsible.
There must be no delay. The labor leaders and
the government bureaucrats, still in the seat of
the mighty, are ready and anxious for one single
failure to prove their contention that neither the
medical profession nor the other voluntary plans
1168
TMSMS
EDITORIAL
can give the complete services they say their people
wish. Government will be pressured into the actual
administering roles they are ready and eager to
assume.
The House of Delegates in our September meet-
ing will have made a decision. We are confident
it will have been right. Whatever the outcome,
the medical profession must not follow the lead ol
our brothers in England who are now regretting
— and belatedly fighting for right.
ASSISTANT EDITOR NAMED
President-Elect of the Wayne
County Medical Society, Louis
J. Bailey, M.D., has been named
by the Council of the Michi-
gan State Medical Society as
Assistant Editor of The Jour-
nal of the Michigan State
Medical Society. The Editor is
Wilfrid Haughey, M.D., of
Battle Creek.
Dr. Bailey was born in De-
troit and received his M.D. de-
gree from Wayne University College of Medicine
in 1925; M.Sc. (Med.) University of Pennsyl-
vania in 1939. He interned at Providence Hos-
pital and now specializes in internal medicine. He
is on the staff of Wayne County General and
Detroit Receiving Hospital, a Fellow of the Amer-
ican College of Physicians, and has been an In-
structor of Clinical Medicine at Wayne University
since 1928.
He has been a member of the Wayne County
Medical Society since 1932, served as President of
the Noon Day Study Club 1938-39, Chairman of
the Membership Committee 1937-39, Chairman of
the Program Committee 1945-46, editor of Detroit
Medical News 1954-56, and trustee in 1955, also
as delegate to the Michigan State Medical Society.
He served in the U. S. Navy from 1918-1919.
Dr. Bailey is married and has three children He
makes his home in Birmingham.
In the past fifty-six years, mortality from tuberculosis
has declined from 199 to 8 per 100,000 population,
according to Health Information Foundation. While
this is remarkable progress, tuberculosis is still a great
health problem, with 100,000 new cases reported in
the United States in 1955.
HELLER REPORT
The House of Delegates of
the American Medical Associa-
tion, in its final hours before
adjournment in New York City
at the annual session, received
a report from the Board of
Trustees that a business and
managerial report had been
made by Robert Heller and
Associates. The Trustees and
the House, respecting the con-
fidential nature of the report,
directed that a committee be appointed to receive
the report, study it, and bring in recommendations
at the Philadelphia meeting in December.
That committee is appointed and at work. The
Chairman is William A. Hyland, M.D., of Grand
Rapids, chairman of the Michigan Delegation to
the AMA. Other members are: Louis A. Alesen,
M.D., California; Harlan English, M.D., Illinois;
Norman Welch, M.D., Massachusetts, and Charles
T. Stone, M.D., Texas.
The Reference Committee which considered this
report wrote:
“Your Reference Committee concurs with the Board
of Trustees that a committee of five members of the
House of Delegates be appointed by the Speaker to study
the report and to select those portions which should
receive action by the House, to discuss those recommen-
dations with the Executive Committee of the Board of
Trustees and such others as may be deemed appropriate,
and to submit a report with recommendations to the
House of Delegates at its next session (Clinical Session,
Philadelphia, December 3-6).”
Copies of this report have now been sent to
members of the House of Delegates, the AMA
officers, and to the State Medical Societies. The
Editor is informed that the report and the work of
its study committee form probably the most im-
portant positive action the AMA has taken for
many years. We congratulate Michigan for possi-
bly sparking the study resulting in this Heller Re-
port, and for furnishing the committee chairman.
We congratulate William A. Hyland, M.D., who
has received many testimonials of our esteem by
receiving our highest offices, and who is still in
the top echelon of our advisors. He has the re-
sponsibility for interpreting and implementing this
new step in medical life.
Louis J. Bailey, M.D.
Wm. A. Hyland. M.D.
September, 1957
1169
Michigan’s Department of Health
Albert E. Heustis, M.D., Commissioner
SPECIAL PROJECTS IN PUBLIC HEALTH
CHRONIC DISEASE PROGRAM DEVELOPMENT
Operating within legislative authority and depart-
mental regulations and policies, the Division of Tuber-
culosis and Adult Health of the Michigan Department
of Health functions to control the spread of tuberculosis
and the venereal diseases; and to encourage and pro-
mote programs directed at the prevention of occurrence
of chronic disease and the control of its progression,
including the promotion of early detection, adequate
treatment and rehabilitation.
For a number of years, the basic budgets of local
health departments have included provision for chronic
disease program development. As a further supplement
to these allotments, the Michigan Department of Health
has used the method of special projects to stimulate
expansion of current activities and to demonstrate new
knowledge and techniques.
The major disease categories receiving allocation
through special projects include tuberculosis, cardio-
vascular diseases, cancer, diabetes and syphilis. Tax
support has come from two sources (for 1956-57); a
state appropriation of $250,000.00 for expanded tuber-
culosis case finding and control and; approximately
$50,000.00 from Federal grants for programs in cancer
and heart disease. In addition, voluntary health agen-
cies have provided financial aid and professional tech-
nical service on a local and State basis. Conservative
estimates of this support, primarily from tuberculosis
associations and cancer societies, totals $30,000.00 for
the period.
Thirty-four local health departments representing fifty-
four counties and four cities have received direct finan-
cial assistance through special projects.
Functionally, project activities carried out from July
1, 1956, to June 30, 1957, can be summarized as fol-
lows:
1. Case finding: Chest x-ray screening for tuber-
culosis, pulmonary neoplasm, cardiac abnormalities; hos-
pital admission x-raying; Mantoux tuberculin testing
(children and adults) ; cervical screening, general cytol-
ogy; mass blood surveys (venereal disease, diabetes),
multiple screening follow-up; special investigation of
problem cases, stationary and itinerant tuberculosis
clinics.
2. Case Management (Treatment, Care and Rehabili-
tation): Medical administration and clinical service
(tuberculosis, venereal disease) ; medical social service;
rehabilitation nursing demonstration, home care (nurs-
ing), adult health clinic service and diagnostic and
treatment centers for venereal disease.
3. Records Management: Refinement of Central Tu-
berculosis register (State and local), promotion of volun-
tary reporting of cancer; refinement of venereal disease
reporting.
4. Education and Training: Provided medical ex-
ternship with field work in tuberculosis, cancer and heart
diseases. Conducted professional conferences and in-
stitutes on chronic disease in general and with specific
disease entities; initiated public education activities de-
signed to promote voluntary participation in case find-
ing surveys; planned lay education, services and mate-
rials to promote greater awareness of the needs and
resources in chronic disease control; established a train-
ing program for radiotherapy technicians for cancer
therapy; provided practicing physicians with annual sub-
scription to the Heart Bulletin.
5. Operational Research: Study of health education
needs of tuberculosis patients and families in terms of
modern therapy; study of the values and limitations of
hospital admission x-raying; an evaluation of tuber-
culin testing among student nurses; study of tuberculosis
home care costs; study of the nature and scope of
chronic disease in a selected county; study of the values
and limitations of 70 mm. x-ray screening in early detec-
tion of pulmonary neoplasm and heart disease; study
of the prevalence of non-tuberculous abnormalities
among patients in nursing and convalescent homes;
study of tuberculosis control measures (tuberculin, BCG,
chest x-ray) among student nurses.
The variety of functions outlined above were ab-
stracted from reports of the fifty-two special projects
operating in the fiscal year 1956-57. They represent
the combined efforts of the State and local health de-
partments, hospitals and voluntary health agencies.
In each instance, the proposed projects were presented
to the medical profession (state and/or local) for study,
advice and support.
It is readily recognized that these activities, when
evaluated in terms of the total problem of long term
illness, represent only the preliminary steps to a con-
certed attack on the problem. They do provide evi-
dence, however, of a gradual reorientation of community
health services to meet this challenge.
HOSPITAL COSTS
Since the last Blue Cross rate adjustment in March,
1956, hospital costs have increased from an average
daily charge of $25.96 to $28.60, an increase of 10 per
cent. In 1950, the average number of employes in all
hospitals in Michigan was 180 persons per 100 patients.
In 1957, this has risen to 207, an increase of 15 per
cent. Since more than 70 per cent of hospital costs
are salaries and wages, that accounts for at least 10
per cent.
UTILIZATION
For each 1,000 persons covered by Blue Cross, there
will be 151 hospitalized each year. For each 1,000 per-
sons covered by Blue Shield, there will be 327 persons
receiving medical, surgical or other services for which
Blue Shield pays.
1170
.TMSMS
RELIEVES THE GNAWING ACHE
Pro-Banthme®provides rapid
control of pain in peptic ulcer
In a two-year study1 2 3 4 5 by Lichstein and co-
workers, documented by intensive personal
observation and by follow-up studies, Pro-
Banthlne (brand of propantheline bromide)
often brought immediate relief of ulcer pain.
Patients (11 per cent) who did not respond
satisfactorily to Pro-Banthlne therapy had
“anxiety manifestations of psychoneurotic
proportions.”
In addition to frequent immediate sympto-
matic relief, Pro-Banthlne reduces gastroin-
testinal motility and diminishes the secretion
and acidity of gastric juice, all-important
factors in the generation and aggravation of
peptic ulcer.
These actions of Pro-Banthlne and its
demonstrated effectiveness in accelerating ul-
cer healing2-5 mark the drug as a most valu-
able adjunct in the treatment of peptic ulcer.
The suggested initial dosage is one 15-mg.
tablet with meals and two tablets at bedtime.
An increased dosage may be necessary for
severe manifestations and then two or more
tablets four times a day may be prescribed.
G. D. Searle & Co., Chicago 80, Illinois.
Research in the Service of Medicine.
1. Lichstein, J.; Morehouse, M. G.( and Osmon, K. L.:
Am. J. M. Sc. 232: 156 (Aug.) 1956.
2. Sun. D. C. H., and Shay, H.: Arch. Int. Med. 97:442
(April) 1956.
3. Rafsky, H. A.; Fein, H. D.: Breslaw, L., and Rafsky,
J. C.: Gastroenterology 27:21 (July) 1954.
4. Schwartz, I. R.; Lehman, E.; Ostrove, R., and Seibel,
J. M.: Gastroenterology 25:416 (Nov.) 1953.
5. Silver, H. M.; Pucci, H., and Almy, T. P.: New Eng-
land J. Med. 252:520 (March 31) 1955.
September, 1957
Say you saw it in the Journal of the Michigan State Medical Society
1171
THE G. A. INGRAM COMPANY
ii 4444 Woodward Avenue. Detroit 1. Michigan
BURDICK UT-1
ULTRASONIC UNIT
Clinical reports, both here and abroad,
have been in agreement on the value of
ultrasound in the following conditions:
Traumatic Injuries • Osteoarthritis * Periarthritis
Fibrositis * Painful Neuroma • Rheumatoid Arthritis
Bursitis * Radiculitis * Scars
A compilation of detailed clinical reports
and ultrasound technics is available upon
request from the Burdick Corporation,
The Burdick UT-1 Ultrasonic therapy
unit is a tested result of pioneering in
this field. It features a coupling signal
that warns when contact is inadequate
for effective treatment. The right-angled
applicator and flexible cable add ease to
operation. Burdick also has a smaller,
portable machine — the UT-4. We will
be happy to demonstrate both machines
to you at your convenience.
The UT-1 and UT-4 are
sold through 296 qualified
medical supply houses
throughout the United
States. Over 1,500 Burdick
sales representatives are
backed by complete serv-
ice facilities for all Bur-
dick equipment.
THE BURDICK CORPORATION
MILTON, WISCONSIN
Branch Offices: CHICAGO • NEW YORK
Regional Representatives:
ATLANTA • CLEVELAND • LOS ANGELES
In Memoriam
Bruce Anderson, M.D., aged eighty-three, Pontiac
physician, was a graduate of McGill University, Mon-
treal, and a member of the American College of Sur-
geons. A charter member of Oakland Hills Golf Club,
Dr. Anderson also belonged to the Blue Lodge, Detroit,
Central Methodist Church and was a left member of
the Detroit Boat Club. Death occurred July 4, 1957.
Roscoe W. Cavell, M.D., aged sixty-one, professor of
psychiatry at the University of Michigan Medical School,
died July 13, 1957, of a heart condition. Dr. Cavell
was born January 20, 1896, in Hamburg and received
his degree as doctor of medicine in 1921 from the
College of Medical Evangelists at Loma Linda, Cali-
fornia.
During World War II, he was chief medical officer
(Colonel) of the U. S. Induction Station in Detroit
before being transferred in 1944 to the Ninth Army as
a consultant in neuropsychiatry.
Leland V. Hewitt, M.D., aged fifty-eight, Detroit and
Grosse Pointe physician and surgeon, was born in Brook-
lyn, Michigan, and was graduated from the University
of Michigan Medical School in 1923 to intern at Grace
Hospital. Dr. Hewitt was a member of the Detroit
Yacht Club and Phi Chi Fraternity. He died July 6,
1957.
Eugene L. Kendall, M.D., aged seventy-eight, a native
of Grand Rapids, began his practice in that city in
1909. He was a graduate of the Detroit College of
Medicine and Surgery, a life member of Valley City
Lodge, Columbia Chapter, a member of the Knights
of Pythias and the First Congregational Church. Death
occurred on July 16, 1957.
Edward A. Malik, M.D., aged forty-nine, Detroit gen-
eral practitioner, died June 1, 1957, of a heart afllction
which had plagued him since his youth.
Dr. Malik interned at Grace Hospital after his gradu-
ation from Wayne State University Medical School
in 1939. He had a residency at Grosse Pointe Hospital.
George W. Moore, M.D., aged eighty-nine, at one
time Bay City Health officer, died July 15, 1957.
During Dr. Moore’s fifteen-year tenure in office, he
fought on two separate occasions to save the city-operat-
ed General Hospital from being closed by city com-
missions. In 1931, he was instrumental in tracing a
typhoid carrier responsible for several deaths in that
year. In the same year, he promoted a smallpox vacci-
nation program in which 11,000 Bay City residents re-
ceived vaccinations. In other accomplishments, he
played a part in establishing the first controls of the
city over its milk supply, in forcing retail food dealers
to cover foods in stores, in revising and improving
plumbing ordinances and the tearing down of old houses
that menaced public health.
Dr. Moore was born in Norwich, Ontario, and was
graduated from Marquette University School of Medi-
cine in 1898. He had maintained a private practice
at his residence since retiring as health officer in 1940.
JMSMS
1172
Say you saw it in the Journal of the Michigan State Medical Society
DOCTOR
we need your opinion
For the purpose of continuous improvement of your STATE MEDICAL JOURNAL — In
reading content — original articles, editorials , news, economics and other subjects
pertaining to statewide and national affairs, it is urgently requested that you spare a
few moments to fill in and return this questionnaire.
YOUR RESPONSE TO QUESTIONS BELOW WILL BE MOST HELPFUL
MORE LESS
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Do you read your STATE MEDICAL JOURNAL?
Every month Frequently Occasionally
Do you read advertisements? Regularly Occasionally
Please indicate one product advertised of particular interest to you in last two issues
Name medical journals you read in order of interest: Indicate position you would
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PLEASE RETURN THIS PAGE TO
P. O. Box 539, Lansing 3, Michigan
The Journal of the Michigan State Medical Society
Legal Opinion
Important
Announcement of
Arteriosclerosis
Treatment
GEROT PHARMACEUTIKA, own-
ers of United States Letters Patent
#2-776-973 issued January 1957 to
Gerhard Gergely of Vienna, Austria,
have licensed MEYER AND COM-
PANY of Detroit, Michigan, to syn-
thesize and market 3, 7-dimethyl-xan-
thine double salt in the United States
of America.
3, 7-dimethyl-xanthine double salt with
oleic acid and magnesium, a stable
compound marketed in Austria since
1950 under the name “Perskleran” and
used in the treatment of ARTERIO-
SCLEROSIS is being marketed by
MEYER AND COMPANY under the
trade name of “Athemol.”
The product is now available in tablet
form.
Literature and clinical samples are
available on request.
MIYII& AND
COMPANY
Pharmaceutical Manufacturers
1636! Mack Ave.
Detroit 24, Michigan
1174
Say you saw it in the Journal of the
Dear Mr. Burns:
You recently referred to me a communication which
states that at a recent meeting of physicians of a
certain area the medical profession was publicly indicted
for “refusal to draw blood alcohols on suspected drunken
drivers who are brought to the hospital emergency
room.” The letter further states that the doctors of
the area would be happy to co-operate with the police
but feel that they are not “legally allowed to draw
blood from anyone without his written permission which
is given in a state of complete sobriety.”
Although I do not believe that the applicable legal
rule is quite as comprehensive as there stated, I agree
completely that the medical profession should not be
indicted for refusal to draw blood alcohols indiscrim-
inately.
I know of no court decisions directly in point, but
I think that under well-recognized general principles
a doctor has no right to draw a blood sample without
the consent of the patient. To do so, in my opinion,
might constitute an assault and would certainly be an
invasion of the person. I believe that the letter may
overstate the case slightly by indicating that the per-
mission must be “written” and that it must be given in
a state of “complete” sobriety.
I doubt that permission would necessarily have to
be in writing, although certainly this is advisable as a
matter of protection to the doctor. I doubt also that
“complete sobriety” would be necessary to give valid
consent. I think the true test of ability to give consent
would be that the subject be capable of understanding
the situation and be able to give a conscious and
rational consent or refusal to the test. This would
necessarily have to be determined by the physician from
observation and by questioning the subject. When I
question the use of the words “complete sobriety,” I
have in mind that many authorities will adopt the view
that even minute amounts of alcohol will cause an
individual to be less than completely sober. I think
the true test should be whether the subject appears,
under ordinary observation, to be capable of giving a
voluntary and rational consent with understanding of
what he is doing.
Unless the physician is able to obtain such consent.
I am of the opinion that the drawing of a blood sample
would be an unauthorized and unwarranted act. Cer-
tainly, in my opinion, the public indictment of the
medical profession of the area based on refusals to
draw blood samples indiscriminately on the request
of the police or other lay agencies is wholly unfair and
unwarranted.
Very truly yours,
Lester P. Dodd
Legal Counsel
Lansing, Michigan
August 12, 1957
Radical operation is indicated for localized ampullarv
lesions and for early carcinoma of the head of the
pancreas.
* * *
The task of early diagnosis in gastric carcinoma is
the concern of the historian and symptomatologist.
JMSMS
Michigan State Medical Society
mg./ml.
700
new
6oo sulfonamide formula
; 4. [ 4
for urinary tract infections
UNEXCELLED SOLUBILITY
optimal concentrations at site of
infection; avoids crystalluria
BROAD ANTIBACTERIAL RANGE
active against wide range of urinary
pathogens, including staphylococci,
gonococci, Escherichia coli
QUICK SYMPTOMATIC RELIEF
hyoscyamus component quickly
relieves pain and burning
FREEDOM FROM TOXIC EFFECTS
low degree of acetylation; no forcing
of fluids or alkalization needed
Uronamide
Each tablet or 5-cc. tsp. provides
250 mg. sulfamethylthiadiazole,
250 mg. sulfacetamide, and equiv.
of 0.015 mg. alkaloids of
Hyoscyamus niger.
DOSAGE: Adults— 2 tablets or 2 tsp.
q.i.d. first 2 days, thereafter.
1 tablet or 1 tsp. q.i.d.
Children — 1 cc. (16 drops) syrup
per 10 lb. body weight first 2 days,
thereafter, 0.5 cc. (8 drops) per
10 lb. SUPPLIED: Tablets,
bottles of 50 and 500. Syrup,
1-pt. and 1-gal. bottles.
font,
Decatur. Illinois
“Sulfamethyl-
thiadiazole . . .
effective chemo-
therapeutic
agent in.
urinary infec-
tion... tolerated
quite well . . .
bacterial spec-
trum is com-
parable to that
of sulfadime-
tine and sulfi-
soxazole.”1
“[Sulfaceta-
mide] ... among
the least toxic
but one of the
most effective
of the sulf ona-
mides against
urinary tract
pathogens .”2
1. Hughes, J.,
et al.: South. M.J.
47:1082, 1954.
2. Kerley, L., and
Headlee. C. P.:
J. Am. Pharm. A.
(Scient. Ed.)
48:82, 1956
SEPTEMBER, 1957
Say you saw it in the Journal of the Michigan State Medical Society
1175
NEWS MEDICAL
MICHIGAN AUTHORS
Vito DeFilippis, M.D., and Irving I. Young, M.D.,
Detroit, are the authors of an article entitled “Evalua-
tion of Adrenocortical Function with Intramuscular In-
jection of ACTH Gel,” published in the New England
Journal of Medicine, July 4, 1957.
Laurence S. Fallis, M.D., Detroit, is the author of an
article entitled “The Billroth I Gastroectomy,” published
in Surgery, Gynecology and Obstetrics, July, 1957.
Robert L. Cowen, M.D., Detroit, is the author of an
article entitled “Tumor of the Tunica Vaginalis Testis:
Case Report of Neurilemmoma,” published in the Jour-
nal of Urology, January, 1957.
Hun Jae Lee, M.D., Ann Arbor, is the author of an
article entitled “Metastatic Carcinoma in the Brain,”
published in the University of Michigan Medical Bulle-
tion, June, 1957.
Arthur L. Norms, M.D., Chicago, formerly of Ann
Arbor, is the author of an article entitled “Osteoprosis,”
published in the University of Michigan Medical Bulle-
tin, June, 1957.
Donald G. Marquis, E. Lowell Kelly, James G. Miller,
Ralph W. Gerard, and Anatole Rapoport, Ann Arbor,
are the authors of an article entitled “Experimental
Studies of Behavioral Effects of Meprobamate on Nor-
mal Subjects,” published in Annals of the New York
Academy of Sciences, May 9, 1957.
James H. Wible, M.D., Lyle F. Jacobson, M.D., Pres-
cott Jordan, Jr., M.D., and Charles G. Johnston, M.D.,
Detroit, are the authors of an article entitled “The
Correction of Aortic Insufficiency with a Spring Valve
Prosthesis,” published in AMA Archives of Surgery,
June, 1957.
D. Emerick Szilagyi, M.D., John G. Whitcomb, M.D.,
and Claibourne P. Shonnard, M.D., Detroit, are the
authors of an article entitled “Replacement of Long
and Narrow Arterial Segments,” published in AMA
Archives of Surgery, June, 1957.
T. Frederick Johnson, M.D., Detroit, is the author of
an article entitled “Blood Changes Following Estro-
gen Administration,” published in Medical Science,
March 25, 1957.
J. DeWitt, Fox, M.D., Detroit, is the author of an
article entitled “Narcotic Addiction Among Physicians,”
published in The Journal of the Michigan State Medi-
cal Society, and condensed in Current Medical Digest,
June, 1957.
Charles T. Disney, M.D., Detroit, is the author of an
article entitled “An Approach to Radiation Health
Problems in Industry,” presented at the Nineteenth
Annual General Motors Medical Conference in St.
Louis, April, 1957, and published in Industrial Medi-
cine and Surgery, July 1957.
* * *
Hurricane Audrey. — On June 27, 1957, Hurricane
Audrey blew through several parishes of Louisiana
and destroyed over 500 lives. Two villages were prac-
tically wiped out. Three doctors lost their homes, offices,
furniture, equipment, and one three children. Red
Cross reports that the doctors of the area worked
heroically and continuously for days, with a well-exe-
cuted relief program. The Louisiana State Medical
Society has established a relief fund with letters to all
their members to replace the lost homes, offices and
equipment so these young men under thirty-seven may
continue their practice. Funds are being accepted from
other states than Louisiana, and should be sent to
Cameron Parish Medical Relief Fund, c/o Louisiana
State Medical Society, Room 105, 1530 Tulane Ave.,
New Orleans, La.
* * *
The Michigan Association for Retarded Children held
its Annual Conference on September 5, 6 and 7 at
Central Michigan College at Mt. Pleasant. The theme
of the conference was “Co-operative Planning to Meet
Needs of Retarded Children.” Michigan doctors par-
ticipating in the program are William Kelly, M.D.,
Lansing; Norman Westlund, M.D., Saginaw; William
L. Harrigan, M.D., Mt. Pleasant; Paul H. Jordan,
M. D., Flint; Robert W. Talley, M.D., Kalamazoo;
James L. Wilson, M.D., Ann Arbor; and Vernon Ste-
ham, M.D., Lansing.
* * *
World Medical Association. — -The House of Delegates
of the American Medical Association urged the members
to join the American Committee of the World Medical
Association and become active in its affairs. The twelfth
annual session of the WMA will be held in Copenhagen,
August 15-20, 1958. Anyone interested in attending
should begin making arrangements, as travel may be
crowded at that time.
The chairman for Michigan on individual member-
ships is William A. Hyland, M.D., Grand Rapids.
* * *
Medical Costs Under Public Assistance. — The Bureau
of Public Assistance reports that incomplete statistics
indicate that hospital care is the most expensive item
involved in the medical care of individuals supported by
federal-state public assistance programs. Involved are
four categories: the needy aged, blind, dependent chil-
dren and permanently and totally disabled. In addition
(Continued on Page 1178)
1176
JMSMS
In the nonhormonal treatment of arthritis
and allied disorders no agent surpasses
Butazolidin in potency of action.
Its well-established advantages
include remarkably prompt action
broad scope of usefulness,
and no tendency to development
of drug tolerance. Being
nonhormonal, Butazolidin
causes no upset of normal
endocrine balance.
Butazolidin relieves pain,
improves function,
resolves inflammation in:
Gouty Arthritis
Rheumatoid Arthritis
Rheumatoid Spondylitis
Painful Shoulder Syndrome
Butazolidin being a potent therapeutic
agent, physicians unfamiliar with its
use are urged to send for detailed
literature before instituting therapy.
Butazolidin® (phenylbutazone
Geigy). Red coated tablets of 100 mg.
GEIGY <t&>
Ardsley, New York
unexcelled in
therapeutic potency
BUTAZOLIDIN
(phenylbutazone Gkicy)
EPTEMBER, 1957
Say you saw it in the Journal of the Michigan State Medical Society
1177
NEWS MEDICAL
CARBASED
ACETYLCARBROMAL tablets
» Proved safe and effective by 6 years’
clinical use.
• Soothes the central nervous system,
produces calmness without hypnosis.
• Non-toxic, non-cumulative, non-addict-
ing, no known contraindications.
• Does not impair mental or physical
function.
• Orally effective within 30 minutes for
sustained action up to 6 hours.
• Economical.
Indications: Tension, nervousness,
anxiety and muscular spasm.
Supplied: White round tablets
Acetylcarbromal 5 g r. in bottles
of 100, 1000.
Write for samples and literature
There's Always A Leader
MALLARD, inc
3021 WABASH, DETROIT 16, MICHIGAN
1178
(Continued from Page 1176)
to helping states pay for these people's support, the
U. S. also sets aside additional money for their medical
bills, money which must be matched in part by the states.
The bureau’s survey, for July-December. 1956, includes
data from 20 states. Hospital care accounted for 37.9
per cent of the medical costs, nursing homes and home
care maintenance for 29.5 per cent, drugs and supplies
for 13.8 per cent, physicians’ services for 13 per cent
and other services for 7.9 per cent. The bureau now is
attempting to obtain more complete information from a
larger number of states on the cost breakdown in the
various items of medical care under PA.
* * *
A Mead Johnson Award for Graduate Training in
General Practice — a $1,000 grant to assist in residency
training of pysicians — was received by Dr. Richard A.
Ferrington (third from left in picture) at a meeting of
the Midland County Medical Society recently in Mid-
land. Dr. Ferrington, a graduate of the University of
Michigan Medical School, had just completed his intern-
ship at the Midland Hospital and planned, with help
of the Mead Johnson Award, to enter residency training
this summer at the University of Michigan Hospital, Ann
Arbor. Shown presenting the award to Dr. Ferrington
is Dr. E. Clarkson Long, secretary of the Michigan
Branch of the American Academy of General Prac-
tice. At far left is Bernard E. Lorimer, administrator
of the Midland Hospital, and at right is Charles Coff-
man, District Sales Manager for Mead Johnson &
Company, sponsor of the General Practice Awards.
Ten such scholarships were granted this spring by the
American Academy of General Practice.
* * *
The Atomic Energy Commission announces the award
of sixty-seven Life Science Research contracts in the field
of atomic energy; fifteen of the contracts are new allot-
ments. Michigan benefits as follows: University of Mich-
igan, L. A. Bernstein, investigator, “Effects of Radiation
on the Intermediary Metabolism of Mammalian Skin,’’
$9,000; Wayne State University, J. E. Lofstrom, investi-
gator, “Studies on the Effects of Maternally Admin-
istered Phosphorus-32 on Foetal and Postnatal Develop-
ment of the Rat,” $10,000; Michigan State University,
(Continued on Page 1180)
JMSMS
Say you saw it in the Journal of the Michigan State Medical Society
MICHIGAN
is an Indian word —
probably means
“Great Lake”
is a trademark —
surely means
^“Better Calcium Assimilation”
MARION wants to be part of MICHIGAN.
We will begin by making *“Better Calcium Assimilation”
available to your doctors and their patients with our
Oyster Shell Calcium Products:
OS-CAL
Oyster Shell Calcium
Natural Trace Minerals
Vitamin D
m ■ m mmmm
OS>-CAL
Therapeutic Iron
Oyster Shell Calcium
Vitamin D
Natural Trace Minerals
m
I
m
"HARDY, J. A.: Obstet. & Gynec. (Nov., 1956)
OS-VIM
Oyster Shell Calcium
B-Complex
Vitamins A-D-C-E
Natural Trace Minerals
Ferrous Sulfate
OS-^-VI M
Therapeutic Iron
Oyster Shell Calcium
Vitamins A-D-C-Bs and K
Natural Trace Minerals
MARION will exhibit with the
Michigan State Medical Societv
September 25-27,
Grand Rapids, Michigan
Attention — Grand Rapids Doctors:
Special Marion Salesman will be in
Grand Rapids September 23 to October 4
for their annual call.
Michigan Academy of General Practice
November 6 and 7,
Detroit, Michigan
Attention — Detroit Doctors:
Special Marion Salesmen will be in
Detroit November 4 to 15 for their
first annual visit.
They will appreciate a prompt, brief interview.
larion Laboratories, Inc. 2910 Grand Avenue Kansas City, Missouri
iPTEMBER, 1957 1179
Say you saw it in the Journal of the Michigan State Medical Society
NEWS MEDICAL
'He**’
BAND-AID
TRADE MARK
Plastic Strips
• ELASTIC PLASTIC
• FLESH COLORED
• STAYS CLEAN
• THIN, SMOOTH PLASTIC
• GREASE RESISTANT
• WON'T WASH OFF
1 00’s 1 "x 3"
lOO’s 3/4"x3"
CcMenieHthj located
in (jtand Rapid*
(Continued from Page 1178)
J. L. Fairley, investigator, “The Role of Various Ali-
phatic Acids in Pyrimidine Biosynthesis,” $5,140; Wayne
State University, “Summer Institute of Radiobiology
for High School Science Teachers,” A. J. Forvald, in-
vestigator, $34,782. This is a new project.
* * *
The revised doctor draft bill has become Public Law
85-62; it was signed by President Eisenhower, June 27,
four days before the expiration of the old doctor draft
law. Under the latter, some 10,000 physicians were I
called up for two or more years of service, starting back
at the time of the Korean war. The new law provides
for the selective call-up of physicians and dentists to
age thirty-five, if they were deferred from the regular
draft at any time after June, 1951, in order to complete
their professional training. The law is effective for two
years, expiring at the same time as the regular draft.
Defense Department estimates that the 2,200 physicians
required by the services this fiscal year will come from
volunteers.
* * *
Medical and scientific meetings scheduled for Wash-
ington, D. C., the balance of this year are: American
Roentgen Ray Society, October 1-4, anticipated registra- p
tion 2,000; Fifth Annual Antibiotics Symposium. Oc-
tober 2-4, anticipated registration 700; D. C. Medical
Society Scientific Assembly, October 14-16, anticipated
registration 3,500; Association of Military Surgeons, :i
October 27-30, anticipated registration 1,500; Medical i
Society of Virginia, October 27-30, anticipated registra-
tion 200; Pan-American Congress of Pharmacy and Bio- )
chemistry, November 3-8, anticipated registration 1,000;
Maryland-District of Columbia-Delaware Hospital Asso-
ciation, November 6-8, anticipated registration 2,000;
Congress of Neurological Surgeons, November 7-9, anti- i
cipated registration 300.
* * *
• Hospital Equipment
• Pharmaceuticals
• Office Equipment
• Physicians’ Supplies
• Trusses
• Surgical Garments
• Physiotherapy Equipment
Medical Arts Supply Company
233 Washington S. E. Phone GL 9-8274
Grand Rapids 2. Mich.
Medical Arts Pharmacy
20-24 Sheldon S.E. Phone GL 9-8274
Grand Rapids 2. Mich.
Medicare Contracts. — All 56 of the government’s
Medicare contracts expired June 30, but every one has
been renewed, without a single exception. New contracts
are for periods of seven to seventeen months, arranged
in escalator fashion so that there will be no more
than six termination in any one month hereafter. Lieut.
Col. Ralph Richards, who had responsibility for contract
renewals under general supervision of Maj. Gen. Paul I.
Robinson, Medicare director, credited “the fine spirit”
of AMA, state medical societies, and other parties direct-
ly involved for the expeditious handling of negotiations.
Shortest term agreements on medical care payments are
those with Florida, New Hampshire, North Dakota,
Puerto Rico and Wisconsin, expiring January 31, 1958.
February 28: Arizona, California, Georgia, Mississippi,
Idaho. March 31 : Arkansas, Indiana, Michigan. New
Mexico, Rhode Island April 30: Alaska, Delaware, Iowa,
Minnesota, Nevada, Texas. May 31: Alabama, Connec-
ticut, South Dakota, Vermont. June 30: Blue Cross,
Mutual of Omaha, Maine, New Jersey, Ohio, Oklahoma.
July 31 : District of Columbia, Illinois, Kansas, Kentucky,
(Continued on Page 1182)
1180
Say you saw it in the Journal of the Michigan State Medical Society
JMSMS
come to
for an Autumn Holiday
Fall is a most delightful time of
the year at country-quiet Dear-
born Inn. Come soon for a pleas-
ant few days or weekend.
You’ll like the Inn’s colonial
charm in a 28-acre estate-like set-
ting— its modern appointments,
including TV and air condition-
ing throughout — its traditional
hospitality — the newly enlarged
cocktail lounge — the fine food
graciously served in either the
Early American Dining Room
or the English Coffee Shop.
And cool, autumn days are ideal
for a visit to nearby . . .
HENRY FORD MUSEUM and GREENFIELD VILLAGE
where you can see a broad profile
of American history from earliest
times to modern day.
Also only a short drive away is
the Ford Rotunda, famous for its
architecture, fascinating exhibits
and miniature test track over
which you can ride.
For further details, write or call
The Dearborn Inn.
135 guest rooms
in the Inn and
Colonial Guest
Houses from
$8 single; $13
double. Reserva-
tions advisable.
The Dearborn Inn
Oakwood Boulevard
Dearborn, Mich.
LOgan 5-3000
Richard D. McLain, Manager
when anxiety and tension "erupts” in the G. I. tract...
IN DUODENAL ULCER
PATH I BAM ATE'
Meprobamate with PATHILON® Lederlo
Combines Meprobamate ( 400 mg.) the most widely prescribed tranquilizer . . . helps control
the “emotional overlay” of duodenal ulcer — without fear of barbiturate loginess, hangover or
habituation . . . with PATH I LON (25 mg.) the anticholinergic noted for its extremely low toxicity
and high effectiveness in the treatment of many G.I. disorders.
Dosage: 1 tablet t.i.d. at mealtime. 2 tablets at bedtime. Supplied : Bottles of 100, 1,000.
‘Trademark ® Registered Trademark for Tridihexethyl Iodide Lederle
LEDERLE LABORATORIES DIVISION, AMERICAN CYANAMID COMPANY, PEARL RIVER, NEW YORK
September, 1957
Say you saw it in the Journal of the Michigan State Medical Society
1181
NEWS MEDICAL
protein
is 3
COMPLETE PROTEIN
Complete protein
is essential to
the maintenance
of body cells
Constant daily replacement
of protein forming the cells of blood, skin,
muscle, nerve, bone, and even teeth, is
necessary to maintain health and vigor. In
order that this process be maintained, the
diet must contain adequate quantities of
“complete protein” with all of the essential
amino acids for simultaneous ingestion.
The Wisconsin Alumni Research Founda-
tion has licensed the production of such a
complete protein in the form of V10 Protein
Concentrate. V10 Protein is composed entire-
ly of grains, yet results of laboratory tests by
the Foundation show that it has a protein
efficiency value equal to casein, the high
quality protein standard commonly used in
protein evaluation work.*
Now V10 Protein is available in Michigan in
V10 Protein Bread and V10 Protein Graham
Crackers. These delicious foods add variety to
the daily dietary requirement for protein. V1'1
Protein Bread and Graham Crackers will great-
ly aid in the planning of meals and will help
promote health and vigor for all age groups.
WISCONSIN )
ALUMNI
RESEARCH
FOUNDATION
:;:A complete report on these animal
feeding studies is available on
request. Address WISCONSIN
ALUMNI RESEARCH FOUNDATION,
P. O. Box 2217, Madison 1, Wis.
(Continued from Page 1180)
New York. August 31: Hawaii, Louisiana, Maryland,
Massachusetts, Montana. September 30: Missouri, Kan-
sas City and St. Louis (separate contracts), Nebraska,
North Carolina, Washington. October 31: Colorado,
Oregon, Pennsylvania, South Carolina. November 30:
Tennessee, Utah, West Virginia, Wyoming. Note: Blue
Cross and Mutual of Omaha serve as fiscal agents for
hospitalization of military dependents in civilian insti-
tutions.
* * •»
Polio Grants. — The University of Michigan Hospital
in Ann Arbor has been awarded a grant of $111,230
from the National Foundation for Infantile Paralysis for
a poliomyelitis respiratory and rehabilitation center. The
grant is one of sixty-seven grants and appropriations,
totaling $4,527,064, made on recommendations of ad-
visory committees composed of leading medical educators
and others in the health field. Besides supporting polio
respiratory and rehabilitation centers, the awards will
support research to solve problems of polio and other
viruses, research into treatment of polio after-effects and
a professional education program aimed at relieving
shortages of workers in health fields and raising the
quality of care for polio and other patients.
* * *
Nutrition in Pregnancy will be the subject of the
1957 symposium of the Council on Foods and Nutrition
of the American Medical Association to be held Oc-
tober 1 1 at the University of Missouri Medical Center,
Columbia, Missouri.
This meeting will provide an excellent opportunity for
the physician and members of the allied professions to
acquaint themselves with current findings in nutrition
and the practical application of these findings to the
management of obstretrical patients.
A copy of the program is available on request.
* * *
An all-day symposium on “Recent Developments in
Diabetes Mellitus” (pathology, diagnosis and therapy)
will be sponsored by the Chicago Diabetes Association
on November 20, 1957, at the Drake Hotel, Chicago.
Registration is scheduled for 8:45 A.M. and lectures
will begin at 9:00. Physicians registering for the course
will be charged an enrollment fee of $25.00, with the
exception of members of the Chicago Diabetes Asso-
ciation and the American Diabetes Association, who may
enroll without charge.
Members of the Academy of General Practice who
attend the conference may claim hour-for-hour Category
II credit.
Henry T. Ricketts, M.D., Professor of Medicine, Uni-
versity of Chicago Clinics, will be moderator.
* * *
The Legislature of Alabama, at its last session, con-
stituted the Medical Association of Alabama as the State
Board of Health. The next session of the Association at
Montgomery will be the first under the new law, and
will consist of measures to provide better days for the
people of Alabama. The successful working of the plan
can be very promising. Other states might follow this
( Continued on Page 1184)
1182
Say you saw it in the Journal of the Michigan State Medical Society
JMSMS
Trasentine-
c I B A
Summit, N. J.
integrated relief . . .
mild sedation
visceral spasmolysis
mucosal analgesia
TABLETS ( yellow , coated), each containing
50 mg. Trasentine ® hydrochloride (adiphenine
hydrochloride Cl BA) and 20 mg. phenobarbital.
2/222SM
September , 1957
Say you saw it in the Journal of the Michigan State Medical Society
1183
NEWS MEDICAL
GREATER EASE in
EXAMINATION AND TREATMENT
with a
RITTER
UNIVERSAL TABLE
Greater flexibility in a treatment table can make
your office practice easier, more efficient. Such is
the Ritter Universal Table. Here is a table that re-
duces effort for both you and your patient. A touch
of the toe to the convenient pedals floats the Ritter
Table to the height desired. The motion of the table
is barely noticeable, giving your patient a feeling of
complete security at all times.
The flexibility of the Universal Table is practically
unlimited. It provides unusually effective facilities
for an improved rectal posture (inverted Icnee-chest) ,
Gyn and many other positions, including a relaxed
approach in the treatment of child or baby.
The extreme low position of the Ritter Universal
Table enables the debilitated or the elderly patient
to get onto the table without a painful and at times
hazardous maneuver. Table rotation of 180° saves
you many steps each day and the rotation lock holds
the table in any desired position.
Expertly designed, carefully built, this Ritter Uni-
versal Table is a sound long-term investment in con-
venience and efficiency — everything about the table
speaks quality from its eye-appealing exterior to its
innermost working parts.
Call us today, and we will be glad to arrange a
demonstration of this table at your convenience.
NOBLE-BLACKMER, INC.
267 W. Michiqan 28148
Jackson, Michigan
(Continued from Page 1182)
lead. In Michigan, the State Medical Society first con-
stituted itself as the State Board of Health, and soon
engineered the establishment of our separate board.
* * *
J. Irvin Nichols, head of the Ken-
tucky Tuberculosis Association for six
years, has been appointed executive
secretary of the Michigan Tuberculosis
Association. On September 1, he suc-
ceeded Theodore J. Werle, who has
been appointed executive secretary
emeritus. Werle, who is completing
forty-seven years of work in the volun-
tary tuberculosis movement, joined the
Michigan Tuberculosis Association in
1921 and became executive secretary
the following year.
* * *
The American Medical Writers’ Association will hold
its fourteenth annual meeting, held at the Sheraton-
Jefferson Hotel, St. Louis, September 27-28, under the
presidency of Dean F. Smiley, B.A., M.D., Evanston,
Illinois, Secretary, American Association of Medical
Colleges. Eighteen medical writers and authors will
address this — “The Americas’ Only Association Exclu-
sively Devoted to Improvement in the Communications
of Medicine and Allied Sciences.” The speaker list for
September 27 includes J. R. Gray, M.D., of Parke, Davis,
Detroit. On September 28, the program will be a work-
shop on Medical Writing by six well-known persons.
All members of the American Medical Writers’ Asso-
ciation and other collegiate graduates are cordially
invited and urged to attend this meeting. There is no
charge for the meeting September 27, but there is a
registration fee of $5.00 for non members of the Asso-
ciation who attend the workshop on September 28. The
twenty-second annual meeting of the Mississippi Valley
Medical Society — “The Midwest’s Greatest Intensive
Post-Graduate Medical Assembly,” will also meet at the
Sheraton- Jefferson Hotel, September 25, 26, 27. Further
details of both meetings may be obtained from Harold
Swanberg, M.D., Secretary, W.C.U. Bldg., Quincy,
Illinois.
* * *
Michigan doctors certified by the American Board of
Obstetrics and Gynecology on May 25, 1957, are: Rich-
ard C. Ashcom, 110 W. Sugnet St., Midland; Everette
Gustafson, 236 Riker Bldg., Pontiac; John M. Nehra,
18408 Mack Ave., Grosse Pointe 36; George S. Sayre,
523 W. Cross, Ypsilanti; Robert L. Segula, 518 Riker
Bldg., Pontiac; John J. Turner, 25447 Plymouth Rd.,
Detroit 39; Corwin G. Van Der Veer, 68 Ransom N.E.,
Grand Rapids.
■* * *
M. K. Newman, M.D., Detroit, presented a paper
entitled “Progressive Muscular Dystrophy- Clinical
Aspects” at the meeting of the Michigan State Society
of Muscular Dystrophy, at Morton House, Grand Rapids,
on July 13, 1957.
(Continued on Page 1186)
1184
Say you saw it in the Journal of the Michigan State Medical Society
JMSMS
in
PREVENTIVE GERIATRICS
a FIRST from TUTAG !
Now — 20 to 1 Androgen-Estrogen
(activity)
Each Magenta Soft Gelatin
Methyltestosterone 2 mg.
Ethinyl Estradiol 0.01 mg.
Ferrous Sulfate 50 mg.
Rutin 10 mg.
Ascorbic Acid 30 mg
B-12 1 meg.
Molybdenum 0.5 mg.
Cobalt 0.1 mg.
Copper 0.2 mg.
Vitamin A 5,000 I.U.
Vitamin D 400 I.U.
Vitamin E I I.U.
Cal. Pantothenate 3 mg.
Write for Latest Technical
‘REFERENCE: J.A.M.A. 163:
ratio* !
Capsule contains:
Thiamine Hcl. 2 mg
Riboflavin 2 mg
Pyridoxine Hcl. 0.3 mg
Niacinamide 20 mg
Manganese ... 1 mg
Magnesium 5 mg
Iodine 0.15 mg
Potassium 2 mg
Zinc I mg
Choline Bitartrate 40 mg
Methionine. 20 mg
Inositol 20 mg
Bulletins.
359, 1957 (February 2)
S. J. TUTAG & COMPANY
DETROIT 34, MICHIGAN
when anxiety and tension "erupts” in the G. I. tract...
IN GASTRIC ULCER
PATHIBAMATE'
Meprobamate with PATHILON® Lederle
Combines Meprobamate ( 400 mg.) the most widely prescribed tranquilizer . . . helps control
the “emotional overlay” of gastric ulcer — without fear of barbiturate loginess, hangover or
habituation . . . xvith PATHILON (25 mg.) the anticholinergic noted for its extremely low toxicity
and high effectiveness in the treatment of many G.I. disorders.
Dosage: 1 tablet t.i.d. at mealtime. 2 tablets at bedtime. Supplied: Bottles of 100, 1,000.
‘Trademark ^Registered Trademark for Tridihexethyl Iodide Lederle
LEDERLE LABORATORIES DIVISION. AMERICAN CYANAMID COMPANY, PEARL RIVER, NEW YORIC
PTEMBER, 1957
Say you saw it in the Journal of the Michigan State Medical Society
1185
NEWS MEDICAL
for modern
control of
salt retention
edema
CUMERTILirf
(Brand of Mercumatilin, Endo)
Tablets
• effective oral diuretic with no sig-
nificant gastrointestinal irritation1
• Suitable for long-term mainte-
nance therapy.
• eliminates need for injections ir
certain cases, lengthens interval
between injections in others
• basically different in chemical
structure, extending the therapeu-
tic choice in organic mercurials
DOSAGE: 1 to 3 tablets daily as required.
SUPPLIED: As orange tablets, in bottles
of 100 and 1000. Also available —
CUMERTILIN Sodium Injection, 1- and 2-cc.
ampuls, in boxes of 12, 25, and 100; and
10-cc. vials, individually and in boxes
of 10 and 100.
1. Pollock, B. E., and Pruitt, F. W.: Am. J. M.
Sc., 226:172, 1953.
THE G. A. INGRAM COMPANY
4444 Woodward Avenue, Detroit 1, Mich.
(Continued from Page 1184)
Donald G. Marquis, M.D., Ann Arbor, presented a
paper at a Panel on Tranquilizing Drugs, at the Hotel
Sherman, Chicago, on May 20, 1957. The title of the
paper was “The Effects of Tranquilizing Drugs on Nor-
* * *
Alfred H. Whittaker, M.D., of
Detroit, was appointed a member
of the Mackinac Island State Park
Commission by Governor G. Men-
nen Williams on July 22. Doc-
tor Whittaker attended his first
Park Commission meeting on
August 1 2, and stressed the need
for preserving the historical char- 1
acter of Market Street and the
downtown area of Mackinac Is-
land.
Congratulations, Commissioner
Wh>tfoker!
* * *
MEDICAL TELEVISION SHOWS
Produced by Michigan Health Council
WJBK-TV, Detroit
June 2 — “To Save a Life” (Film).
June 9 — “Secrets of the Heart” (Film).
June 16 — “Cerebral Palsy” — Guests; Mrs. Francis Shil-
ling, Reuben Kurnetz, M.D., Mrs. Maryann Aman,
George V. Pendy, M.D., Miss Mary Cook, all of
Detroit.
June 23 — “Preface to a Life” (Film).
June 30 — “Water Safety” (Film — “Learning How to
Swim”) .
July 7 — “Public Opinion Survey” — Guests: L. Fernald
Foster, M.D., and Mrs. Ruth Van Damme, both of
Detroit. Also J. K. Altland, M.D., Hugh W. Brenne-
man and Kay Asby, all of Lansing.
July 14 — “Health Careers” (Films — “Medical Associ-
ates” and “Health Careers”).
July 21 — “Mental Health” (Film — “We, the Mentally
ni”).
July 28 — “Guard Your Heart” (Film).
WKAR-TV , East Lansing
June 6 — “Search for T.B.” — Guests: George N. Phil-
lips, M.D., of Jackson; John Isbister, M.D., Theodore
J. Werle, Miss Margaret Farro, all of Lansing.
* * *
Doctors of Medicine have given $500 million in the
last ten years toward expanding and improving com-
munity hospitals — according to a survey among mem-
bers of the American Association of Fund-raising Coun-
sel and other professional fund-raisers. The study shows
that M.D.’s contribute nearly 20 per cent of the total
amount raised in most hospital campaigns.
* * *
We can no longer say that the development of home
care programs is a future charge on health departments.
The time is now. — Leonard A. Scheele, M.D., Sur-
geon General, PHS, Public Health Reports, Published
January, 1956.
* * *
The Southern Medical Association broke ground for
its new office building in Birmingham, Alabama (High-
land Avenue and Niazuma Street), on August 4, 1957.
* * *
(Continued on Page 1188)
mal Persons.”
A. H. Whittaker,
M.D.
1186
Say you saw it in the Journal of the Michigan State Medical Society
JMSMS
New
effective
Your patients will like this new, different treatment
for fast, effective, pleasant relief from the discom-
forts caused by
Respiratory ailments such as
• Nasal Allergies
• Nose and Throat Irritations
• Sinusitis
• Head Colds
Because of its thin, one-piece seamless shell, the
INSTA-MELT spherical capsule releases its pleas-
ant soothing vapors immediately when dropped into
a cup of hot water or a vaporizor. Nothing messy
. . . quick . . . easy to use!
INSTA-MELT
“INHALANT”
CAPSULES
An outstanding
product of
General Capsule
Corporation
different
insta* * melt
THERAPEUTIC
“INHALANT”
CAPSULES!
INSTA-MELT inhalant capsules and other General
Capsule pharmaceuticals are available only through
the medical profession. Below is just a partial list of
pharmaceuticals produced in the General Capsule
laboratories by its exclusive capsulation process. All
proprietaries listed are manufactured only in the thin-
shell, one-piece, spherical, seamless GCC capsules.
• Vitamin A, natural and synthetic in various unit
potencies.
• Tocopherols (Vit. E) in 50 mg. and 100 mg. concen-
trations.
• Vitamin B-12— 25 meg. concentration.
• Vitamin A and D in various potencies.
• Dextro-Amphetamine sulfate— 5 mgs.— capsule sizer
(2 minim).
We will he pleased to mail our catalog showing our
full line of pharmaceuticals. Write for it today.
GENERAL CAPSULE CORPORATION
FRASER, MICHIGAN
September, 1957
Say you saw it in the Journal of the Michigan State Medical Society
1187
NEWS MEDICAL
I Continued from Page 1186)
New Safety Automobile. — In The Massachusetts Phy-
sician for June-July, 1957, there is an article and a pic-
ture of the Liberty-Cornell Safety Car. This is a new
safety automobile, which was designed to give both driver
and passenger maximum protection against collision in-
juries. It is the result of a joint study undertaken by
the Cornell Aeronautical Laboratory and the Liberty
Mutual Insurance Company. The car possesses ( 1 )
rounding bumpers to produce a glancing blow rather
than a direct one, (2) side bumpers to reduce shock of
impact and property damage, (3) energy absorbing ma-
terial between the bumper face and the frame, (4)
recessed headlights to avoid protuberances at the front
end.
Even more daring are the interior changes: (1) the
driver is placed in the center to obtain maximum visi-
bility and better control of the car, (2) steering wheel
is replaced by a lever-type, power-steering system. Under
crash conditions, the driver is kept in position by a
U-shaped webbing supported between two side arms,
(3) conventional seats are replaced by bucket seats.
Other safety features of this car are: augmented roof
padding forward of the seats; roll over bars to safeguard
against body crushing; and special doors, double the
width of conventional doors, which are hinged to fold
together and swing outward, and which provide positive
locking in case of a crash.
At its Boston meeting in December, 1955, the Ameri-
can Medical Association urged President Eisenhower to
request legislation “authorizing the appointment of a
national body to approve and regulate safety standards
of automobile construction.” Such legislation was intro-
duced on February 20, 1957, by Sen. Lyndon Johnson,
of Texas, proposing the establishment within the Depart-
ment of Health, Education and Welfare of a separate
division to co-operate with other public and private
agencies to reduce traffic accidents.
This proposal was also cited by John D. Rogers, M.D.,
of Michigan, when he testified before the House Inter-
state and Foreign Commerce Committee’s special sub-
committee on traffic safety, in March, 1957. He recom-
mended that either manufacturers get together volun-
tarily to place proven safety features on all cars, or
Congress authorize a national body to approve and
regulate safety standards of automobile construction.
* * *
A Llniversity of Michigan senior medical student was
the recipient of a $500 scholarship for research and clini-
cal training in the field of allergic diseases. The stu-
dent was Jose N. Correa of Puerto Rico, and the grant
was made by the American Foundation for Allergic
Diseases.
Correa will work under John M. Sheldon, M.D..
concentrating on the possibility of finding fractions
(Continued on Page 1190)
1188
Say you saw it in the Journal of the Michigan State Medical Society
JMSMS
It's an "OPEN AND SHUT CASE" for ScftlMl 111*41
THE MEDICAL SUPPLY CORPORATION
OF DETROIT
3502 Woodward Avenue TEmple 1-4588 Detroit h Michigan
The new WELCH ALLYN instrument
case that offers you far greater
• DURABILITY
• CLEANLINESS
• COMPACTNESS
• BEAUTY
ILLUSTRATED -
Welch Allyn Oto-
scope - Ophthalmoscope
Set No. 983, complete with
Sandura Case.
The Sandura Case is molded in reinforced
material to stand great shock or abrasion,
with tarnish-proof soft rubber lining which
protects instruments from shock. The en-
tire case can be washed or sterilized with
alcohol.
when anxiety and tension "erupts” in the G. I. tract...
IN ILEITIS
PATH I BAM ATE'
Meprobamate with PATHILON® Lederle
Combines Meprobamate ( 400 mg.) the most widely prescribed tranquilizer . . . helps control
the “emotional overlay” of ileitis — without fear of barbiturate loginess, hangover or
habituation . . . zvith PATHILON (25 mg.) the anticholinergic noted for its extremely low toxicity
and high effectiveness in the treatment of many G.I. disorders.
Dosage: 1 tablet t.i.d. at mealtime. 2 tablets at bedtime. Supplied: Bottles of 100, 1,000.
‘Trademark ® Registered Trademark lor Tridihexethyl Iodide Lederle
LEDERLE LABORATORIES DIVISION, AMERICAN CYANAMID COMPANY, PEARL RIVER, NEW YORK
September, 1957
Say you saw it in the Journal of the Michigan State Medical Society
1189
NEWS MEDICAL
(Continued from Page 1188)
of allergen extract which have relatively great ability
to neutralize skin-sensitizing antibodies in comparison
with their ability to elicit skin reactions.
* * *
The Interstate Postgraduate Medical Assembly will be
held at the Palmer House, Chicago, September 30-
October 3, 1957. For program, write J. Mather Pfeiffen-
berger, M.D., President, Box 1109, Madison 1, Wiscon-
sin.
* * *
A course in occupational skin problems will be pre-
sented by the University of Cincinnati Institute of
Industrial Health at the Kettering Laboratory, Cin-
cinnati, Ohio, October 28-November 1, 1957. For
program, write the Secretary, Kettering Laboratory,
Eden and Bethesda Avenues, Cincinnati 18, Ohio.
* * *
The fourth annual meeting of the Academy of Psycho-
somatic Medicine will be held October 17-19 at the Mor-
rison Hotel, Chicago, and will be devoted to “Psycho-
somatic Aspects of Obstetrics, Gynecology, Endocrinology
and Diseases of Metabolism.” For program and infor-
mation, write William S. Kroger, M.D., Secretary, 104
South Michigan Avenue, Chicago 3, Illinois.
* * *
The American College of Chest Physicians announces
a postgraduate course on diseases of the chest at Hotel
Knickerbocker, Chicago, October 21-26. The same
course will be repeated at the Park-Sheraton Hotel, New
York City, November 11-15 and at the Ambassador
Hotel, Los Angeles, December 9-13. Tuition for the
course is $75. For information and application blank,
write the Executive Director of the College, 112 E.
Chestnut Street, Chicago 11, Illinois.
* * *
Frederick A. Coller, M.D., Ann Arbor, retiring Chair-
man of the University of Michigan Medical School’s
Department of Surgery and Grover C. Penberthy, M.D.,
of Detroit, Clinical Professor of Surgery at Wayne
State University, were honored at the 1957 annual
Coller-Penberthy Medical Conference in Traverse City,
July 25-26, a meeting originated by E. L. Thirlby, M.D.,
Traverse City, in 1922, which attracted a record attend-
ance of 140 physicians this year. Dr. Alexander G.
Ruthven, former University of Michigan President, spoke
at the dinner-meeting on “Education.” Also on the eve-
ning program was Dr. Gordon H. Scott, Dean of Wayne
State University College of Medicine.
Doctor Coller stepped down as Chairman of the
U. of M. Department of Surgery on July 1, after
having held the position since appointment in 1930.
Doctor Coller will continue to practice surgery and
conduct research without “the intolerable administra-
tive load,” as he describes the directing affairs of Uni-
versity Hospital’s most populous department. He will
also continue on the medical faculty as consultant
and teacher, giving a special course in the history of
(Continued on Page 1192)
BRIGHTON HOSPITAL
A non-profit Foundation
FOR ALCOHOLISM
A facility designed to rehabilitate or to aid
the addict in arresting his addiction.
Walter E. Green, M.D., Superintendent and Medical Director.
Brighton Hospital meets the stand-
ards established by the Michigan
State Board of Alcoholism and is
recommended by that Board.
12851 East Grand River
(U.S. 16)
Brighton, Michigan
Academy 7-1211
1190
Say you saw it in the Journal of the Michigan State Medical Society
TMSMS
^ All important laboratory exam-
inations; including—
Tissue Diagnosis
The Wassermann and Kahn Tests
Blood Chemistry
Bacteriology and Clinical Pathology
Basal Metabolism
Aschheim-Zondek Pregnancy Test
Intravenous Therapy with rest rooms for
Patients
Electrocardiograms
Central Laboratory
Oliver W. Lohr, M.D., Director
537 Millard St.
Saginaw
Phone. Dial 2-4100—2-4109
The pathologist in direction is recognized
by the Council on Medical Education
and Hospitals of the A.M.A.
EVERY WOMAN
WHO SUFFERS
IN THE
MENOPAUSE
DESERVES
"PREMARINI
widely used
natural, oral
estrogen
AYERST LABORATORIES
New York, N. Y. • Montreal, Canada
5645
September, 1957
Say you saw it in the Journal of the Michigan State Medical Society
1191
NEWS MEDICAL
(Continued from Page 1190)
medicine which he originated many years ago. He
has been with the University of Michigan thirty-seven
years.
Dr. Coller will be honored by the Michigan State
Medical Society at a testimonial luncheon during the
Michigan Clinical Institute in Detroit, March 19, 1958.
* * *
The Michigan Chapter, American College of Sur-
geons, early in 1957 established a fund to assist resi-
dents in surgical training who find themselves in finan-
cial difficulties.
J. A. Witter, M.D., Detroit, Secretary of the Michi-
gan Chapter, states that applicants are carefully screened
and the money is loaned free of interest with the under-
standing that it will be repaid to the Fund as soon
as the recipient is established in practice. In the short
space of a few months, three loans have been made.
This is a self-perpetuating or revolving fund. For fur-
ther information, write Joseph A. Witter, M.D., 344
Glendale Avenue, Detroit 3, Michigan.
* * *
To reduce the cancer mortality rate, a nation-wide
program emphasizing an annual cytologic test for uterine
cancer for all women is urged by Charles S. Cameron,
M.D., former Medical Director of the American Cancer
Society.
“The number of deaths from uterine cervical cancer
would be cut by as much as 90 per cent,” Doctor
Cameron states in a new 25-cent pamphlet called Cell
Examination — New Hope in Cancer, “if every woman
in the country had this examination every year. This
would mean an annual saving of 16,000 lives.”
Cell Examination is the 252nd pamphlet in a series
published by the Public Affairs Committee at 22 E.
38 Street, New York 16, N. Y.
* * *
The World Congress of Gastroenterology will be held
in Washington, D. C., May 25-31, 1958, according
to release received from Secretary-General H. M. Pol-
lard, M.D.. of Ann Arbor.
The official languages of the Congress will be English,
French, and Spanish, rendered in simultaneous transla-
tions at the Sheraton-Park Hotel. The World Congress
will hold its scientific meetings Sunday through Thurs-
day, to be followed by the 59th Annual Scientific Ses-
sion of the American Gastroenterological Association
(Friday and Saturday).
Objective of the Congress is to bring together scien-
tists from all parts of the globe who are actively con-
tributing new knowledge and experience in the funda-
mental sciences or clinical behavior patterns related to
disorders of the alimentary tract.
For program and complete information, write Secre-
tary-General Pollard, University Hospital, Ann Arbor.
* * *
“Doctor — Do You Need a Medical Secretary?” That
was the title of a leaflet inserted with the latest Genesee
County Medical Society Bulletin. The flyer invited
attention to a course to meet the shortage of medical
(Continued on Page 1194)
1192
Say you saw it in the Journal of the Michigan State Medical Society
jmsm:
ST. JOSEPH’S RETREAT
Member: American Hospital Association
Catholic Hospital Association
National Association of Private
Mental Hospitals
The Central Neuro-Psychiatric
Hospital Association
Under the direction of the
Daughters of Charity of Sf. Vincent de Paul
Serving Metropolitan Detroit
and Michigan almost a century
Martin H. Hoffmann, M.D.
Medical Director
23200 West Michigan Avenue
Dearborn
Logan 1-1400
r
each coated tablet contains: Phenaphen
Phenacetin (3 gr.) 194.0 mg.
Acetylsalicylic Acid (*lVz gr.) . 162.0 mg.
Phenobarbital i}k gr.) .... 16.2 mg.
Hyoscyamine Sulfate .... 0.031 mg.
plus
Prophenpyridamine Maleate . . 12.5 mg.
Phenylephrine Hydrochloride . 10.0 mg.
Phenaphen Plus is the physician-requested
combination of Phenaphen, plus an anti-
histaminic and a nasal decongestant.
Available on prescription only.
J
September, 1957
Say you saw it in the Journal of the Michigan State Medical Society
1193
NEWS MEDICAL
(Continued from Page 1192)
secretaries which exists in Flint today, offered by the
Flint Junior College. The lectures have the endorsement
of the Genesee County Medical Society and the Genesee
Medical Assistants Society. Incidentally, the slogan of
the energetic Flint Junior College is “A Partner in
Education.”
* * *
George F. Lull, M.D., Chicago, who has served eleven
years as Secretary-General Manager of the American
Medical Association, has been elevated to the newly
created position of Assistant to the President of the
AMA. He will continue serving as Secretary, which is
an elective office.
F. J. L. Blasingame, M.D., Harton, Texas, appoint-
ed by the AMA Board of Trustees to the position of
General Manager, will take over his new duties January
1, 1958. Dr. Blasingame, fifty, has been active in
medical affairs for many years, both at the state and
national level. He served as President of the Texas
Medical Association in 1955; has been a member of the
AMA House of Delegates since 1949. He has maintained
a teaching connection with his Alma Mater (University
of Texas) since his graduation from medical school in
1928. He and his family of five children, three daugh-
ters and two sons, will move to Chicago shortly after
the first of the year.
* * *
MSMS President Arch Walls, M.D., was guest of
honor at the Annual Genesee County Cancer Day Pro-
gram, April 17.
■*■•*■*
M.D. LOCATIONS
Through August 1, 1957
Placed by Michigan Health Council
Donald Schimnoski, M.D.
Henry N. Smit, M.D.
G. B. Goodard, M.D.
Robert A. Schmeider, M.D.
Andrew J. Hopkins, M.D.
Van O. Keeler, M.D.
Assisted by Michigan Health Council
Walter Poznanski. M.D.
Jacob J. Miller, M.D.
MICHIGAN POSTGRADUATE
PROGRAM IN MEDICINE
The Michigan State Medical Society, in co-operation
with the University of Michigan Medical School, Wayne
State University College of Medicine, and the Michigan
Department of Health announces the extramural post-
graduate program for the fall, 1957.
EXTRAMURAL COURSES
Alpena
Battle Creek
Bay City
Flint
Jackson
Lansing
Muskegon
Port Huron
Traverse City
Upper Peninsula:
Escanaba
Menominee
Iron Mountain
Sault Ste. Marie
Marquette
Houghton
Ironwood
INTRAMURAL COURSES
Clinical Internal Medicine (Thursdays)
University Hospital
Ann Arbor, Michigan
October3-March 13
Clinical Exercises for Practitioners (Wednesdays)
University Hospital
Ann Arbor, Michigan
October 9-March 1 2
In Lansing
HOTEL OLDS
Fireproof
400 ROOMS
Opened Practice
Three Rivers
Hamilton
Otsego
Dearborn
Dearborn
Otsego
Birmingham
Detroit
.November 7
....October 1
.November 6
..October 3
..October 15
..October 29
..October 18
..October 1
.November 7
.November 5
.November 6
.November 7
.November 8
.November 5
.November 6
.November 7
MERCY WOOD SANITARIUM
Conducted by Sisters of Mercy
Treatment for Mild Nervous and Mental Disorders
JACKSON ROAD ANN ARBOR, MICHIGAN
NOrmandy 3-8571
1194
Say you saw it in the Journal of the Michigan State Medical Society
JMSMS.
when anxiety and tension "erupts” in the G. I. tract...
in spastic
and irritable colon
PATH I BAM ATE
Meprobamate with PATHILON® Lederle
Combines Meprobamate ( 400 ȣ.)the most widely prescribed tranquilizer. . . helps control the
“emotional overlay” of spastic and irritable colon — without fear of barbiturate loginess, hangover or
habituation . . . with PATHtLON (T5 *jr.)the anticholinergic noted for its extremely low toxicity
and high effectiveness in the treatment of many G.I. disorders.
Dosage: 1 tablet t.i.d. at mealtime. 2 tablets at bedtime. Supplied: Bottles of 100, 1,000.
'Trademark ® Registered Trademark for Tridihexethyl Iodide Lederle
LEDERLE LABORATORIES DIVISION, AMERICAN CYANAMID COMPANY, PEARL RIVER, NEW YORK
September, 1957
Say you saw it in the Journal of the Michigan State Medical Society
1195
THE DOCTOR’S LIBRARY
Acknowledgments of all books received will be made in this column,
and this will be deemed by us as full compensation to those
sending them. A selection will be made for review, as expedient.
BOOKS RECEIVED
HEREDO-RETINOPATHIA CONGENITALIS. Mono-
hybrida Recessiva Autosomalis. A Genetical-statistical
Study. By Carl Henry Alstrom. Laboratory No. 2 for
Human Genetics, the Psychiatric Clinic of the Caro-
line Institute, Stockholm. In clinical collaboration
with Olof Olson, The State Institute for the Blind,
Tomteboda, Stockholm. Lund, Sweden, 1957.
THE EFFECTS OF THE SULFONYLUREAS AND
RELATED COMPOUNDS IN EXPERIMENTAL
AND CLINICAL DIABETES. Annals of the New
York Academy of Sciences, Volume 71, Art. 1,
Pages 1-292.
CARDIOVASCULAR DISEASES, SECTION XVIII.
Excerpta Medica Foundation, 111 Kalverstraat, Am-
sterdam, The Netherlands. New York Academy of
Medicine Building, 2 East 103 Street, New York 2S,
N. Y. A new monthly publication aided by a grant
from the National Institutes of Health of the Depart-
ment of Health, Education and Welfare. The first
issue of eighty-four pages contains mostly listings, with
short abstracts of 303 articles on the subject, divided
into twenty chapters.
The aim of this publication is to provide a regular,
up-to-date and comprehensive service of abstracts of the
world literature in the field of cardiovascular diseases.
SIGNS AND SYMPTOMS. Applied Pathologic Physi-
ology and Clinical Interpretations. Edited by Cyril
Mitchell MacBryde, A.B., M.D., F.A.C.P. Associate
Professor of Clinical Medicine, Washington University
School of Medicine; Assistant Physician, The Barnes
Hospital; Director, Metabolism and Endocrine Clinics,
Washington University Clinics, St. Louis, Missouri.
Third Edition, with 191 illustrations and six color
plates. Philadelphia and Montreal: J. B. Lippincott
Company. Price $12.00.
Dr. MacBryde, in his third edition of Applied Patho-
logic Physiology of over 970 pages, has divided his sub-
ject into thirty-four chapters, using twenty-eight authors.
The chapters are quite complete treatises involving defi-
nitions, physiology, medical significance, et cetera, quite
an exhaustive study. The type is large, two columns
and easily read. The illustrations are adequate and
clear and each chapter is concluded with a liberal refer-
ence list. We like the book.
SCIENCE LOOKS AT SMOKING. A New Inquiry
into the Effects of Smoking on Your Health. By Eric
Northrup. Introduction by Dr. Harry S. N. Greene,
Chairman, Department of Pathology, Yale University.
New York: Coward-McCann, Inc., 1957. Price $3.00.
The question of causation of lung cancer and tobacco
is assuming ever greater significance. Books, even the
Department of Health and the Congress, are debating
the issue, with the weight probably against tobacco.
This book is on the other side. The writer of the
introduction, thirty-five pages of negative argument, is
a Doctor of Medicine and has analyzed the evidence.
The author has added 145 pages of pure argument.
The HAVEN SANITARIUM, Inc.
Rochester, Michigan
In operation since 1932
M. O. Wolfe, M.D.
Director of Psychotherapy
Ralph S. Green, M.D.
Clinical Director
Graham Shinnick
Manager
A private psychiatric hospital for the intensive treatment
of mental and emotional illnesses.
Telephone: OLive 1-9441
"WHY TAKE CHANCES?"
No practice is too small — no group too large
to benefit from PM's management experience
WRITE OR CALL FOR INFORMATION
•PROF E S SI0I1AL Security Bank Building — Battle Creek
* in a n a g e m e n t SAGINAW — GRAND RAPIDS — DETROIT
A C0I11PLETE BUSINESS SERVICE FOR THE 111 E D I C A L PROFE SSI0I1
Affiliated Offices in Other Cities
1196
Say you saw it in the Journal of the Michigan State Medical Society
JMSMS
THE DOCTOR’S LIBRARY
The case is interesting, and from his standpoint the
author has won. He opens up many questions of what
work should be done, and asks questions which others
have answered, but whose answers he says are statistical
only. This is another opus added to the accumulating
material — is it evidence?
CHEMICAL TESTS FOR
INTOXICATION
(Continued from Page 1130)
and at the same time protecting the moderate
drinker, the recommendations of state and county
medical societies could carry great weight in sup-
porting law enforcing agencies in their endeavor
to provide the protection we all need.
References
1. Fact Book on Accidental Death. Washington,
D. C.: U. S. Public Health Service, 1957.
2. Michigan’s Health. Lansing, Michigan: Michigan
Department of Health, Nov., 1956.
3. Spain, D. M.; Bradess, V. A.; and Eggston, A. A.:
Alcohol and violent death: A one-year study of con-
secutive cases in a representative community.
J.A.M.A., 146:334-334 (May 26) 1951.
4. Report to the National Safety Council. Harry
Shew, Superintendent, Delaware State Police, 1957.
5. Freimuth, H. C., and Fisher, R. S.: Toxicological
aspects of accident investigation. lA paper read at
the American Academy of Forensic Sciences meet-
ing, February 28, 1957.
6. Report of Committee to Study Problems of Motor
Vehicle Accidents. J.A.M.A., 124:1292 (April 29)
1944.
7. Donigan, Robert L. : Chemical Tests and the Law.
2nd edition. Evanston, Illinois: Northwestern Uni-
versity Traffic Institute, 1957.
8. Harger, R. N. ; Lamb, E. B. ; and Hulpieu, H. R. :
Rapid chemical test for intoxication employing
breath. J.A.M.A., 110:779-785 (March 12) 1938.
9. Jetter, W. W., and Forrester, G. C.: Perchlorate
method for determining concentration of alcohol
in expired air as medico-legal test. Arch, path.,
32:828-842 (Nov.) 1941.
10. Jetter, W. W. ; Modre, M.; and Forrester, G. C.:
Studies in alcohol; new method for determination
of breath alcohol; description and examination of
perchlorate method for breath alcohol determina-
tions. Am. J. Clin. Path. (Tech. Suppl.), 5:75-89
(March) 1941.
11. Lester, D., and Greenberg, L. A.: Alcoholism, 1941-
1951. III. The status of physiological knowledge.
Quart. J. Studies on Alcohol, 13:445, 1952.
12. Smith, J. Chandler: The accuracv and reliability
of breath tests for the determination of blood al-
cohol using the intoximeter device. Paper presented
at a hearing of the House Judiciary Committee of
the Michigan legislature. May 2, 1957.
13. Report of Committee on Medical Aspects of Auto-
mobile Injuries and Deaths. J.A.M.A., 163:1149-
1150 (March 30) 1957.
September, 1957
Protection against loss of income from
accident and sickness as well as hospital
expense benefits for you and all your
eligible dependents.
PHYSICIANS CASUALTY & HEALTH
ASSOCIATIONS
OMAHA 31, NEBRASKA
Since 1902
SAMMOND PLEASANT LODGE
Ofiers to the elderly and chronically ill
Peace and quiet. Freedom of a large and richly
furnished home and acres of lawns and wooded
rolling grounds, scientifically prepared tasty
meals, congenial companionship. A real
"Home away from Home "
Approved by the American Medical Association
and Michigan State Department of Social Wel-
fare— Highly recommended by members of the
Medical Profession who have had patients at
the Lodge.
For further information write toi
SAMMOND PLEASANT LODGE
124 West Gates Street
Romeo. Michigan
Say you saw it in the Journal of the Michigan State Medical Society
1197
Plainuell
Sanitarium
PLAINWELL, MICHIGAN
Member American Hospital Association
EDWIN M. WILLIAMSON, M.D.
Psychiatrist-in-Chief
Professional care for the nervous
and mentally ill.
Telephone MUrray 5-8441
Restful Six-acre Estate Overlooking the Kalamazoo River
The Child Welfare Committee sponsored the March,
1957 issue of The Journal MSMS; promoted educa-
tion of law and medical students on the problem of
adoption; considered the problem of prophylaxis for
neonatal ophthalmia; technique of examining children’s
eyes; visual acuity testing equipment; continued screen-
ing clinics for hearing defects; worked on school health
problems and standardized forms; initiated action toward
poison control centers and accident prevention ; and pro-
posed a joint meeting of committee members and repre-
sentatives of each county society to promote child welfare
activities locally.
WOLVERINE
the GOODWILL
Uotdf in DsTCOiT
500 ROOMS
each with
Shower Bath
Singles $4.t>0-$7
Doubles $6.00-$ 12
Suites $ 1 0-$20
Home of The Tropics
FAMOUS DETROIT
NITESPOT
Overlooks
Grand Circus
Park
Immediate facilities for
shopping, theatres,
transportation.
Elizabeth Street
I BLOCK EAST OF WOODWARD
Classified Advertising
$2.50 per insertion of fifty words or less, with an
additional five cents per word in excess of fifty.
OBSTETRICIAN -GYNECOLOGIST, Pediatrician,
Ophthalmologist, Board eligible or certified, to join
14-man group in metropolitan Detroit. $14,000-$16,-
000. Lakeside Medical Center, 987 E. Jefferson Ave-
nue, Detroit 7, Michigan.
INTERNIST : With special interest and fellowship
training in cardiology, desires association with group in
Michigan, preferably one academically inclined, con-
centrating on full, personal patient care. Board
eligible, 31, family, veteran. Especially interested in
Ann Arbor area. Reply Box 4, 606 Townsend Street,
Lansing 15, Michigan.
WANTED: Associate in Internal Medicine sought by
older physician with practice limited to Internal Medi-
cine, well-equipped office and laboratorium. Fritz W.
Bramigk, Ph.D., M.D., 523-527 Professional Bldg.,
Detroit 1, Michigan.
FOR SALE: Cambridge Simpli-Trol Portable Electro-
cardiograph. Guaranteed to be in excellent condition.
Clyde H. Chase, M.D., 8868 Hendrick Drive, Brighton,
Michigan. Telephone: ACademy 7-1082.
OTOLARYNGOLOGIST WANTED (Board or Board-
eligible) — To join clinic group of nineteen. Attractive
salary leading to partnership. Unlimited potential.
Completely modern EENT Department. Lake Michi-
gan city of 45,000. Write P.O. Box 487, Sheboygan,
Wisconsin.
MEDICAL SUITE — Reception room, office, three con-
sultation rooms, and laboratory. Established dentist,
other suite, downtown East Lansing. Finest com-
munity and working location in Michigan. Ervin
Realty, 322 W. Ottawa Street, Lansing 33, Michigan.
Phones: IVanhoe 2-0781, EDgewood 2-1850.
1198
Say you saw it in the Journal of the Michigan State Medical Society
TMSMS
THE JOURNAL
of the Michigan State Medical Society
OLUME 56 OCTOBER, 1957 NUMBER 10
Contributors to This Issue
I
i
S. H. Sturgis, M.D.
Table of Contents
The Kaleidoscopic Nature of Psyche and Soma
Peter A. Martin, M.D 1249
Clinical Manifestations of Anxiety
Peter A. Martin, M.D 1252
Psychological Medicine
John M. Dorsey, M.D 1255
A New Approach to the Clinical Management
and Treatment of Behavior Problems
John T. Ferguson, M.D 1266
Evaluation of the Use of Reserpine in the Psychoses
A. L. Olsen, F.A.P.A., M.D., and Harry Vander
Kamp, M.S., M.D 1271
Management of Chronically Disturbed Patients with
Sparine
Horace ]. Prescod, M.D., and Merlin C.
Townley,M.D 1273
Psychiatric Aspects of Gynecologic Care
Somers H. Sturgis, M.D 1275
Medical and Psychiatric Collaboration
Kenneth E. Appel , M.D 1280
Value of a Department of Physical Medicine and
Rehabilitation in a County Hospital
Stanley Olejniczak, M.D.. and S. D. Jacobson.
M.D ; 1284
The Importance of Differentiating Petit Mai from
Other Forms of Minor Seizures
E. Rodin, M.D 1289
Medicine and Labor in These Changing Times
Walter P. Reuther 1293
President’s Message:
The Challenge 1299
Editorial :
Mental Health and Mental Illness 1300
Practical Citizenship 1300
Federal Legislation 1301
The Crossroads 1302
What Do You Mean — “Non-Profit’’? 1302
Michigan’s Department of Health 1304
In Memoriam 1306
News Medical 1308
Communications 1332
The Doctor’s Library 1335
You and Your Business 1208
PR Report 1212
AMA Washington Letter 1218
AMA News Notes 1222
Social Security and Jenkins-Keogh Bills 1230
© 1957 by Michigan State Medical Society
gtober, 1957
1203
THE JOURNAL
of the Michigan State Medical Society
:VOLUME 58
OCTOBER, 1957
NUMBER 10 :
PUBLICATION COMMITTEE
B. M. HARRIS, M.D,, Chairman Ypsilanti
WILLIAM BKOMME. M.D Detroit
O. B. McGILLICUDDY, M.D Lansing
W. S. STINSON, M.D Bay Citv
T. P. WICKLIFFE, M.D Calumet
OFFICERS OF THE SOCIETY
Office of Publication
2642 University Avenue
Saint Paul 14, Minnesota
1956-1957
President G. W. SLAGLE, M.D Battle Cree
President-Elect G. B. SALTONSTALL, M.D Charlevoi
Secretary L. FERNALD FOSTER, M.D Detroi
Treasurer W. A. HYLAND, M.D Grand Rapic
Speaker K. H. JOHNSON, M.D Lansin
Vice Speaker J. J. LIGHTBODY. M.D Detro:
Editor WILFRED HAUGHEY, M.D Battle Cree
Assistant Editor L. J. BAILEY, M.D. Detroi
Editor
WILFRID HAUGHEY, M.D.
610 Post Bldg., Battle Creek, Michigan
THE COUNCIL
Assistant Editor
L. J. BAILEY. M.D.
620 Vinewood Avenue, Birmingham, Michigan
Secretary and Business Manager of THE JOURN AL
L. FERNALD FOSTER, M.D.
441 E. Jefferson, Detroit, Michigan
Executive Director
WM. J. BURNS, LL.B.
606 Townsend Street, Lansing 15, Michigan
D. BRUCE WILEY, M.D., Chairman , Utica
W. B. HARM, M.D., Vice Chairman , Detroit
L. FERNALD FOSTER, M.D., Secretary , Bay City
T erm
Expire
196
196
196
..Kalamazoo 196
..Grand Rapids 196
District
A. E. SCHILLER. M.D 1st Detroit
O. B. McGILLICUDDY, M.D... 2nd Lansing
H. J. MEIER, M.D 3rd Coldwater
RALPH W. SHOOK, M.D 4th.
C. ALLEN PAYNE, M.D 5th .
Flint 196
..St. Clair 196
..Breckenridge 196
Traverse City 196
Bay City 196
.. Muskegcn 195
All communications relative to exchanges, books for review, manu-
scripts, should be addressed to Wilfrid Haughey, M.D., 610 Post
Bldg., Battle Creek, Michigan.
All communications regarding advertising and subscription should
be addressed to Wm. J. Burns, 2642 University Avenue, Saint
Paul 14, Minnesota, or 606 Townsend Street, Lansing 15, Michigan.
Telephone Ivanhoe 57125.
© 1957, by Michigan State Medical Society.
Published monthly by the Michigan State Medical Society as its
official journal at 2642 University Avenue, Saint Paul 14, Minnesota.
Entered at the post office at Saint Paul, Minnesota, as second
class matter, May 7, 1930, under the Act of March 3, 1879.
Acceptance for mailing at special rate of postage provided for
in Section 1103 Act of October 3, 1917, authorized August 7, 1918.
Yearly subscription rate, $6.00; single copies, 60 cents. Additional
postage; Canada. $1.00 per year; Pan-American Union. $2.50 per
year; Foreign. $2.50 per year.
PRINTED TN TT S.A.
H. H. HISCOCK, M.D 6th .
J. F. BEER, M.D 7th .
E. S. OLDHAM. M.D 8th.
D. G. PIKE, M.D 9th.
O. J. JOHNSON, M.D 10th.
W. M. LeFEVRE, M.D 11th
B. T. MONTGOMERY, M. D 12th Sault Ste. Marie 195
T. P. WICKLIFFE, M.D 13th Calumet 195
B. M. HARRIS, M.D 14th Ypsilanti 195
D. BRUCE WILEY, M.D 15th Utica 196
G. THOMAS McKEAN, M.D 16th Detroit 196
W. B. HARM, M.D 17th Detroit 195
WILLIAM BROMME, M.D 18th Detroit 195
G. W. SLAGLE, M.D President Battle Cree
G. B. SALTONSTALL, M.D President-Elect Charlevoi
K. H. JOHNSON, M.D Speaker Lansin
J. J. LIGHTBODY, M.D Vice-Speaker Detroi
L. FERNALD FOSTER. M.D Secretary Detroi
W. A. HYLAND, M.D Treasurer Grand Rapid
ARCH WALLS, M.D Past President Detroi
EXECUTIVE COMMITTEE OF THE COUNCIL
D. BRUCE WILEY, M.D Chalrma:
W. B. HARM, M.D Vice Chairma
W. M. LeFEVRE, M.D.. . ...Chairman, County Societies Committe
B. M. HARRIS, M.D Chairman, Publication Committe
RALPH W. SHOOK. M.D. Chairman, Finance Committe
K. H. JOHNSON, M.D Speake
J. J. LIGHTBODY, M.D Vice Speake
G. W. SLAGLE. M.D. Presiden
G. B. SALTONSTALL. M.D Presid»nt-Elec
L. FERNALD FOSTER. M.D. Secretar
W. A. HYLAND. M.D Treasure
SECTION OFFICERS
Dermatology and Syphilology
Wm.'*T. Kruse, M.D Grand Rapids
Chairman
Coleman Mopper, M.D Detroit
Secretary
Gastroenterology and Proctology
N. D. Nigro, M.D Detroit 1
Chairman
E. J. Tallant, M.D Detroit
Secretary
General Practice
F. P. Rhoades, M.D Detroit 2
Chairman
F. C. Brace, M.D Grand Rapids
Secretary
Nervous and Mental Diseases
W. R. Slenger, M.D Ann Arbor
Chairman
S. C. Mason, M.D Ann Arbor
Secretary
Occupational Health
Public Health and Preventive
Medicine
J. D. Monroe, M.D Pontia
Chairman
J. K. Altland, M.D Lansing
Secretary
O. J. Johnson, M.D Bay City
Chairman
P. B. Rastello, M.D Detroit 9
Secretary
Gynecology and Obstetrics
J. H. Beaton, M.D Grand Rapids
Chairman
R W. McClure, M.D Detroit 26
Secretary
Medicine
J. M. Kaufman, M.D Detroit 26
Chairman
J. W. Hall, M.D Traverse City
Sei retary
Ophthalmology and Otolaryngology
B. C. Wildgen, M.D Muskegon
Chairman ( Ophth .)
W. K. Locklin, M.D Kalamazoo
Co-Chairman (Oto.)
H. A. Dunlap, M.D Detroit 14
Secretary (Ophth.)
H. L. LeVett, M.D Lansing
Co-Secretary (Oto.)
Pediatrics
Radiology, Pathology, Anesthesiolog
R. B. Sweet. M.D. Ann Arbc
Chairman (Anes.)
E. R. Jennings, M.D Detro
Vice-Chairman (Path.)
E. O. Pearson. M.D Kalamazo
Secretary (Rad.)
Surgery
E. T. Thieme, M.D Ann Arbc
Chairman
H. M. Bishop, M.D Sagina
Secretary
C. E. Booher, M.D Grand Rapids
Chairman
A. M. Hill, M.D Grand Rapids
Secretary
Urology
R. P. Lytle, M.D Detroit
Chairman
J. F. Harrold, M.D Lansin
Secretary
Delegates
DELEGATES TO A. M. A.
Alternates
W. A. Hyland, M.D., Grand Rapids, Chairman 1957
J. S. DeTar, M.D., Milan 1957
C. I Owen, M.D.. Detroit 1957
W. D. Barrett, M.D., Detroit 1958
W. H. Huron, M.D.. Iron Mountain 1958
R. L. Novy, M.D., Detroit 1958
W. W. Babcock. M.D.. Detroit 19!
E. F. Sladek. M.D.. Traverse City 19!
O. J. Johnson. M.D.. Bav City 19!
William Bromme. M.D.. Detroit 19!
J. R. Rodger, M.D., Bellaire 19!
G. W. Slagle, M.D., Battle Creek 19!
Section Delegate
1204
G. C. Penberthy, M.D. (Surgical Section) Detroit
JMSM
<- READ THIS
tober, 1957
Say you saw it in the Journal of the Michigan State Medical Societv
1207
You and Your Business
“REFRESHERS” ARE DEDUCTIBLE
The U. S. Internal Revenue service regulation
(effective August 9, 1956) makes deductible ex-
penditures for education for a “refresher” course,
or similar type of course taken to maintain the
skills directly and immediately required by the
physician in his employment or business. Such
a course must be of short duration, not to be
taken on a continued basis, and not carry academic
credit.
When a doctor of medicine travels away from
home primarily to obtain “refresher” education,
his expenditures for travel, meals, and lodging
while away from home are deductible.
The Michigan Clinical Institute (Detroit,
March 19-20-21, 1958) and the Michigan State
Medical Society Annual Session (Detroit, October
1-2-3, 1958) are “refresher” courses.
FEE-SPLITTING LAW OF THE
STATE OF MICHIGAN
Section 338.53 of the Compiled Laws of 1948
as amended by Act No. 54 of the Public Acts
of 1954:
“Sixth. The board of registration of medicine may re-
fuse to issue or continue a certificate of registration or
license provided for in this section to any person guilty
of grossly unprofessional and dishonest conduct. The
words ‘unprofessional and dishonest conduct,’ as used in
this act, are hereby declared to mean:
CC
“(h) Employing or being employed by any capper, so-
licitor or drummer for the purpose of securing patients;
or subsidizing any hotel or boarding house with a like
purpose, or paying, or offering to any person, money
or any other thing of value with a like purpose, or
advertising to do so in any form whatsoever; or the
division of fees in a consultation or a reference of a
patient to a specialist, when no actual professional serv-
ice is rendered by the physician referring the case, with-
out the knowledge of the patient or the person concerned
in the payment thereof.”
HIGHLIGHTS OF EXECUTIVE
COMMITTEE OF THE COUNCIL
Meeting of August 14, 1957
• Opinion Study of Prepaid Medical Care Cover-
age in Michigan. — Up-to-the-minute progress
report was presented. The sub-titles of the sur-
vey are to be (a) “Prepaid Medical Care Cover-
age and Related Costs Survey,” (b) Survey of
Consumer Opinion on Medical Care Protec-
tion,” (c) “Doctor Opinion Survey on Prepaid
Medical Care Plans,” (d) “Survey of Related
Studies on Protection Against Medical Service
Fees.”
Letters of appreciation were authorized sent to
the Lansing State Journal, the Detroit Tim ,
and to Mr. Jack Pickering for cooperation i
the publishing this survey.
• Beaumont Memorial. — The Michigan Mackim
Island State Park Commission, on July 13, a]
proved the agreement between MSMS and tl
Commission, whereby the ownership of the pe
sonal property in the Beaumont Memorial h;
been transferred to MSMS. (This ageement w;
approved by MSMS July 12, 1957.)
A. H. Whittaker, M.D., of Detroit, recent!
appointed by Governor G. Mennen Williams :
a member of the Mackinac Island State Pai
Commission, was fittingly congratulated on th
signal honor.
• President-Elect G. W. Slagle, M.D., made add
tional appointments to 1957-58 MSMS Con
mittees.
• 1957 Annual Session. — Various details connec
ed with the Annual Session, Grand Rapids, Sep
tember 25-26-27 were decided.
• Use of the MSMS addressograph was autho:
ized for Blue Cross (Michigan Hospital Service
to facilitate its mailing a letter in connectio
with creation of review committees in all ho:
pitals as part of the continuing control prc
gram in Blue Cross cases.
• Group Life Insurance program for MSM
Members. — Progress report of survey, to At
gust 12, 1957, indicated that 2,242 cards hav
been returned by MSMS members, with 1,39
indicating interest in a group life insuranc
program.
• Co-sponsorship by MSMS of a Seminar o
“The Epidemiology, Bacteriology, and Therap
of Staphylococcus Infections in Hospitals,
Lansing Civic Center, September 19, was ap
proved.
• Legal Counsel reported a reactivation of hosp
tal litigation in Oakland County (MSMS is nc
a party in this suit) .
Legal Counsel also stated that he was in th
process of developing a non-profit, tax-exemp
corporation to be known as the “Beaumor
Memorial Foundation,” as per instruction c
the MSMS House of Delegates. The Executiv
Committee instructed that the members of th
Beaumont Memorial Committee be listed z
incorporators of the Beaumont Memorial Four
dation.
• History of Michigan Medical Service. — Con
menting on a recent historical item receive
(Continued on Page 1210)
1208
JMSM
for a spastic gut
• Spastic conditions of abdominal
viscera can be promptly relaxed with Trasentine®-Phenobarbital .
It acts both on smooth muscle and parasympathetic nerves; it has
a direct anesthetic effect on gastrointestinal mucosa; it calms the
patient as a whole. You can prescribe Trasentine-Phenobarbital to
alleviate pain and spasm in ulcers, colitis, cholecystitis, pyloro-
spasm, ureteral colic or dysmenorrhea. Tablets (yellow, coated),
each containing 50 mg. Trasentine® hydrochloride (adiphenine
hydrochloride CIBA) and 20 mg. phenobarbital . C I B A Summit, N. J.
TOBER, 1957
Say you saw it in the Journal of the Michigan State Medical Society
YOU AND YOUR BUSINESS
(Continued from Page 1208)
from Frederick A. Baker, M.D., of Pontiac, the
Executive Committee of The Council, upon
suggestion of L. Fernald Foster, M.D., Presi-
dent of Michigan Medical Service, authorized
Editor Wilfrid Haughey and John B. Kantner
(Michigan Ffealth Council) to write an histori-
cal record of Michigan Medical Service.
• Practice of Medicine by a Corporation. —
MSMS objection to the Michigan Hospital
Service proposal to offer medical service to its
subscribers, was discussed; The Executive Com-
mittee of The Council reaffirmed its action as
expressed in its August 2nd letter of protest to
Blue Cross, and authorized Legal Counsel to
proceed with any necessary legal action that is
feasible if out-patient (i.e., medical) care is
added to contracts of Blue Cross.
• H. Waldo Bird, M.D., of Ann Arbor, and
G. Thomas McKean, M.D., of Detroit, were
added to the Committee on VA Hometown
Medical Care Program, at the recommenda-
tion of Committee Chairman Wm. Bromme,
M.D., of Detroit.
• B. L. Masters, M.D., Chairman of MSMS Rural
Medical Service Committee, was authorized to
attend Rural Health Institute (sponsored by the
AMA) at Purdue University, October 4-5.
• E. H. Wiard, long -time Executive Secretary of
the Michigan Health Council, resigned as of
September 1 to enter business. A letter of com-
mendation for his significant contribution to the
growth of Michigan Health Council was au-
thorized sent to Mr. Wiard.
• Committee Reports Presented. — (1) Arbitra
tion Committee, meeting July 12; (2) Commit
tee on National Defense, July 17; (3) Scier
tific Radio Committee, July 17; (4) Legisla
tive Committee, July 18; (5) Venereal Di;
ease Control Committee, July 18; (6) Commii
tee on Course in Medical Economics and Ethic:
August 6; (7) Permanent Advisory Committe
on Fees, August 7; (8) Public Relations Con
mittee, August 1 1 .
TWO DECADES OF HEALTH SERVICE
PRICES REVIEWED
A featured special article in current (Sept,
issue of Monthly Labor Review is an informativ
review of the ups and downs in consumer price
for medical care and hospital services betwee
1936 and 1956. Using the years 1947-49 as
base, the price index for medical care at clo;
of 1956 was highest of all major items (housini
clothing, etc.), just as it is today. But this artic'
points out that if hospitalization is stripped oi
of medical care, the price increase for this iter
between 1936 and 1956 actually is the smallest <
all.
In this 20-year period, hospital room rates wei
up 264.8 per cent, which explains why the medic;
care index has risen so much. At the same tim
however, surgeons’ fees have gone up only 59
per cent, general practitioners’ fees 72.8 per cei
and dentists’ fees 82.1 per cent. This compan
with a 220.9 per cent rise for haircuts, 135.0 f(
shoe repairs and 112.9 for public transportatioi
— WRMS, October 7, 1957.
MEDICAL MEETINGS AND CLINIC DAYS
A list of known medical meetings and clinic days, sponsored by country medical societies and
other physician groups in Michigan, follows:
1957
Autumn
Oct. 24-25
Nov. 6-7
Dec. 3-6
1958
Jan. 22-24
Jan. 29-31
Jan. 31
Feb. 1-2
Mar. 19-21
Spring
MSMS Postgraduate Extramural Courses
Michigan Cancer Conference
Michigan Academy of General Practice — 11th Annual Fall Postgraduate
Clinic
AMA Clinical Session
1 1 th Annual Michigan Rural Health Conference
Annual Meeting of the MSMS Council, Sheraton-Cadillac Hotel
MSMS County Secretaries-Public Relations Seminar, Sheraton-Cadillac
Hotel
Michigan Clinical Institute, Sheraton-Cadillac Hotel
MSMS Postgraduate Extramural Courses
Statewide
East Lansing
Detroit
Philadelphia
Ann Arbor
Detroit
Detroit
Detroit
Statewide
12.1.0
JMSN
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‘CO-DELTRA’ and ‘CO-H YDELTRA' are
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MERCK SHARP & DOHME
DIVISION OF MERCK a CO.. INC.
PHILADELPHIA 1. PA.
OBER, 1957
Say you saw it in the Journal of the Michigan State Medical Society
1211
PR REPORT
SURVEY PUBLICITY GOES TO TOWN
The powerful press enabled the Michigan State
Medical Society to wind up its Opinion Study
of Prepaid Medical Care Coverage in Michigan
with a flood of mail revealing opinions of over
12,000 people.
Through the timely cooperation of all media,
the public became aware of the need to fill out
and return their question-
naires— hence, a record-break-
ing response to the doctor’s
questions!
Over 5,000 releases hit the
desks of Michigan’s daily and
weekly editors during this four-
month period of concentrated
publicity.
No medium escaped the en-
gulfing publicity of the MSMS
Study. TV editors were pre-
sented with attractive cartoon
slides, and good copy to run
at their good will.
Radio editors were handed
hard-hitting announcements —
urging the public to meet the
questionnaire deadline. Five,
fifteen, and thirty-minute radio
shows hammered out the im-
portance of the Study to the
uninformed. A half hour TV
show presented an interview
in action.
Secretary s Letters kept the medical society sec-
retaries, presidents, and editors up to date on
Study progress. The Woman’s Auxiliary and the
Michigan State Medical Assistants Society were
individually contacted by mail, informed of the
Study, and enlisted to “get the doctors to re-
turn their questionnaires!”
Stories, pictures and cartoon mats felt the
punch of the postage meter’s tattoo as Mich-
igan’s publications heard about the Study. Organi-
zations and associations were
mailed copies of the question-
naire, suggested announce-
ments for their group, and
questionnaire request form
cards.
The Lansing State Journal
ran two-king-sized feature ar-
ticles, pictures and the ques-
tionnaire. The Detroit Times
printed the questionnaire, then
relinquished choice space for
an editorial and thought-pro-
voking articles.
Announcements of the Study
pierced the cork of insurance
companies’ bulletin boards;
telegrams were dispatched to
hospital staff chiefs — urging
doctors to get their question-
naires in, and the Detroit State
Fair saw thousands winding
their way to the MSMS booth
to “Watch the slide show, take
a guess for a bond, and while
you’re at it, take this informative material on the
survey home with you!”
Here is what was read, seen and heard, about
the MSMS Study:
May 23
May 29
June 4
June 5
June 10
June 21
June 21
June 23
Publicity Schedule for Opinion Study on
Prepaid Medical Care Coverage in Michigan
Release: Announcement of the survey
Release: Meeting of survey committee
Release: Methods of obtaining information
Secretary’s Letter No. 191: To all presidents, secretaries and editors of
component medical societies
1000-word article on study plans and progress
All organizations in Michigan Health Council Directory
All voting members of Michigan Health Council
Letter to members Capital Club, enclosing article for their bulletins
Release: Survey questions
Release: “Lansing used as test city” (Feature)
372 newspapers
83 radio
13 TV
372 newspapers
83 radio
13 TV
372 newspapers
83 radio
13 TV
124 people
372 newspapers
45
50 members
(representing
120,000
opinion leaders)
372 newspapers
Lansing State
Journal
1212
JMSMS
■Rif
|jg§|§ig^
Si
to counteract
- if&. % ‘4S4444. v
MIC
using It?
^TCH “ASIATIC7 FLU-
e New Virus Threat From Orient
it" flu
there
i cases
ucture of the vir. :
sently used vaccines
STEARATE (Erythromycin Stearate, Abbott'
effective against staph-, strep- and pneumococci
■
QMrytt
ldden change tor
irus in 1947, F
me -ine thj
FFilmtab— Film-sealed tablets. Abbott: pat. applied fo
PR REPORT
(Continued from Page 1212)
June
24
Letter to editors containing two suggested editorials and the survey time-
table
372 newspapers
June
26-
Release: County mailings of survey questionnaires going out; release was
sent to editors of the respective counties informing them their area
was due to receive mail questionnaires
372 newspapers
July
1
July
5
Secretary’s Letter No. 192: To members of MSMS House of Delegates
and presidents, secretaries and editors
260 officers
and editors
July
7
30 minute TV show announcing the study
WJBK
July
12
Letter informing of survey and questionnaire to all Better Business
Bureaus, Chambers of Commerce in Michigan
400 organizations
July
12
Article on plans of the study
Women’s Auxiliary
Bulletin
July
14
2-column editorial and questionnaire printed in full
Detroit Times
July
14
Questionnaire printed in full
Lansing State
Journal
July
16
Letters to Service Clubs in Michigan, enclosing questionnaire. Sug-
gested announcement and reply card.
750 club
secretaries
July
18
Letter to Capital Club members, enclosing questionnaire
50 members
(representing
120,000 top
opinion leaders)
July
18
Letter to presidents of all County Medical Societies
55 presidents
July
18
Letter to secretary of each County Medical Society, with release
55 secretaries
July
19
Special story about study
Medical Economics
July
19
Bulletin board announcements regarding study to interested companies
60 announcements
July
19
Letter to all Michigan TV program managers from Michigan Health
Council, with two slides and newscast insertion for 2-30 second spot
announcements
13 TV stations
July
19
Letter to all Michigan radio program managers from Michigan Health
Council with 4-30 second spot announcements.
63 radio stations
July
20
Release: To all papers in St. Joseph County re: first person to return
questionnaire
6 newspapers
July
22
Release: to County Medical Society presidents
55 presidents
About
Release: for use in Association publications with enclosure of survey
340 publications
July
15
questionnaire
July
25
Release: Details regarding study, went out through Michigan Press
372 newspapers
July
25
Release: Feature about Study
Lansing State
Journal
July
25
Picture of Circuit Judge Marvin Salmon of Lansing being personally
interviewed
Lansing State
Journal
July
25
Release to editors all County Medical Society bulletins
14 editors
July
26
Release: Barry Laboratories, Inc.
1 company
publication
July
26
Story: Special article re: study for Bureau of Business Research, MSLh
1 publication
July
26
Mailing to officers and committee chairman of MSMS Women’s Auxi-
liary, county and state, to inform of survey and enlist co-operation
118 officers
July
26
Mailing to all MSMS Women’s Auxiliary to inform of survey and enlist
co-operation
3200 members
July
29
Telegram to chiefs of hospital staff urging doctors to fill out questionnaires
200 chiefs of staff
July
29
Mailing to all members Michigan State Medical Assistant Society
800 members
July
30
15-minute “Farm and Home” radio show re: Study
WKAR radio
Aug.
1
Release: Announcing rate of returns (Michigan Press)
385 newspapers
Aug.
10
5-minute radio tape about Study — “What it means to you”
67 radio stations
Aug.
15
Release: Response and number of returns (MHC)
372 newspapers
Aug.
16
Story to all company publications and house organs in Michigan, enclos-
ing carton mats and article
192 publications
Aug.
26
Feature article
Detroit Times
Aug.
29
Secretary’s Letter No. 193, to presidents, secretaries, editors, all com-
ponent medical societies
124 officers
and editors
Aug. 30
to Sept. 8
State Fair, MSMS exhibit booth on Study
Aug.
30
Release: Announcement of pilgrimage to Annual Session MSMS
372 newspapers
Sept.
15
30-minute radio show: Doctors Foster, Lightbody and Lichter
WJBK
Sept.
17
Release: Annual Session — Results to be revealed (Michigan Press)
385 newspapers
1216
JMSM5
simple, well-tolerated routine for "sluggish" older patients
one tablet t.i.d.
DECHOLIN
‘therapeutic bile’
Establishes free drainage of biliary system— effectively combats bile stasis and
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Corrects constipation without catharsis — copious, free-flowing bile overcomes tendency
to hard, dry stools and provides the natural stimulant to peristalsis.
Relieves certain G.I. complaints — improved biliary and intestinal function enhance
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Decholin Tablets: (dehydrocholic acid, Ames) 33A gr.
^ w 23757
AMES COMPANY, INC • ELKHART, INDIANA • Ames Company of Canada, Ltd. .Toronto
er, 1957
Say you saw it in the Journal of the Michigan State Medical Society
1217
AMA Washington Letter
THE MONTH IN WASHINGTON
In the last few years interest has built up in
the problems of the older people — how they are to
get their bills paid, how to spend their ti(me con-
structively, what chronic medical conditions are
causing them the most trouble. Innumerable na-
tional and local conferences have searched for ways
to make life more satisfying and healthy for people
entering old age, and committees are at work
on the problem in thousands of communities.
In this favorable climate, when every device
that might help the older citizens is being ex-
amined, there is being revived a scheme that met
with no success at all when first proposed more
than six years ago.
It is a plan for government-paid hospitaliza-
tion under the Old Age and Survivors’ Insurance
system.
Here is the argument that is made for it:
People in old age generally have less income
than when they were younger, but at the same
time they require more medical attention and
hospital care. Neither voluntary nor commercial
health insurance has been able to offer these
people the protection they need. The only solu-
tion, sponsors of the plan say, is to get the federal
government into the picture.
Opponents of the idea agree that older people
are sick more often and generally don’t have much
money, but they disagree violently with the other
arguments. They point out that slowly but sure-
ly insurance coverage is being extended to older
people at a price they can afford to pay. Most
important, hospitalization-at-sixty-five critics main-
tain that a system like this is in effect national
compulsory health insurance under Social Secur-
ity.
Early this year Reps. Emanuel Celler (D.,
N. Y.) and John Dingell (D., Mich.) introduced
bills on this subject. They would allow sixty
days a year free hospitalization for OASI-covered
men sixty-five and over and women sixty-two
and over. Rep. Kenneth A. Roberts (D., Ala.)
offered a similar bill.
Just before the session ended two developments
occurred that are evidence the proponents of this
system of hospitalization are getting ready to make
a real fight for it next year.
First, Rep. Aime J. Forand (D., R. I.) pre-
sented a bill that would make extensive liberaliza-
tions in the social security program, including
creation of a hospitalization that would give free
surgical service to the aged program. Some na-
tional labor leaders immediately pledged their
1218
support to this bill, a not unexpected move as
AFL-CIO is officially behind the general idea.
Then Senator Richard L. Neuberger (D., 0
gon) made it plain he, too, wanted the old peo
to have free in-hospital medical care. The s
ator said he hadn’t firmed up his thoughts, 1
that he believed the best approach would be sor
thing like the Military Dependent Medical C
program (Medicare), making use of Blue Gi
or other nonprofit groups. He estimates that
1 per cent increase in payroll taxes for bi
employer and employee would meet the ex
costs.
Mr. Forand, on the other hand, is specific,
would make all persons receiving OASI reti
ment benefits eligible and also surviving wide
and children, but would not include persons
ceiving OASI disability payments. He woi
broaden the time period by allowing 120 d
of hospital or nursing home care each year, w
hospital stays limited to sixty days.
The Forand measure also has a provision, :
contained in most earlier bills, for OASI also
pay for in-hospital surgical services certified
necessary by the physician.
Mr. Forand would take no chance of runn
out of money. He would levy social security p
roll taxes on all income up to $6,000 (pres
limit $4,200), and also increase the tax rat<
half per cent for employer and employee al
and three-quarters of one per cent for the s
employed.
It is almost certain that these and other sim
suggestions will receive serious consideration
Congress next year, with passage of a bill mi
more likely than in 1951 when President Tran
and Oscar Ewing first proposed the idea.
NOTES :
When Congress returns January 7, one of
measures waiting its attention will be a bill
control union welfare funds through registral
and publicity. (Most funds involve medical-1
pital benefits.)
* * *
Jenkins-Keogh legislation, for deferment of
come taxes on money put into retirement p j
by the self-employed, now is assured of a heai
next year when the House Ways and Me
Committee goes into all phases of taxation.
# * *
The Atomic Energy Commission has made
100,000th shipment of radioisotopes, many of tl
for medical use.
TM
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Aralen is usually well tolerated. Toxic effects are
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Gastrointestinal disturbances (e.g. nausea,
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Pleomorphic skin eruptions (e.g. lichenoid,
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treatment with gradually increasing doses, discon-
tinue Aralen till the lesion again disappears and
consider resuming treatment with Plaquenil®
(brand of hydroxychloroquine).
Less frequently transitory vertigo, headache,
lassitude, or neurological disturbances, such as
nervousness, irritability, emotional change, and
nightmares have been reported. Instances of unex-
plained slight gradual weight loss as the patient’s
general health and arthritic condition improved
have been mentioned. Occasional instances of
bleaching (depigmentation) of the hair have been
described.
Although an occasional instance of leukopenia,
with normal differential count, has been reported
(WBC about 3000), it has not proved troublesome
because it has always been reversible on discontinu-
ance, or diminution of the dose. Even spontaneous
reversal may occur while full dosage is maintained.
Caution:
Aralen is known to concentrate in the liver and,
although hepatic damage has never been reported,
the drug should be used with caution in the pres-
ence of liver disease. In the presence of severe
gastrointestinal, neurological, or blood disorders,
the drug should be used with caution or not at all.
If such disorders occur during the course of ther-
apy, the drug should be discontinued. Concomitant
use of gold or phenylbutazone with Aralen should
be avoided because of the tendency of these agents
to produce drug dermatitis.
Clinical Comments :
Of fifty patients receiving Aralen therapy, “43
have become really well ; that is, they have no stiff-
ness, and any pain that occurs can reasonably be
attributed to use of joints affected by secondary
degenerative changes. They have no evidence of
joint inflammation, but may have a raised erythro-
cyte sedimentation rate. They have little or no need
for analgesics.” Freedman1 2 3
“One hundred and twenty-five private patients
have been carefully followed clinically and haema-
tologieally while receiving well over 200 patient-
years of chloroquine [Aralen] therapy. The results
are considered good in 70%, one-half of these cases
being in remission. Improved work performance,
sedimentation rate, and hemoglobin levels para-
lleled the major objective gain in this 70%. 90% of
them remained on chloroquine [Aralen] therapy,
half for more than two years. Classical peripheral
rheumatoid arthritis, spondylitis, arthritis of
juvenile onset, and rheumatoid disease with
psoriasis, all appeared to respond about equally
well.
“It is suggested that chloroquine comes closer to
the ideal for long-term, safe, control of rheumatoid
disease than any other agent now available.”
Bagnall 4
“Out of the 36 rheumatoid arthritis cases we
treated . . . favorable results were obtained in 32
Cases. Bruckner et al .5 6 7
References
1. Haydu, G.G.: Rheumatoid arthritis therapy; a rationale and the use of
chloroquine diphosphate. Am. J. M. Sc. 225:71, Jan., 1953.
2. Rinehart, R.E.: Chloroquine therapy in rheumatoid arthritis. Northwest Med.
54:713, July, 1955.
3. Freedman, A.: Chloroquine and rheumatoid arthritis, a short-term controlled trial,
Ann. Rheum. Vis. 15:251, Sept., 1956.
4. Bagnall, A.W. : The value of chloroquine in rheumatoid disease, a four year study
of continuous therapy, read at the Ninth International Congress on Rheumatic Diseases
in Toronto, Canada, June 23-28, 1957.
5. Bruckner I., and Rosenzweig, S.: Treatment of chronic rheumatoid
arthritis with synthetic antimalarials, read at the Ninth International Congress
on Rheumatic Diseases in Toronto, Canada, June 23-28, 1957.
6. Cohen, A.S., and Calkins, Evan: A controlled study of chloroquine as an antirheumatic
agent, read at the Ninth International Congress on Rheumatic Diseases
in Toronto, Canada, June 23-28, 1957.
7. Scherbel, A. L., Schuchter, S.L., and Harrison, J.W.: Comparison of effects of two
antimalarial agents, hydroxychloroquine sulfate and chloroquine phosphate.
AMA News Notes
AMA PLANS ELEVENTH CLINICAL MEETING
The birthplace of American independence — Phila-
delphia— will be the scene of the American Medical
Association’s 11th Clinical Meeting, December 3-6. Cen-
ter of activities will be Convention Hall where scientific
exhibits, color television, motion pictures, technical ex-
hibits and scientific lectures will be presented “under
one roof.” Headquarters for the House of Delegates will
be the Bellevue-Stratford Hotel.
Highlights of the three-and-a-half day convention
geared especially for the nation's family doctors include:
(1) Special transatlantic conference between distin-
guished physicians in London and Philadelphia on “Ad-
vances in Chemotherapy of Cancer” via two-way tele-
phone at 3 p.m. EST Wednesday: (2) complete color
television schedule of surgical demonstrations emanating
from Lankenau Hospital: (3) motion picture program
daily, plus a special session Tuesday evening; (4) ex-
hibits featuring a well-rounded program and special dis-
plays on the history of medicine in the Philadelphia
area, fractures and manikin demonstrations on problems
of delivery; (5) panel discussions on cardiovascular dis-
ease, cancer, emotional problems of menopause, hyper-
tension, diabetes, arthritis, traumatic injuries; (6) the
General Practitioner of the Year Award to be presented
by AMA to an outstanding family doctor.
.AD INDUSTRY TO JOIN BATTLE
AGAINST POLIO
Local polio drives will get publicity assistance this
fall from the Advertising Council, Inc. This voluntary
group of advertisers and businessmen has taken on the
vaccine campaign as one of its public service projects,
mapping out a complete promotional program which
utilizes newspapers, business papers, industrial publica-
tions, transportation and outdoor advertising, as well as
radio and television. Local use of these materials will,
in many cases, depend on whether or not a community
vaccination drive has been planned or is in progress.
Using the theme “Don’t Press Your Luck — Get Your
Three Polio Shots Now!”, the materials make frank use
of scare techniques by contrasting the tragic effects of
polio with the simplicity of getting Salk shots. Advisors
for the campaign were the American Medical Associa-
tion, the U. S. Public Health Service and the National
Foundation for Infantile Paralysis.
U. S. TO OBSERAT “MEDICAL
EDUCATION WEEK” IN APRIL
The third annual Medical Education Week, nation-
wide tribute to the progress of American medical schools,
will be promoted during the fourth week in April by
U. S. medical schools and the medical profession.
April 20-26 will be devoted to an all-out effort to
create a greater understanding among the public of both
the achievements and the problems of medical schools.
Each of the sponsoring organizations — the American
Medical Association, the Student American Medical As-
sociation, the Woman’s Auxiliary to the AMA, the 1
Association of American Medical Colleges, the American
Medical Education Foundation, and the National Fund
for Medical Education — is asking its membership to re-
serve this week for community and statewide salutes to
area medical schools.
Local and state programs will be reinforced by na-
tional publicity through network television and radio,
newspaper syndicates, and magazines. In addition, the !
sponsors will send promotional aids to their state and
county officers to help in local observances.
During the 1957 Medical Education Week, medical
societies in thirty-two states and woman’s auxiliaries in
forty-two states planned various activities, and their I
past successes are expected to lead to an even more
widespread acknowledgment of the achievements of
medical schools in 1958.
AMA PARTICIPATES IN SAFETY CONGRESS
America’s doctors will again join in presenting a
program this fall at the National Safety Congress in
Chicago. The AMA’s Council on Industrial Health will
co-sponsor a session on “Vision in Industry” with the
American Society of Safety Engineers and the National
Safety Council’s occupational health nursing section
Among the areas to be covered in the discussion of eye p
safety programs are visual ability to meet job require-
ments, eye protection, and proper first aid for eye in-
juries. This program will be held Thursday morning,
October 24, at the Congress Hotel.
AMA PREPARES LIABILITY' KITS
For us in claims prevention and claims review pro-
grams, the American Medical Association’s Law Depart- :
ment is making available to each state medical society |
a packet of materials dealing with “medical professional
liability.” The kit will contain reprints from the Journal \
of the American Medical Association “Medicine and the
Law” section dealing with such things as statues of
limitation, court decisions and “res ipsa loquitur.” Also
enclosed will be the results of an opinion survey and
a report on medical professional liability case histories,
keyed to each state. Distribution is slated for October 1.
M.D.’s TO CO-OPERATE IN
“FARM-CITY WEEK”
The national committee for Farm-City Week, Novem-
ber 22-28, has extended a special invitation to all state
and county medical societies to join in a program to
“build better relationships between town and country
neighbors.” As in the past two years, this observance
will be conducted nationally and locally by hundreds
of civic, industrial, agricultural, professional and youth
organizations — all spearheaded and coordinated by Ki-
wanis International.
The AMA, which is represented on the Farm-City
(Continued on Page 1224)
1222
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AMA NEWS NOTES
M.D.’S TO CO-OPERATE IN
“FARM-CITY WEEK”
(Continued from Page 1222)
board of directors, this month (October) will send to
all societies a series of suggestions for highlighting their
urban and rural health services during the Week. In
most cases, local programs will be coordinated by com-
munity Kiwanis clubs. Names of both regional and state
Farm-City Week chairmen also will be sent to medical
societies so that physicians may be represented on the
local planning committees.
THREE NEW AMA EXHIBITS
Three new exhibits previewed at the American Medi-
cal Association’s 1957 Public Relations Institute in
Chicago, August 28-29, will be available for bookings
by state and county medical societies in September.
( 1 ) “Digestion” — shows the organs involved in di-
gestion, the passage of food through the body, the
mechanics of swallowing, the action of the stomach and
intestines, and the body’s absorption of food. (2) “Al-
coholism Is Your Business”- — (for professional audiences)
gives the viewer an opportunity to eavesdrop on a con-
versation between a distraught spouse and the family
physician over the treatment of alcoholism. (3) “Or-
gans of the Human Body” — three dimensional models
of the torso show location of various organs in the
body and their functions.
Further information on these displays may be secured
from the AMA Bureau of Exhibits.
AMA TO PUBLISH MEDICOLEGAL MATERIAL
To guide physicians and hospitals in the selection of
appropriate medicolegal forms, the AMA’s Law De-
partment has compiled a series of six brief articles
for the Journal of the AMA. These articles will appear
weekly in the Journal, beginning about September 1.
In addition, the Law Department will publish a booklet
encompassing the material plus case citations and legal
analysis for distribution about October 1.
Chief purpose of this material will be to provide
up-to-date information and miscellaneous medicolegal
forms which physicians and their attorneys may adapt
for their own needs. Subjects to be covered: (1) con-
sent to operations and other medical procedures;
(2) patient’s right to privacy; (3) confidential com-
munications and records; (4) artificial insemination;
(5) the physician-patient relationship; (6) autopsy.
In all cases, the Law Department strongly advises
doctors to seek competent legal advice locally.
AMA LENDS HAND TO MEDICAL
ASSISTANTS GROUPS
A new how-to-do-it organizational manual for medical
assistants will be introduced at the second national con-
vention of the American Association of Medical Assist-
ants in San Francisco, October 4-6. Edited by leaders
in assistants groups around the country, the manual is
being published by the AMA’s Public Relations Depart-
ment. The manual, titled “Take-off Techniques,” dis-
cusses such organizational processes as securing medical
1224
society cooperation, planning educational programs anc
keeping members informed.
This is the second publication for medical assistant;
the AMA has prepared this fall. A new medical as-
sistants packet, outlining medical assistants’ organiza-
tional aims and activities, was completed recently anc
is available on request to medical societies and assistant;
groups.
Women from assistants groups in some twenty state:
are expected to attend the San Francisco session o
A AMA. The San Francisco Medical Society, the Cali
fornia Medical Association and the AMA will co-sponso:
a reception Friday evening, October 4, for A AMA mem
bers.
AMA CONFERENCE ON NUTRITION
IN PREGNANCY
Because nutrition plays such an important role ii
all phases of reproduction, the AMA’s Council on Food
and Nutrition has selected “Nutrition in Pregnancy
as the title of its 1957 symposium. The meeting wil
be held October 11 at the University of Missouri Medi
cal Center, Columbia, Missouri. Joint sponsors witl
the AMA are the University of Missouri Medical Schoc
and Adult Education and Extension Service and th
Boone County Medical Society.
The symposium will provide an excellent opportu
nity for physicians, nutritionists, dietitians, nurses an
others to acquaint themselves with current findings i
nutrition and the practical application of these finding
to the management of obstetrical patients.
Topics to be discussed include: the influence of m:
ternal nutritional level on the fetus and infant; metabc
lie and biochemical changes in normal pregnancy; in
portance of nutritional state of mother prior to cor
ception ; nutrition experiments as an instrument of ter:
tologic research ; the effect of the reproductive cycl
on nutritional status and requirements; dietary habi
during pregnancy; panel discussion to review epidem
ologic studies.
If physicians and patients alike maintain a hie
index of suspicion, and if all available diagnostic pri
cedures are utilized, many more cases of esophage
and gastric cancer will undoubtedly be uncovered whi
still in a stage permitting curative operation.
* * *
The great pitfall in cytologic exa-nination is tl
false negative result. A negative cytologic study do
not exclude the diagnosis of cancer.
* * *
There is no single characteristic onset or sympto i
complex in the earliest expressive stage of gastric canct
* * *
Any symptom referable to the upper abdomen m
be a symptom of cancer of the stomach.
* * *
Approximately one-third of all patients with gasti
cancer may present symptoms of peptic ulcer.
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or q.i.d., or one Extentab q,12h.
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Social Security and Jenkins-Keogh Bills
Actions of the AMA House of Delegates at its
June, 1957 annual meeting on these subjects were
as follows:
1238
No. 23. Resolution on Postponement of
Income Tax Payments
The following resolution was introduced by Dr. James
E. Feldmayer on behalf of the California delegation and
was referred to the Reference Committee on Insurance
and Medical Service:
Whereas, The California Medical Association has de-
clared itself in favor of the U. S. House of Representa-
tives Resolutions 9 and 10 permitting postponement of
payment of income tax on certain sums earned by self-
employed persons, known as the Reed-Keogh bills; now,
therefore be it
Resolved, That the California Medical Association
does urge the American Medical Association to continue
its strenuous efforts toward the passage of this or similar
legislation.
REPORT OF REFERENCE COMMITTEE ON
INSURANCE AND MEDICAL SERVICE
Dr. James P. Hammond, Chairman, Vermont, read
the following report, which was adopted:
Resolutions No. 23, 40, and 57 on the J enkins-Keogh
Bills. — The subject matter of these resolutions is identi-
cal, and the purpose of all of them is to endorse the
Jenkins-Keogh bills. Your committee recommends that
they be adopted.
1243
No. 39. Resolutions on Social Security Benefits
Dr. Christopher Wood for the New York delegation
introduced the following resolutions, which were referred
to the Reference Committee on Legislation and Public
Relations:
Whereas, 70 million Americans are currently eligible
for retirement and survivors benefits under the Federal
Social Security system; and
Whereas, Congress amended the Social Security Act
in 1954 and 1956 bringing self-employed professionals,
such as dentists, lawyers, pharmacists, social workers,
engineers, and others, the benefits of Old-Age and Sur-
vivor’s Insurance; and
Whereas, Doctors of medicine are now the sole self-
employed professional group excluded ; and
Whereas, Because of this unfair exclusion physicians
must pay $7,000 to $25,000 more for retirement and life
insurance than other citizens; and
Whereas, There is no logical or professional reason
why practicing physicians should be denied benefits avail-
able to millions of other Americans; and
Whereas, Congress has passed bills whereby no volun-
tary coverage will be granted physicians; therefore be it
Resolved, That the American Medical Association res-
cinds its opposition to compulsory social security for doc-
tors of medicine; and be it further
Resolved, That we urge the Congress of the United
States of America to extend the benefits of social security
to self-employed doctors of medicine; and be it further
Resolved, That the President of the United States of
America, tbe presiding officer of the Senate, the Speaker
of the House of Representatives, and members of appro-
priate congressional committees be sent copies of this
resolution.
REPORT OF REFERENCE COMMITTEE ON
LEGISLATION AND PUBLIC RELATIONS
Dr. S. J. McClendon, Chairman, California, read th
following report which was adopted:
Resolutions No. 39 and 46 on Compulsory Social Se
curity Coverage for Physicians. — Your committee hear
a number of persons relative to these resolutions, am
makes the following recommendations:
That the House of Delegates reaffirm its long-standin
opposition to the compulsory coverage of physician
under the Old-Age and Survivors Insurance provisions c
the Social Security ' Act. It recommends a strongl
stepped-up informational program of education whicl
will reach every member of the Association, explainin
the reasons underlying the position of the House c
Delegates on this issue.
Physicians and medical societies have for many year
led the fight against federal encroachments in their pei
sonal and private affairs. The pattern of social insuranc
schemes in other countries growing from retirement pay
ments to survivorship payments to permanent and tota
disability payments to temporary cash sickness benefit
and, finally, to national compulsory health insurance, i
all too clear. It is equally clear that greater federa
control and the placing of responsibility for an increas
ingly greater percentage of our people in the hands o
the government will result in loss of freedoms impos
sible to reclaim. For these reasons, and because of th
actuarial instability of the Old-Age and Survivors Insur
ance program, your reference committee recommend
that these resolutions be not adopted.
The Association’s position favoring the Jenkins-Keogl
bills is a more logical approach, as it encourages thrif
and discourages inflation and dependence upon the fed
eral government.
No. 40. Resolution on Participation of Physicians
in Pension Plan for Self-Employed
The following resolution was introduced by Dr. Ed
ward P. Flood on behalf of the New York delegatioi
and was referred to the Reference Committee on Legis
lation and Public Relations:
Whereas, It is desirable for physicians to receivi
tax-free pension rights; and
Whereas, Participation in such plans (Jenkins-Keogl
bill) would not negate our participation in the Federa
Social Security program; and
Whereas, Such participation would permit a self
employed physician to put part of his earnings befor
taxes into a retirement fund; therefore be it
Resolved, That the American Medical Association ap
proves participation of its members in such a pensioi
plan for the self-employed.
Note : The report of the Reference Committee oi
Legislation and Public Relations on Resolution No. 4'
will be found following Resolution No. 23.
124
No. 46. Resolution on Compulsory Social Security
Coverage for Physicians
The following resolution was introduced by Dr. Joh
N. Gallivan on behalf of the Connecticut delegation an
was referred to the Reference Committee on Legislatio
and Public Relations:
(Continued on Page 1232)
1230
JMSM
In keeping with its tradition of responding to the immediate
needs of the medical profession, Lederle announces the avail-
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Asian Strain,” produced according to N.I.H. specifications.
The vaccine is specific against the known strains of the so-
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TOBER, 1957
Say you saw it in the Journal of the Michigan State Medical Society
1231
SOCIAL SECURITY AND JENKINS-KEOGH BILLS
(Continued from Page 1230)
Whereas, The Connecticut State Medical Society con-
ducted a referendum among its 3,100 members during
March and April of 1957 asking for a statement of opin-
ion relative to the compulsory inclusion of doctors of
medicine under Old-Age and Survivors Insurance in the
Social Security Law; and
Whereas, 61 per cent of the members of the society
voted in this referendum and 73 per cent of them were
in favor of compulsory inclusion of doctors of medicine
under the Social Security Law (which was 45 per cent
of the total ballots distributed) ; and
Whereas, The House of Delegates of the Connecticut
State Medical Society at its 165th annual meeting on
April 30, 1957, directed the delegates from the society
to the American Medical Association to present and
support at the next meeting of the House of Delegates
of the American Medical Association in New York City,
June, 1957, a resolution sponsored by the Connecticut
State Medical Society, favoring social security coverage
for all physicians; now therefore be it
Resolved, That the House of Delegates of the Ameri-
can Medical Association assembled at its Annual Meet-
ing in June, 1957, place itself on record as being in
favor of compulsory inclusion of doctors of medicine
under the Federal Social Security Law.
Note : The report of the Reference Committee on
Legislation and Public Relations on Resolution No. 46
will be found following Resolution No. 39.
1248
No. 57. Resolutions Supporting the Jenkins-Keogh Bills
Dr. John K. Glen for the Texas delegation introduced
the following resolutions, which were referred to the
Reference Committee on Legislation and Public Rela-
tions:
Whereas, The legislation now pending in Congress,
generally known as the Jenkins-Keogh bills, which would
permit those with self-employment income to place a
small part of their earnings before taxes into a retire-
ment fund; and
Whereas, More widespread interest and support for
the Jenkins-Keogh legislation is evident now than ever
before, therefore be it
Resolved, That the House of Delegates of the Ameri-
can Medical Association again endorses the principles of
the Jenkins-Keogh bills in the interest of fairness and
equality to the self-employed individuals of the United
States; and be it further
Resolved, That copies of this resolution be sent to the
President, all members of his Cabinet, and all members
of the Congress.
1251
No. 69. Resolutions on Nationwide Referendum on
Social Security
Dr. Stanley Weld for the Connecticut State Medical
Society introduced the following resolutions, which were
referred to the Reference Committee on Legislation and
Public Relations:
Whereas, The burning question of social security still
confronts the physicians of the United States; and
Whereas, According to the statement of Frank G.
Dickinson, Ph.D., Director, A.M.A. Bureau of Medical
Economic Research, in The Journal, July 21, 1956, page
1163: “Unfortunately the use of a variety of questions
in the state association polls makes a tabulation of the
composite replies from all polls, particularly on the corn-
1232
pulsory versus voluntary issue, meaningless” ; therefore
be it
Resolved, That the Secretary of the A.M.A. be in-
structed and empowered to conduct a nationwide referen-
dum of the members of the A.M.A. on the issue of social
security for self-employed physicians; and be it further
Resolved, That to obviate the confusion resulting from
the statewide polls, the questions presented in the pro-
posed referendum be phrased simply as follows:
I favor social security for physicians.
I do not favor social security for physicians,
and be it further
Resolved, That the referendum be preceded by the
publication in The Journal of factual briefs for and
against social security and that the same factual briefs
shall also accompany the referendum ballots.
REPORT OF REFERENCE COMMITTEE ON
LEGISLATION AND PUBLIC RELATIONS
Dr. S. J. McClendon, Chairman. California, read the
following report, which was adopted :
Resolution No. 69 on Nationwide Referendum on
Social Security. — Your committee met for two hours and
listened to discussions for and against this resolution.
In its report on Resolutions No. 39 and 46, your com-
mittee has recommended “a strongly stepped-up infor-
mational program of education which will reach every
member of the Association, explaining the reasons under-
lying the position of the House of Delegates on this
issue.”
From the discussions at the open hearing, it was
obvious that such a program was necessary, and that
until such a program is effected, your committee recom-
mends that the resolution be not adopted. — JAMA, July
13, 1956.
laUtatmj CxatninatUm
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Autopsies
Bacteriology
Basal Metabolism
Chemistry
Electrocardiograms
Hematology
Papaniculau Stain
Pregnancy Tests
Protein Bound Iodine
Urinalysis
Serology — Kahn and Wassermann
CENTRAL LABORATORY
Oliver W. Lohr, M.D., Director
537 Millard Street
Saginaw, Michigan
PHONE: Pleasant 2-4100
2-4109
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Say you saw it -in the Journal of the Michigan State Medical Society
'Tke JOURNAL
of the Michigan State Medical Society
Issued Monthly Under the Direction of the Council
/OLUME 56 OCTOBER, 1957 NUMBER 10
rhe Kaleidoscopic Nature of Psyche and Soma
By Peter A. Martin, M.D.
Detroit, Michigan
T1 HE TERM “psychokaleidoscopics” was coined
by the author for this paper, in an attempt
o emphasize the constantly changing combina-
ions (like a kaleidoscope), of psyche and soma
within each patient. Confusion as to how psyche
nd soma are related is not uncommon in medical
iractice. Psychiatrists frequently encounter two
xtreme attitudes in their nonpsychiatric col-
sagues. One is the attitude in which, in the ab-
ence of positive physical and laboratory findings,
he patient is told by his physician that there is
lOthing organically wrong with him, so he must
>e neurotic and he is referred to a psychiatrist,
rhis is an erroneous method of diagnosis of a
leurosis by the exclusion of physical findings. The
ither attitude is a newer one, but one that . is en-
ountered with surprising frequency and appears
o be a misguided offspring of the rising emphasis
>n psychosomatic medicine. It erroneously con-
ludes that psyche and soma should always be
onsidered as one, and thus every somatic illness
5 either partially or wholly due to psychologic
orces. This view may result in a referral to a
•sychiatrist for total care of a patient even in the
ace of proven organic findings of a nonpsychiatric
lature. As will be illustrated in the clinical ma-
erial which follows, one-sided viewpoints can place
he patient in a dangerous position.
Pertinent clinical material will be presented
rom the case histories of several patients. This
Read at a meeting of The Michigan Society of Neu-
ology and Psychiatry, Detroit, Michigan, March 21,
957.
Dctober, 1957
material illustrates the kaleidoscopic nature of the
human organism, and leads to conclusions about
the danger not only of oversimplification of the
relationship between psyche and soma but, also,
the danger of complacency after establishing the
relationship in a particular patient, in believing
that it will continue thereafter unchanged.
Case Reports
Case 1. — The first case is that of a twenty-eight-year-
old white man who was transferred from the psychiatric
section of a general hospital to the state hospital with
a diagnosis of schizophrenia. His previous medical his-
tory was one of periodic episodes of vomiting for a
duration of five years. During these episodes, he was
unable to “hold anything on his stomach.” According to
the informant, no one was ever able to determine what
was physically wrong with him. His last attack, which
began with persistent vomiting and epigastric pains,
forced admission to the general hospital. At the time
of admission he was described as a person having many
frends, being very sociable and always liked by people.
This patient was kept on the medical service for
three-and-a-half months and given an intensive medical
work-up to determine the cause of his pain and vomiting.
His case record was thick with laboratory reports. The
following is a very brief summary of his chart after
months of hospitalization:
History on Admission: Persistent vomiting for one
week — epigastric pain. No response to medical treat-
ment. Physical Findings: Essentially negative. Labora-
tory Findings: Essentially negative. X-Ray Findings:
GI series — No cancer, ulcer or vitamin deficiency. Steer
horn stomach and possible gastritis. Barium enema —
no pathology shown. IV pylogram — no pathology
shown. Gastroscopic: poor emptying stomach — hyper-
secretion. Possible hypertrophic gastritis, pylorospasm or
1249
PSYCHE AND SOMA— MARTIN
pyloric stenosis. Treatment : Patient received atropine,
phenobarbital, tincture belladonna, I.V. fluids, and vi-
tamins. He showed no response to treatment and be-
came progressively more depressed, withdrawn and
resentful when told nothing was wrong with him.
Remarks: “Patient completely washed up on medical
sendee. Variety of drugs tried with no success.”
Final Diagnosis: Vomiting — psychogenic in origin. De-
pressive state.
Because of the foregoing picture, he was presented at
the psychosomatic seminar which was headed by a
psychiatrist. There, a tentaive diagnosis of schizophrenia
was made and a recommendation that he be transferred
to the psychopathic wards. Following his transfer, he
became more depressed and then frankly psychotic. He
refused to talk to anyone for three weeks and, when
asked why, told his sister that he thought his mouth
got him into trouble. He attempted suicide because he
was told that his vomiting was all in his mind. He then
developed a mood change to one of excitement, in
which he was very happy, cried, and believed that he
would leave the hospital entirely well. These alternating
moods of depression and excitement finally resulted in
his commitment to the state hospital. His family did not
believe there was anything mentally wrong with this
patient and resented his hopitalization.
When admitted to the state hospital, he was despond-
ent, apathetic, confused and disoriented. This picture,
coupled with the extensive physical work-up he had re-
cently had and his transfer diagnosis, caused him to be
placed on electroshock therapy. He showed no response
and continued his vomiting between such treatments.
A steady downhill course necessitated sending him to the
hospital ward where he expired six weeks after admis-
sion to the state hospital and fifteen days after his last
shock treatment.
Following are the pertinent sections of the autopsy
report: “The stomach, after evacuation of the contents,
measures 29x16x2 cm. At the duodenal cap, 2 cm. from
the pyloric ring, there is an old scar from an old peptic
ulcer. This appears to be what has produced the
chronic obstruction. There is no suggestion of malig-
nancy and the stomach appears to be in fairly good
condition except for the enormous distention. There is
no evidence of active ulceration. The hepatic duct is
involved in the scar tissue. . . . Cause of death: pyloric
obstruction.”
Careful re-examination of the entire case his-
tory of this patient led to these conclusions. The
underlying schizophrenic potential broke through
under the stress of his disheartening prolonged
hospitalization. If surgical intervention had taken
place, both his psychosis and his death could
have been prevented. This man died because of
the lack of recognition of these principles: (a)
Referral from competent medical men does not
rule out organic illness. There is an increasing
collection of literature to verify this conclusion.
(b) The presence of obvious mental illness does
not prove it to be the cause of any physical symp-
toms present. The psychotic picture was accepted
as explanation for his vomiting. His symptom
complex was considered to be a psychosomatic
one. Actually the preterminal picture was a soma-
topsychic one.
Case 2. — This patient was a fifty-five-year-old white
woman brought to the hospital from another mental
hospital where she had just received seventeen electro-
shock treatments. Her diagnosis was paranoid schizo-
phrenia. She still had auditory hallucinations with
paranoid delusions on admission. In adition, this picture
was complicated by the marked type of confusion which
often accompanies electroshock. The psychiatrist’s ad-
mission examination indicated necessity for a further in-
tensive physical work-up. A referral to an internist con-
sultant resulted in the diagnosis of myxedema, mixed
with multiple gland deficiency. Subsequent inquiries
into previous medical illnesses revealed that the history
of previous recognition of this organic pathology had
been ignored by the psychiatrist who gave her shock
therapy. Her basal metabolic rate was — 21. Stomach
contents revealed an achlorhydria. The internist con-
sultant placed her on thyroid, pituitary extract, lextron
and acidulin. The daily change, though gradual, was
dramatic. The psychosis cleared up as her physical
condition improved. She was discharged in four weeks
after onset of medication.
The second patient like the first had an underly-
ing psychotic potential. The paranoid psychosis
broke through with the organic trauma of the
severe hypoendocrinism. The hypoendocrinism
precipitated but did not cause the psychosis. The
psychosis did not cause the hypoendocrinism.
These mutually exclusive entities were interrelated,
but not as cause and effect. In the presence of
malfunction of physiologic activities, healthy ego
defenses failed.
Case 3. — The third patient in this series was a forty-
seven-year-old white woman who was admitted to the
hospital where her husband had undergone serious ab-
dominal surgery. She was described as having made
a nuisance of herself at the hospital by doubting the
efficiency of the nurses and the doctors and fearing her
husband would die. For this reason, and in order to
prevent disturbing the husband's convalescence at home,
his surgeon sent her to the private mental hospital for
observation. A careful psychiatric evaluation revealed
considerable stress at home but, on the basis of the
examination, the psychiatrist could positively state that
she was neither psychotic nor neurotic. Her medical
history and examination indicated some physical dis-
order present and she was referred to the consulting
internist. Following is a portion of the initial report:
“From the clinical standpoint, she has a chronic
bronchitis and possibly a chronic cholecystitis. I would
1250
TMSMS
PSYCHE AND SOMA— MARTIN
ecommend a gall bladder series for the latter. There
s no explanation for the high leukocytosis (17,000) at
iresent.” Chest and gall bladder x-rays were negative.
..eukocytosis persisted despite a course of penicillin. The
onsultant then ordered a gastrointestinal series, which
evealed a questionable lesion in the stomach. She was
hen referred to her own internist for definitive action,
le ridiculed the need for surgery. The psychiatric team,
hen, had to insist upon gastroscopy. Through the lat-
er procedure, a small sessile polyp was visualized. The
'Sychiatric team insisted on surgery, despite objections
f her internist as to the benign nature of the lesion,
’his resulted in partial gastric resection and posterior
astrojej unostomy. Portions of the biopsy report follow:
The biopsy of the gastric mucosa shows marked lympho-
ytic and plasma cell infiltration with some poly-
uclears. There are areas of atypical glandular hyper-
lasia with mucin formation. In some areas this appears
3 be a small benign adenoma but where there is evi-
ence of infiltration, the tumor is evidently an early
denocarcinoma arising from abberant tissue.”
This paper is written eight years after surgery
nd the patient has been in good health, both
hysically and mentally up to the date of this
fllow-up study. An eight-year cancer cure of
le stomach has been achieved. A psychiatrist’s
iagnosis of no mental illness has been confirmed.
Casfi 4. — The fourth case is that of a middle-aged
lap who suffered from severe frontal headaches for
lany years. He had repeated medical examinations but
d cause for his headaches was discovered. At one large
ledical center, he was finally scheduled to be examined
y a psychiatrist. There, after a half hour of question-
ig, he found himself denying the psychiatrist’s repeated
legations that his headaches were due to his hatred
jainst his father. Finally the psychiatrist heatedly said,
How can you say you don’t hate your father when you
ild me he was a beggar?” In horror, the patient who
>oke with a New York accent explained to the mid-
estern psychiatrist that he had said his father was
“baker” and not a “beggar.” His headaches continued
labated by this interview.
The patient’s wife was a person who had phobic re-
gion to doctors. So, when his wife had to see an ear,
3se and throat specialist, he said he would go and be
camined first in order to get her to the doctor, and
also in a vain search for relief from his headaches.
Upon examination, he was told that nothing was wrong
with him except for a slightly deviated septum, but that
his wife needed immediate surgery for nasal polyps. In
order to overcome her neurotic fear, he offered to go
into the hospital for surgery on his deviated septum at
the same time as she would have her polyp surgery. At
his operation, when the nasal septum deviation was re-
moved, a large soft tissue tumor occupying the frontal
sinus was exposed and removed in its entirety. His
headaches disappeared forever after this surgery. How-
ever, his wife complained for weeks after surgery about
pain and discomfort in her nose. The surgeon said
that he could find no reason for it, that surgery had
been successful and it must be an emotional reaction
in this neurotic woman. Fortunately, her symptoms dis-
appeared a few days later when a nasal pack which
had been left in at surgery dropped out unexpectedly.
The shifting conditions of psyche and soma are
clearly illustrated in this last case history. These
kaleidoscopic pictures need frequent reviewing in
order to see what changes have taken place. Over-
simplification or one-sided viewpoints are danger-
ous to the patient. It would take a mathematician
to work out the number of combinations of psyche
and soma that the physician should look for. Just
a few will be listed here : ( 1 ) A somatic illness
with minimal, mild, or moderate or severe emo-
tional reactions to it; (2) an emotional illness with
minimal, mild, moderate or severe physiological
reaction to it; (3) a somatic illness and an emo-
tional illness present at the same time but not
related as to cause and effect; (4) an emotional
conflict leading to an organic illness which leads
to the development of an emotional illness not
directly related to the original emotional conflict.
Summary
The author has attempted to illustrate clinically
a few of the many varying relationships between
psyche and soma which may occur in any patient.
It emphasizes the need for continuing evaluations
of these relationships in all patients.
Forty per cent of patients complaining of postmeno-
tusal bleeding have cervical carcinoma.
* * *
The treatment of cervical cancer is largely irradiation
erapy and should be given in centers properly equipped
give radium and deep x-ray therapy.
The treatment of endometrial carcinoma is a com-
bination of irradiation and surgery.
* * *
Bleeding should never be ascribed to a benign cause,
such as a cervical polyp, until curettement has ruled
out endometrial carcinoma.
CTOBER, 1957
1251
Clinical Manifestations of Anxiety
By Peter A. Martin, M.D.
Detroit, Michigan
r | 1 HIS paper will be directed primarily to the
presentation of the clinical manifestations of
anxiety; however, to avoid the lack of understand-
ing that results from pure description, theoretical
assumption will be continuously interspersed. We
will start with the picture of the fetus in utero.
In this veritable paradise, the fetus is subjected
to a minimum of stimuli, a minimum of activity,
and a minimum of unpleasure. But at birth a
marked change occurs. Paradise is lost. In-
stinctual needs are no longer being automatically
and continuously gratified. The newborn is in-
troduced to loud noises, bright lights, and to the
need to breathe for itself and to actively par-
ticipate in its own nourishment. At birth we can
observe the muscles of the infant’s face contorted,
as if in pain, we can observe undirected muscular
discharges in the extremities and we can hear his
disturbed cries. What we are seeing is a disruption
of homeostasis. This is a diffuse dystonic reaction
to a disturbance of inner equilibrium. Subsequent-
ly, a similar total and overwhelming reaction in-
volving the entire organism occurs whenever an
infant’s homeostasis is disturbed by intense hunger,
thirst, inner discomfort or outside stimuli that in-
terfere with its balance. We cannot know directly
what the precise qualities of the emotion experi-
enced by the infant are at this time. However, we
can say that at this early stage, the infant experi-
ences unpleasure due to a mixture of several af-
fects, prominent among which is the forerunner
of anxiety.
Let us carry the infant a step further. Let us
suppose he has succeeded in mastering the art
of nursing. He has experienced the gratification
and satisfaction of his hunger pains, the change
from unpleasure to pleasure. His stomach does
not know that mother has been instructed to place
the infant on a rigid four-hour feeding schedule.
His pangs of hunger may become severe in three
hours. During the one hour’s wait until mother
Presented before students and faculty, Wayne State
University College of Medicine, Detroit, Michigan, Feb-
ruary, 1957.
feeds him, he experiences an accumulation of
unpleasant stimuli against which he is powerless.
Manifestations of anxiety develop in response to
being so overwhelmed. The establishment of
anxiety results from the infant’s biologic and
psychologic inability to cope on his own with the
increase of tension arising from nongratification
of his needs. This disturbance of homeostasis is
experienced as a threat to his existence and, in
reality, this is so. If uncared for, the human
newborn dies.
As the growing infant’s experiences increase, and
his other ego functions develop, such as memory
and sensory perception, the child becomes able to
predict or anticipate that a state of unpleasure
will develop. For example, his first pangs of
hunger at the three-hour mark, though mild may
be a signal to touch off a severe reaction in an-
ticipation of a repetition of previous severe dis-
comfort.
We can now define anxiety as it will be used
throughout this presentation. Anxiety is an un-
pleasant emotion or affect which is evoked by the
anticipation of danger. It serves a function of
being a signal of trouble to come, trouble to the
extent of possible annihilation. But anxiety is
not only a psychic phenomenon. There are, as
mentioned, physiological expressions which are
adrenosvmpathetic. These anxiety equivalents
are characterized by an increase in the cardiac and
respiratory rates, and by gastrointestinal hyper-
motility, by a rise in blood pressure and changes
in the vascular system throughout the body. The
physiologic discharge phenomena form a syndrome
which can be studied objectively and which is
constant from individual to individual. These vis-
ceral responses change very little after birth ex-
cept that they acquire a somewhat favored local-
ization in one system of organs. One person may
react more intensely by cardiovascular, another by
gastrointestinal, and a third by respiratory system
reactions. Chronic effects of anxiety form the
basis of so-called pschosomatic conditions. Prob-
ably the localization is due to an infantile trauma
1252
JMSMS
CLINICAL MANIFESTATIONS OF ANXIETY— MARTIN
and fixation, with some hereditary factor.
In the adult, the cardinal feature of anxiety is
its vagueness. This quality characterizes both its
affective or feeling aspect and its expressive as-
pects. The affect of anxiety is perceived as an un-
easiness of varying degrees of painfulness and
pressure, together with a quality of uncertain fore-
boding. The expression of anxiety includes diffuse
activity from mild excitement to extreme restless-
ness. But, like its affect, the activity is objectless
and undirected. Extraordinarily alert and expect-
ant, the anxious individual is ready to adapt to
changes in the outer situation.
The wide range of responses to anxiety is well
known. For example, mild anxiety is felt in read-
ing stirring passages of a book, or just before the
trigger is pulled in hunting. At such times, the
person is on the alert, with no definite purpose
other than the most general one of being ready
for anything. Similar reactions, but with greater
urgency and restlessness, occur in more disturb-
ing situations. Extreme degrees of anxiety, ap-
parently out of proportion to the external stimulus,
occur among neurotic and psychotic individuals.
Normal individuals, under marked stress, as in
war, can experience regression to extreme anxiety.
This may appear when the stimulus is great, sud-
den and overwhelming. A sudden exposure to
great danger catches the organism unaware and
unprepared. The widespread diffuse paralyzing
reaction of disorganization is known as shock or
panic. Rational conduct is paralyzed; fragmenta-
tion and shattering of habitual reactions occur
and there is regression to infantile reactions. The
individual is said to “lose his head” or “go to
pieces.” Inhibitory learned processes are detached
and the person says and does things that under
normal circumstances he would avoid. Prolonged
states of anxiety may occur in continuously diffi-
cult situations which cannot be resolved, such as
the maladjustment of some men in military serv-
ice. Free-floating anxiety with no apparent cause
results from unconscious conflicts.
The above description gives the more obvious
manifestations of anxiety. There are also hidden
manifestations of anxiety as seen in the character
of an individual. To illustrate the latter, let us
return to the picture of the infant. The days fol-
lowing birth are indeed difficult ones. Even under
ideal circumstances, the infant is faced with un-
avoidable frustrations to which he responds with
intense undifferentiated affects and physical dis-
charges. At first psyche and soma are one. Any
psychic trauma has a somatic discharge. Any
somatic traumas leave psychic impressions. Dis-
turbances in the infant-mother symbiotic rela-
tionship in the first few months lead to anxiety
resulting in feeding problems, colic, diarrhea, con-
stipation and what may be the anlage of the
psychic components in psychosomatic disorders,
such as peptic ulcers, asthma and ulcerative colitis.
Increased frustration of essential instinctual needs
abnormally increase the amount of anxiety with
deleterious physical results. Motherly affection
during this period is an essential need, and infants
who do not receive it may react with mirasmus
and die despite adequate nourishment.
At six months of age the first deciduous teeth
erupt. The infant then has his first and most
powerful weapon. If he becomes frustrated, he
may respond by biting the offending parent.
Mother may punish him or speak crossly to him.
This feels dangerous. He develops anxiety.
When he starts to crawl and to investigate, he
may be hindered by unwelcome restraints. He is
forbidden to touch, to sample, to destroy, to soil,
to slap, to kick, to scratch, to bite, to spit, to
suck, to scream and so on ad nauseum. But he
learns that if he expresses his mental or physical
nausea, Mother withdraws her love. This is
dangerous since he is dependent upon Mother for
his life. Both birth anxiety and the anxiety of
the infant alike claim separation from the mother
as their prerequisite. This fear of separation can
occur in thousands of minor experiences like the
ones given above.
Let us take another common example of an
anxiety provoking experience: rivalry. The old
problems of Joseph and his brethren, sibling
rivalry, frequently disrupt the peace of the home.
Also, the child is jealous because his parents love
one another and because they love the other chil-
dren. The child wishes to be the one and only
beloved of his mother and father. When the new
baby is born, the child often says, “Send him back.
We don’t want him.” Or the child awaits an oppor-
tunity to hit the new infant. Or the child may
attempt to destroy the sibling by pushing him
down the stairs, hanging him on the clothes line,
sticking a nipple down his throat, or feeding him
poison tablets from the medicine chest. These are
but a few examples from real-life experiences.
October, 1957
1253
CLINICAL MANIFESTATIONS OF ANXIETY— MARTIN
Jealousies between fathers and sons and mothers
and daughters are important producers of much
anxiety. This anxiety is an expression of the fear
of separation from the parents. What then does
the child do with all this anxiety? It is too pain-
ful to live with.
The child may transform the anxiety by one of
several mechanisms:
1. Perhaps the child avoids the anxiety com-
pletely by developing “good boy” character traits.
He may become overly kind to the younger sibling
whom he hates or overly admiring of the father
whose tyranny he cannot stand. He becomes
gentle, shows horror of violence and great solici-
tude for the supposed loved ones. He can’t stand
the sight of blood, or vomitus or feces. He may
become teacher’s pet. Under the calm exterior, the
anxiety will short circuit elsewhere — migraine, co-
litis, hypertension, polyuria, diarrhea.
2. Pehaps he does not disguise his reaction to
prohibitions completely, but may redirect them
from the parents to people of lesser importance
or to inanimate objects. He may kick the dog,
beat the cat, break his toys or pick a fight with
a smaller neighborhood child. He may spit at
strangers or throw rocks at passing cars. The
relief in family tension is offset by negative at-
titudes to people outside of the family circle. As
he grows he continues to behave in the pattern
established when very young. He may continue
to be destructive and cruel, to fight, to bully, to
lose his temper. He may later express hostility
to teachers, employers, wife, husband, child or
anyone with whom he feels he can get away
with it. Attitudes such as these are not reversible
by experience, because they are anachronistic.
They are not based on what the teachers, em-
ployers, really are like, but are based on the dis-
placed hostility from the authoritarian figures of
the nursery years. Such a pattern is responsible
for much of the strain, suspiciousness and intoler-
ance in the relationships between individuals and
nations. Sissy and bully are common patterns.
3. Perhaps the child eliminates anxiety by
projecting unacceptable feelings outward. They
cease to be felt as part of the child’s inner world
and are ascribed ro persons or things in the ex-
ternal world. One example was the concern of
a mother over her three-year-old who had de-
veloped a fear of having a bowel movement be-
cause she was terrified that the movements would
bite her. This caused frequent trips to the lava-
tory with no results. We worked this problem
out successfully, because we came to understand
that the child was feeling anxious because of
hostile feelings to the mother at that time and
in an attempt to deny these feelings and avoid
further anxiety, projected her desire to bite mother
out on to the bowel movement and substituted
herself as the object of the biting. Another ex-
ample is the mother who became upset because
her child became terrified of her and claimed that
mother was going to hurt her despite vigorous
repeated denials by the mother. The mother had
previously been the object of much affection
from the child. But mother had gone away on a
trip. This aroused separation anxiety. The sud-
den change in the child was an attempt by the
child to feel safe by projecting her resulting hos-
tility on to the mother. By putting the mother
in the role of aggressor and persecutor, she dis-
guised her desire to hurt mother. These similar
ideas and mechanisms are seen in the mentally
ill adults. They are seen in paranoid personali-
ties and in paranoid schizophrenics who have de-
lusions of persecution and auditory hallucinations
of a persecutory nature.
4. Perhaps the child avoids his anxiety by
turning his hostility in against himself. He be-
comes furious with himself and feels wicked and
shameful. The harmful consequences are mani-
fold and are expressed by a heightened inclina-
tion to develop organic illness, a tendency toward
frequent harmful accidents, and in the mental
sphere as manifestations of an overly strict con-
science, as in the depressive states.
A man reported a clear-cut example in his own
child. Each evening at the dinner table he had
brought verbal pressure on her because she was
not eating well and finally he had threatened
punitive action. The next evening just before
dinner time she made what was for her an un-
usually clumsy movement, fell over the dog
and hit her front teeth on a chair. Without cry-
ing she arose, sat down at the table and an-
nounced that she couldn’t eat because she had
hurt her teeth. Thus the child avoided anxiety
by turning her hostility inward against herself —
punishing the teeth with which she was desirous
of biting her father and at the same time con-
quering the situation through self-inflicted injury.
5. Perhaps the child's anxiety doesn’t develop,
(Continued on Page 1265)
1254
JMSMS-
Psychological Medicine
By John M. Dorsey, M.D.
Detroit, Michigan
Self Consciousness vs. Self Hypnosis
“A dangerous tendency is to such a limitation to
a speciality as will lead to withdrawal from the
common interests of the profession. A medical
specialist should not thereby, in his sentiments and
conduct, be any the less a physician ; the honor,
dignity, and usefulness of the profession, as a whole,
should be as sacred in his estimation as if he were
not a specialist. If the effect of specialism be other-
wise, alas for the medical profession of the future, as
regards the respect of others and the self-respect of
its members!”
Austin Flint1
HP HE FOLLOWING venture in medical realism
is one which I find helpful. At first reading,
one or another of its self-observations seems pretty
high-up, although none is, or can be, over my
head. May it awaken an able mind to the im-
portant task of a weightier and more attractive
presentation of medical psychology as being the
physician’s study and practice of medicine in his
mind. The more every physician lives himself
consciously the more he grows a wide awake view
that his whole “world” is all his, his world which
he grows within himself as a creation of his own
mind. Seeing that every meaning of health and
of illness has a psychologic existence, he develops
the insight that it is profitable for him to study
and practice himself as a psychologist in each
activity of medicine.
In his charming witty address “Careers In Medi-
cine,” Dr. William Bennett Bean, State Univer-
sity of Iowa, comments sagely upon “the splintered
subunits of medicine” now tending to alienate one
specialist from another, as well as physician from
layman. In his conclusion he says, “If he achieves
intellectual honesty, the physician is beholden to
no man, no political group, no industrial ma-
chine.”2
Dr. Austin Smith, Editor, Journal of the Amer-
ican Medical Association, counsels the men and
women “who cherish the letters ‘M.D.’,” upon the
importance of the “attitude of mind.” He asserts
From Wayne State University College of Medicine.
^ October, 1957
that, “the future can be made secure only when
truth, fearlessness, respect, and perseverance domi-
nate the actions” of every physician.3
This particular autobiographical sketch intends
as fearlessly as possible to extend my concept of
my full wakefulness to mean only waking up to
myself, so that I shall see all of my medicare as
self-care. Although the “individual variant” has
always represented the basic orientation of the doc-
tors of medicine, in the name of Aesculapius, why
is it that radical individualism, implicit in the self-
evident truths that every patient must restore him-
self to, and maintain, his health, has not been
sufficiently a serious medical position?
The person of hysterical character, who carica-
tures the self-development of the mature person,
depends for his “show” of living upon the illusion
that “somebody else” can be conscious for him.
Thus his system of psychology depends upon his
illusion of being “in the lime light,” “up stage,”
“front and center,” and so on, without “stage
fright.” “Stage fright,” or “buck fever,” is the
product of a self consciousness which is capable of
only a restricted range of selfhood. The “hysteri-
cal” one has no insight that all of his apparent
“between-ness” is really within-ness, or that his
apparent use of his language for “communication”
is really a soliloquizing. The hysterical character
closely precedes the mature character in point of
psychogenesis,' hence its creator may succeed in
taking himself for mature mental development.
The mature minded one, however, aware that all
consciousness is self-consciousness, that “grand
standing” is self-ignoration, readily renounces liv-
ing “for the gallery” in favor of the full joy of
living inherent in his calling his soul his own and
seeing his own soul in all of this living.
Any part of my living which I cannot consider
my own, and, therefore, which I must live as if
foreign to me — all such made unconscious force
in my life does not thereby become inactive. Far
from that, it functions on as an obstruction to my
harmonious existence. For instance, all of my
1255
PSYCHOLOGICAL MEDICINE— DORSEY
“not-I” living, which I cannot see as my very
own, enforces an obstructive psychology, necessi-
tates great disorder of my human economy, uses up
my energy for purposes of maintaining my self
deception, and makes me generally live myself as
if my individuality is not intact.*
When I am able to use this kind of self-insight
I am able to see that my ailing world is in constant
and urgent need of medically esteemed and regu-
lated psychological medicine. The opiate of self-
unconsciousness develops the most injurious of all
addictions. The health indication for my assessing
myself as a psychologist presents itself insistently
whenever I observe that every phase of my medical
work involves nothing but my use of my mind. All
of my “doing” is really my minding, or mental
doing, which is mostly unrecognized as such. It
is my living only which can “make.” My life
makes what I “do.”
As a physician of any division of medicine, my
only question about using psychological medicine is
whether I shall employ psychotherapy consciously,
that is, in a way in which I can voluntarily control
its dosage, or unconsciously, that is, in a way in
which I leave its dosage largely to my patient’s
decision, or to my other unconscious forces some-
times conveniently summed up in the word
“chance.”
The Study and Practice of Medicine in Myself
“The eyes of the dead are closed gently;
We also have to open gently the eyes of the living.”
Cocteau
The psychical work of delicately opening my
mind’s eye to be able to see that every “fact of my
immediate experience” is nothing at all except a
sign of my own living, to be able to discern that I
show “signs of life” by just such self growths as
my sensations and perceptions — this human exer-
tion may well be described as a process of “mak-
ing my self conscious,” so that I can escape fixing
my life and self esteem on some lower round of
activity. Nowhere can I suffer more from arrest
of development than in my self-awareness! No-
where can I enjoy more the momentum of progress
than in extending my conscious self-tolerance.
•Professor Walter H. Seegers, Chairman of Wayne’s
Department of Physiology and Pharmacology, pays due
attention to the physiological expressions of clear and
obstructive psychology in the training of his student in
integrative physiology.
What else can my external “observation” be other
than a creation of my introspection!**
I consider that the culmination of my personal,
including professional, development occurred when
I grew strength of mind sufficient to diagnose my-
self as a patient, a psychiatric patient, suffering
both from mental weakness and mental illness,
and thus became able to devote myself continu-
ously to the strengthening and healing of my mind.
Before I was unable to diagnose my way of living
myself as being ill, I was unable to consider treat-
ing myself well. As Dr. Alfred T. Schofield noted,
“Is it not extraordinary what value the public
attach to such a trivial matter as ‘cure’; and yet
how utterly incapable they seem of grasping the
importance of ‘diagnosis’? A sage M.D. sees his pro-
fessional role as a medical psychologist, a psycho-
logical physiologist. He observes that the removal
of psychology from any medical work leaves no-
thing, that a body without a mind is dead, that
life without mind is life without meaning. He will
find himself striving to see to it that every one
of his fellow physicians in organized (integrated)
medicine is alerted to the comprehensive meaning
of psychological medicine.
It is not hard to trace the origin of any physi-
cian’s uncertainty as to whether or not he is
entitled to regard himself as a professional medical
psychologist. From his earliest years he may have
enjoyed little or no opportunity for disciplining
himself to look to his mind as the source of his
vitality, or even to observe the living of his own
creaturehood in the workings of his mind. His
early schooling may not have served a means
for his observing his education, or learning, to be
nothing but an expression of his self-growth,
nothing but his very own mental development.
Even in his medical school living he may not
have trained his mind to observe the various data
of his several medical disciplines as being nothing
but psychological data, em :mly self- iscoveries con-
stituting the building r _ , s very own medical
character. Chances are may have kept himself
so 1 y “learning the facts” about what he called
Gregor Center is a small thirty-three bed general
hospit Uofcd by "y department faculty as a training
center my mt 'affstudent may observe in practice
the u '-apeutic force . medical concentration upon self-
reliance, self-h seif heal, self recovery, and self es-
teem which in' ies feeling grateful to one’s self for
the self power e .abling all such self control over one’s
health interests.
1256
TMSMS
PSYCHOLOGICAL MEDICINE— DORSEY
‘anatomy,’’ “physiology,” “chemistry,” “psychiat-
ry,” and so on, that he forgot the only truth of
the matter, namely, the one fact of his own devel-
opment as a medical student. If in one or another
oart of his curriculum, he did have the opportunity
:o study his school work as being entirely his own
>elf-growth, the rest of his medical school living
may have favored his mental dissociation to an
extent calling for, but not receiving, his giving
limself the one psychiatric treatment efficacious
rnder the circumstances, namely, restorative self-
:onsciousness. Every medical student’s life creates
and controls all that he lives. His medical school
lives in him, not he in his medical school. His life
:ontributes all of the possible meaning his profes-
;or or his textbook can have. His life-force is all
hat can possibly have any basic meaning to him,
i>r create any auxiliary meanings for him. His
vitality is his vis medicatrix naturae. His four years
tf living his medical school are best devoted to
hs finding out in a self-reliant way the true won-
ierfulness of himself as a human being, his mar-
velous powers as an individual, his unique vital
orce as a person. Can it be that his present oppor-
:unity to discover his potential strength by training
lis mind in the way of medical living can be im-
troved. As William James observed, for an em-
piricist every difference must make a difference.
Happily any kind of unconscious medical school
iving, requiring the medical student to work his
lead “off” instead of on, “the morbid pursuit of
lealth,” has been yielding place to the living of
;afe and sa.ne medical education recognizable as
:elf-activi The picture is a cheerful one. The
veteran practitioner has grown the insight that he
s a medical ps) hologist, in the unfailing school
if personal experience; the recent graduate has
nethodically trained himself as being a medical
isychologist. It is only the remaining practitioner
vho discovers o his surprise that his patient’s mind
s crying for a ^eKef fr- a specific kind of disre-
gard clearly definable as lf-hypnosis. Neverthe-
ess, this brother physician may sense his own
mpreparedness to : md, to care for, hints* . as
i medical psychologist. He cannot recognizr that
elf-consciousness is truly the healthy e: iting
■nlivening, yet tranquilizing f ce whi''E it is,
particularly if he has had the sort fie habi. of
nind which associates the use of consciousness
>nly with the production of pain and of self-
Dctober, 1957
unconsciousness only with the alleviation of pain.
He can help himself tremendously with the dis-
covery that self-consciousness is such a life neces-
sity that if a child cannot live it self-reliantly he
must have his “somebody else” live it for him (by
“attention seeking”), and that his patient, over-
whelmed by stress of suffering, invariably regresses
to this “childish” way of expressing his need to
live more of himself as worthy of consciousness
than just his complaints.
It is this latter physician particularly who may
appreciate finding in his own medical journal re-
curring considerations on psychological medicine.
He is an earnest sincere practitioner who, recog-
nizing ( 1 ) the extremity of his patient’s need for
mental support, and (2) the dearth of specialist
psychiatric helpfulness in his community, may turn
to some professional man, not a physician, as pos-
sibly able to supply psychological medicine. Al-
though I feel certain that no one who is not a
physician, and who knows what he is doing, would
find it possible to assume, or usurp, this life-and-
death kind of responsibility, or would consider
medical work for which he is untrained to be a
welcome opportunity for him, nevertheless it is
readily conceivable that many a well-intentioned
nonmedical man may get himself into this kind of
serious trouble without realizing its full extent.
Any and all prevailing illusional views of what
constitutes, or shall constitute, the legal practice
of medicine, may be seen as of health account, in
calling attention to the clear picture of the neces-
sity for the study, as well as the practice, of medi-
cine in one’s physician. I may be intolerant of
my brother physician’s disregard for his force of
mind as a tremendous medical force, but I will
not expect my brother layman to assume that pro-
fessional prerogative. Likewise, my brother physi-
cian will not expect his brother layman to practice
psychological medicine in himself before studying
it. That is, he will not expect such an accomplish-
ment once he recognizes its full implications. The
very idea of a layman undertaking “wild” medical
work must be one for every physician to renounce
kindly and firmly, realizing as he does the innum-
erable and inevitable life risks involved in his own
medical living. Is it not likely, however, that neg-
lect of the conscious use of the mental force by
the doctor of medicine necessarily encourages its
conscious use with medical intention by others?
1257
PSYCHOLOGICAL MEDICINE— DORSEY
The Legal Practice of Medicine
Nearly half a millennium B.C., Socrates came
back from army service to report to his Greek
countrymen that in one respect the barbarian
Thracians were in advance of Greek civilization:
They knew that the body could not be cured with-
out the mind. “This,’ he continued, “is the reason
why the cure of many diseases is unknown to the
physicians of Hellas, because they are ignorant of
the whole.’ It was Hippocrates, the Father of Medi-
cine, who said: “In order to cure the human body
it is necessary to have a knowledge of the whole of
things.” And Paracelsus wrote: “True medicine
only arises from the creative knowledge of the last
and deepest powers of the whole universe; only he
who grasps the innermost nature of man, can cure
him in earnest.” To us today this seems rather an
impossible demand.
Flanders Dunbar
Who should practice psychotherapy? How should
undergraduate medical training represent psy-
chiatry? Should this training even consider psy-
chiatric education as a separate discipline apart
from every other kind of medical training? May
not such a first view of psychiatry, as being isolable
from other medical interests, be an unrecognized
basis for a physician’s later dissociation of psycho-
therapy from “other” medical and surgical diag-
nosis and treatment? Ought not undergraduate
medical training be aimed at the development of
every physician as a psychotherapist, not at inter-
esting a few students in “going into psychiatry as
a specialty?” May not this recognition of the mind
as living itself in bodily ways, as giving the only
meaning to “body” that body can have, provide a
greatly needed insight for the health education
(preventive medicine) program? May not the
servant of the poor in health, the attending physi-
cian, attain his full therapeutic power in discover-
ing that healthy self-esteem is the product of
extending self-consciousness, quite as unhealthy
self-disesteem is the product of ignoring the great-
ness of one’s own being?
As a student of psychological medicine for some
thirty-two years, I see clearly its present develop-
ment, hence future achievement, to be centered
in the mind of every physician. May responsibility
for being a medical psychologist, a student and
practitioner of psychological medicine, be either
in the consciousness or on the conscience of each
and every medical practitioner.
The interest of every one of us is now properly
excited by a question frequently raised: What
shall constitute the legal practice of medicine?
Surely this is a question to which every medical
educator, each qualified doctor of the profession
1258
of medicine, wishes and intends to see the cleare ;
answer. It is also understandable that he viev |
this question as one which cannot be answere i
without the voice of the physician himself. As |.
physician he respects the law of his land as autho
itative in deciding what shall constitute the leg: i
practice of medicine. He knows from his ow ,
personal experience what it means to grow himse j
as a physician, licensed to practice his professioi
He has discovered many of the innumerable pe:
sonal risks involved in his pursuing his medic:
way of life. He has grown a healthy respect fc
such medical meanings as “symptom,” “con
plaint,” “protest,” “suffering,” “early signs of ser
ous disorder,” “growing pains.” His helpful sir
cere hopefulness and watchfulness are lived i
terms of potential awareness of serious trouble, c !
grievous health risk, of unhappiest living.
Every physician’s view as to what constitute
the legal practice of medicine contains the keene:
appreciation of the nature of the privileges an
responsibilities inherent in his professional work
He regards his medical living not only as a sourc
of his livelihood but also as the source of his lii
itself, as devoted to cherishing and furthering th
liberty and happiness inherent in healthy huma
development. He cannot abdicate his physiciar
ship to anyone of his fellowmen who is not
physician, on account of the simple fact that h
has personally grown his own insight as to wht
constitutes the privilege and responsibility spelle !
out in the words “The Legal Practice Of Med
cine.” He sees that violation of “medical practice
might be attempted but cannot be perpetratec
any more than the passing of counterfeit mone
can succeed in making it legal tender. The un
que specificity implicit in the study and practice t
myself in medicine is factual and inviolable insofs |
as my qualifications meet all of the professiona
including legal, requirements involved. I ca
conceive of no worse predicament for anyone tha
that of taking upon himself the responsibility fc
being a physician without having the proper med
cal and legal qualifications for it.
It is to the credit of every American that ever
citizen’s demand for proper health care has bee
steadily on the increase. As respect for the dignit
of individuality grows in every citizen, certain c
his rightful needs are bound to be sensed by hii
as properly insistent upon attention. One of thes
is his right to educate himself, another is his righ
to secure his health, prevent illness and acciden
JMSM
PSYCHOLOGICAL MEDICINE— DORSEY
and recover himself from any kind of disorder.
The American physician gladly sees his fellowman
exercise this right, recognizing it as basic for his
pursuit of life, liberty and happiness. This same
physician recognizes the need for many more
trained medical personnel, just as he is painfully
aware of the critical risks involved in the licensing
af inadequately trained medical workers, not to
mention the actual harm involved if a nonmedi-
:ally trained one independently assumes medical
-esponsibilities.
Health benefit, the opportunity for wholesome
self-help, being the first concern in the mind of
every American citizen, it is only prudent for him
:o safeguard by law what shall constitute the prac-
ice of medicine. Every physician recognizes that
tis fellow citizen is 'entirely free to help himself
n every matter pertaining to his health. How he
hall help himself is also a matter of his free choice,
vvery physician realizes that it is up to every
sitizen to treat himself well, in a way which will
lot interfere with his fellow citizen’s treating him-
elf well. Every doctor of medicine, in studying
md practicing himself in his own chosen profes-
ion, cherishes his fellow citizen’s right to take care
if himself as best he can. Caveat emptor may
ippear to be a weak warning call which seems to
ibandon the buyer in an open market, but that
5 only a seeming. It is in truth a proper watchcry
'f the deeply concerned medical educator. Con-
cious freedom of individuality, including his
lealth interests, is an indispensable basis for every
me’s progress in health and strength.
In a comprehensive sense, a person treats him-
slf in numerous ways which he considers being
good for his health.” For instance, all of his
3rmal education may be conceived as education
1 3 health, and all of his religious living may be
imilarly considered. His “job” may be seen as
ccupational therapy. Even his climate has this
1 ealth value for him, and so on. In appreciating
ill of the various ways in which his fellow man
an help himself to strength and health, the physi-
ian has never in any way attempted to mono-
i olize health helpfulness. His medical profession
as succeeded on account of the fact that full
ispect for the total human individual is the basis
>r all of its work. However, as a layman, and as
physician, it is his civic duty to uphold what
! e regards as opening, and renounce what he
■gards as impeding, the way of health.
All of Medicine is Psychological Medicine
“What unsatisfactory cases these are! This clever
charming, and widely known lady will some day
disgrace us all by being juggled out of her maladies
by some bold quack who by mere force of assertion
will give her the will to bear, or forget, or suppress
all the turbulences of her nervous system.”
Sir James Paget, 1866
In this brief article it is possible to report the
basic meaning of psychological medicine. In the
first place this kind of self-discipline involves the
physician’s systematically aiming at viewing his
patient as a part of his own living. In order to
treat my patient as myself I have to be able to
be conscious of a sense of my identity, a sense
of living myself, in all that would be traditionally
known as “the patient’s living.” For me, observing
my patient is a matter of growing my perceptions
and my sensations which I personify as my patient,
a matter of regarding a series of perceptions and
sensations of mine as “my patient.” I do not, as
the saying goes, “put myself in my patient’s
shoes,” or have my patient “put himself in my
shoes.” Quite the contrary my patient is to be
cherished in terms of all of his (my “his”) in-
dividuality. For instance, just as I see my patient
as a living part of myself which I call my patient,
similarly I see my patient as living a part of him-
self which he calls his own physician.
In my study and practice of psychiatry in my-
self I renounce the pleasing view that I can help
my patient, but I claim the more gratifying view
that my patient is able to help himself. Thereby,
I observe in action the vitalities of all healing, or
virtue, in the simple heart of selfhood. My pa-
tient’s realization of his ability to help himself is
an invigorating one, contributing to his proper
sense of self-esteem. By treating my patient as a
part of myself I insure humaneness, kindness, in
my every medical procedure. Psychological medi-
cine is a modification of the Golden Rule. I do
unto myself as I would have my patient do unto
his self. I remain aware that I am self-contained
in my living of my patient, renouncing every
temptation to live myself as if I could be “out of
my mind” and getting at a life other than my own.
Any and every way in which I live myself is a
development of my individuality, a growing of my
personality, which has any and every meaning for
me only in so far as that meaning exists in my
mind. What does my nourishment, or my medi-
cation, or my operation, or my patient mean?,
CTOBER, 1957
1259
PSYCHOLOGICAL MEDICINE— DORSEY
is the same as asking, how am I living each of
those meanings? Awareness, or lack of awareness,
changes the meaning itself no more than does my
liking or disliking it. However, awareness does
reveal each meaning as my own to care for. “I
hate to admit it but it’s true,” is a viewpoint as-
sociated with all psychological “growing pains.”
All Data Are Self Data
It has been asserted, by one who was laboring
under mental derangement, that the only difference
between the sane and the insane, is, that the former
conceal their thoughts, while the latter give them
utterance. This distinction is far less erroneous
than might generally be supposed, and is not desti-
tute of analogy to the remark of Talleyrand, that
“language was invented for the purpose of conceal-
ing thought.”
Pliny Earle*
Depending entirely as it does upon my human
system for all of its meaning, my system of
pedagogy may best be described as psychagogy,
as made up entirely of selfness. The term psychic,
or mental, is not a term parallel to “physics,” or
“material,” but rather is a meaning which sub-
sumes all meaning.
It is well to observe that the statement, “I
am my only reality,” is not simply a restatement
of a dogma of philosophy known as “psychic
monism.” My consciousness of my oneness, indi-
viduality, is not a product of theorizing, hypoth-
esizing, philosophizing, but of psychologizing, of
using self-observation. My appreciation of myself
as an individual is not based upon judgment or
reasoning in any respect whatsoever. “I see,”
“I sense,” “I perceive,” “I feel,” “I observe,” —
each of these expressions does describe a basis
for my appreciation, or measurement, of myself as
an indivisible whole person originating all of
my human being.
As an individual I search myself. What does my
human being consist of? The next view I see is
a clarifying one. An individual can consist only
of individuality. A self can consist only of self-
ness, quite as a tree can consist only of tree-ness.
Everywhere I view myself, I find my property of
individuality. As I grow my perception of my
fellowman, my fellowman is seen as an individual,
absolutely autonomous, radically unique. Thus,
everywhere I turn I can find only particular self-
ness, such selfness characterized by the property
of oneness. Seeing myself clearly as an individual
*Physician to the Bloomingdale Asylum for the Insane,
New York City. American Journal of Insanity , January,
1845, Article I. The Poetry of Insanity.
necessitates my seeing every individuation of my-
self as living this property of wholeness which is
true of my complete individuality.
Again, it is helpful to realize that all apparent
“between-ness” can only really be “within-ness.”
Loving my everyone and my everything is only
living to the full, my natural self-love. My living
can be health education to the extent that I am
capable of observing it as my own, hence express-
ing my spirited, soulful, humane meaning. I can-
not remind myself too often of my selfish interest
in every “view of life,” for it is my living. Being
extreme in this direction leads only to being ex-
tremely sane. Sensing intensely the absolute
uniqueness of my unity or selfhood provides me
with true appreciation of every element of my
world which lives within me.
Sometimes one finds expressed the idea, “Medi-
cine has two categories of health activity, ( 1 )
purely psychological, having to do with theory, and
(2) purely ‘physical’ (nonpsychological) , having
to do with practice.” The former medical living
is then implied to contain all of the humanics,
the latter all of the mechanics, of medical living.
It is well to see any such illusion as this for what
it is, namely an illusion, so that it can be dispelled,
renounced as a dim view which does not recognize
every aspect of the so-called “mechanics” of medi-
cine for its true psychological significance. For
instance, as a surgeon performing an operation,
I am only applying my psychological insights in
the form of skilled techniques.4
All of my human experience may be accurately
defined as psychological only, insofar as it has
any meaning for me at all. “Meaning” is always
a mental element, a psychological entity. For in-
stance the meaning of any word I use points to
a living existent of my mind. As Bentham noted,
“Lamentable have been the confusion and dark-
ness produced by taking the names of fictitious for
the names of real entities.” The history of my
language reveals my mental development. What
has no meaning for me is incomprehensible to me.
My life produces all that I make conscious, my
consciousness does not produce my life.
The one kind of training or discipline possible
is self-development. The best and most search-
ing self-activity is called “learning.” It is as-
sociated with the insight that meaning of any
kind can be nothing but each one’s self-felt ex-
perience. It is possible for me to live most of
my life in the shallows of illusional “not-self,”
1260
TMSM5
PSYCHOLOGICAL MEDICINE— DORSEY
without making the all important philological dis-
overy that every word of every lagnuage of any
neaning to me is a word which spells out some-
hing about me. I have no civilization or edu-
!:ation whatsoever except that which is constituted
)f my own life. And my concentration upon this
joint of view, that my whole world is nothing but
ny personal being, is indispensable for my main-
lining my sanity.
What is “on my mind” is a part of my mind,
and cannot exist for me apart from my mind. My
truth is found in my life process, there being
nowhere else for me. In this same sense, all of
my medicine must be observable as psychological
medicine. This realistic view of objective truth
(of seeing my identity in all of my living) spares
me such a sorry scene as, “The psychiatrist is off
his medical base, and every other doctor of medi-
cine is off his psychological base.” In 1905, Freud
described psychotherapy as the treatment of every
kind of health disorder with psychological means.5
He described how the perceptual thinking of the
scientifically schooled physician of his day spe-
cifically trained him in the use of sensations and
perceptions, trained him as a means not as an
end. This training, however, did not include the
development of the medical student’s apprecia-
tion of his sensations and perceptions as being
creations of his own mind, as being his own psy-
chological (self) data. To a varying extent the
same kind of “impersonal” medical training exists
to this day. However, modern medicine is al-
ready on the road to the discipline of self study
with self-insight. The one mental identity under-
lying all body, and all other “external world,”
meanings, is becoming more and more the focus
of attention of the student who is increasing his
appreciation of his body as a mental instrument,
and his “external world” as an internal existence
of his own. As my Osier’s beloved Ralph Waldo
Emerson observed, the world is nothing, the
man’s world is all! Ricardo noted somewhat the
same view, “The pursuit of individual advantage
is admirably connected with the universal good of
the whole.”
For me to recognize every statement on psycho-
logical medicine as a clearly evident self-observa-
tion, it is essential that such deep medical insight
be readily developed by me. Quite as the religious
educator has discovered that everyone must save
his own soul, as a physician, I may discover that
everyone is entirely responsible for the preserva-
tion of his own health. The individual seeking
religious or medical helpfulness finds it in the
purest form in his religious or medical counselor
who upholds this supreme degree of reverence for
his own individuality. It is as though the radical
religious, or medical, individualist is endowed
with charismatic virtue.
The Comprehensive Medical View of Human
Individuality
“We must all be born again atom by atom from
hour to hour, or perish all at once beyond repair.”
Chief Justice Holmes
In everything having to do with health it is
essential that the over-all significance of self-esteem
be thoroughly appreciated. The full realization
of the health significance of self-esteem makes
understandable the need for the most radical re-
spect for the dignity of the individual, and ac-
counts for the healing force concentrated in the
physician’s keen awareness of the inviolability of
his own, hence his patient’s, individuality. This
extreme degree of self-consciousness, extreme san-
ity, is of greatest medical significance. It is im-
plicit in every physician’s most complete satis-
faction in having his patient consciously help him-
self, admittedly cure himself. Only the human in-
dividual can strengthen or heal himself. Every
kind of illness or accident threatens his proper
wholesome feeling of self-esteem. His ability to
restore himself is a power which he needs to
see as his own in order that his full sense of
self-esteem, healthy-mindedness, may be retained.
Being a medical educator, in my profession I
require a psychology which will work peacefully
for me, as I “see to it” that each one of my medi-
cal students reveres the dignity of his own de-
veloping medical character. I have attempted to
record the psychological foundation of my peda-
gogical system as being nothing but the living of
myself, and thereby growing my medical student
instructor and curricular data, consciously as self-
experiences of my very own. All of this, my medi-
cal Video, I write as an authority, but only with
regard to my own genesis as a physician. Soren
Kierkegaard, a self-conscious existent of one hun-
dred years ago, recorded that his own individuality
“by relating itself to its own self and by willing
to be itself is grounded transparently in the Power
which constituted it,” adding “this is the definition
of faith.”
October, 1957
1261
PSYCHOLOGICAL MEDICINE— DORSEY
Any current doctrines of “medical education”
which try to personify abstraction apparently by
distraction from person, or make way for the
studies by obliterating the student, are necessari-
ly negative to the requirements and rights of hu-
man individuality. I am entirely a self, not an
aggregate of self and not-self! Little wonder that
the natural feeling of certainty has to be “sci-
entifically” validated only by multiple verifications.
Every aggregate is an individual one, but has in-
dividuality, or self identity, in no other sense than
as an aggregate! Physiology not studied as psycho-
logical physiology must be studied as an aggregate
of life processes. Instead of being viewed as
naturally due to one organic wholeness, any fitness
of its parts must be appraised as pure coincidence.
The ontology of an aggregate is a matter of
peripheral collection of each of its separate parts,
not a growth of one being from within out. Every
“part” of a human being has its entire life and
selfish meaning by virtue of its being a part of a
whole human being, and not an independent
isolable unit of an aggregate. Each man speaks
selfishly for all of himself, even though he must
show the extent of his self-unconsciousness in the
act. Every organ of his body utters the degree of
self-consciousness with which he lives himself
(Organsprache) . Continuing research in psycho-
logical physiology, human physiology, made pos-
sible by insights derivable from self-consciousness,
may confidently be expected to discover the truths
of human physiology and of the proper care of
the independent self-acting human individual.*
How I have grown higher and higher stages of
mind and yet cherished for its indispensability to
my healthy living each preceding deeper mental
stage, needs no further elucidation than that I
helped all of myself in that way. I continue my
aim to live myself consciously for I find it too
unhealthy to be continually aiming at self-ignora-
tion. When I overwhelm myself with the im-
portance of this or that, I can restore my homeo-
stasis (mental equilibrium) by realizing that all
of the importance of my “this” or “that” is only
*Dr. Thomas J. Heldt, for decades as the able director
of the division of neuropsychiatry of The Henry Ford
Hospital, created a splendid record of unifying psychi-
atric with general hospital living. Every general hos-
pital has a wonderful development as it adds a psychi-
atric service. All honor to Dr. Heldt! Dr. Albert M.
Barrett was the first in the United States to have a
psychiatric service in association with a University hos-
pital.
my own importance which is showing. How right
the view, “I’m alive and that’s what counts!”
The substantiality of my appreciating myself as
a self-conscious one increases every time I live
(create) the view of being my own “this” or
“that” or “everything.” The force of mind made
up of my apperceptions pertaining to my con-
sciousness of the allness of my individuality is
most life-affirming. Realizing that I must grow
myself in the direction of my devotion, I am de-
voting as much of my living as possible towards
the creation of the self-conscious habit of mind, by
repeated acts of seeing and owning my own soul
in my swiftly growing sensations and perceptions.
My “old” psychology consisted of my traditional
view of being an all-important mite in a mighty
universe. I felt important even with that dis-
couraging self estimate, but I did have no end
of trouble “justifying” the sense of importance
I had. With the extension of my consciousness
to include more of my individuality, the very
“external world” views with which I formerly
had to dwarf my “self-realization” served to re-
veal my true self size. At last, the high sounding
magnanimities of the consciously great ones began
to make sense. Where else could the kingdom
of God be but within me? How truly could I
be true to “anyone else” except by being true
to myself? How else can I love my neighbor ex-
cept as myself? Why not love my enemies, my
very own creations? — and so on. Gradually, I
began to see clearly that formerly I used my imag-
ination wildly to deceive myself that my external
world was not mine at all, not my self-contained
internality at all. As I revised my self-estimate to
correspond with my growth of insight, of self-
consciousness, I was appalled with the degree my
verbalization of myself alone appeared to stand
for a disease of language, a delirium of being able
to live “out of my mind,” “beside myself,” “of!
my base” of selfhood, and the like. The signifi-
cance of naming his things and his others for the
little child, suddenly clarified itself as being of
greatest significance for his sanity. How essential
that every name be a synonym for his own name,
and be appreciated as such!
As I calmed down, I realized that I had to go
“through the mill” in order to get through it, and
that everyone of my fellow creatures similarily
must help, and is helping, himself, all that he can,
to progress. “Meddling” grew to be a term of
1262
JMSMS
PSYCHOLOGICAL MEDICINE— DORSEY
j peat meaning for me, designating my getting in
I ny own way, defeating my purpose with good in-
:entions unsupported by good insight. A par-
icularly apt story, narrated by my Moncure D.
Honway, helped me to stay out of trouble.
An American missionary on a savage island made
one convert but refused to baptize him, for he had
four wives. But one day the convert came and said
he had but one wife. “What has become of the
others?” asked the missionary. “I ate them,” said
the convert.
In his spirited challenging book, “The Force of
Mind,” published by Funk and Wagnalls Com-
pany, 1902, Alfred T. Schofield, M.D., M.R.C.S.,
drew a curious analogy upon the prevailing neg-
lect of psychotherapy in the treatment of the
mind and the rigid British military tactician’s
refusal to adapt his warfare to the methods and
terrain of his Boer enemy, counselling that the un-
successful physician study the methods of the suc-
cessful “quack.” Perhaps the analogy is not curi-
ous, after all, if one considers the degree to which
fitness of health has carried the significance of
fitness for warfare. Today’s physician is too often
pictured as a man of war fighting disease, rather
than as a man of peace kindly studying his human
nature in order to become able to enjoy to the
full his harmonious existence. Neither peace, nor
war, nor anything else, can exist in “between-
ness,” for instance, between one man and an-
other. Peace, or war, is to be found only within
each human being. Between-ness is no man’s land ;
within-ness is the nature of all that exists. In
growing out of his quackery, did my historic physi-
cian try to throw the baby, “Imagination,” out
with the bathwater of “exact perceptions”? Does
it not seem sometimes as if reference to “psychic”
is not considered to be sufficiently “physic” even
though it is the psychic alone which obtains?
When I say “practical” I often mean “easy.” In
reading a text book of medicine today, I am
profoundly moved by its impersonal tone, by
having to read humaneness into it. That which
is overlooked in study is apt to be ignored in
practice, and so it is too often, is it not? Is it
not easy to attend raptly even to his medical his-
tory and be inattentive to my fellow man? Can
human being ever be taken for granted in care-
ful medical work?*
The only force which can vitalize the “scientific
data of medicine” is one which vivifies what mean-
ing each of these facts may thus have. “Mean-
ing” is entirely and clearly a mental force. If
one can imagine even dead impersonal data as
being vital with meaning, how much more quick
with meaning may live personal data be imagined
to be. Scientific flashes of imagination are, in
every instance, deeply personal experiences hav-
ing to do with consciously unifying meaning
which was not consciously unified before. The
human being is not a chaos of aggregated facts;
gradually waking up to that fact has been a proc-
ess of training myself as a medical psychologist.
Everyone of my organs derives any and all of its
meaning, its vitality, from one source only, from
the truth that it is a part of the whole of my
living self. To make something out of it other-
wise is impossible. It reveals the meaning of me
only in the sense that it is a part of me, and in
no other way. This fact is useful in helping me
to renounce the mad search for research upon
my mind through the study of “something other
than my mind.”
Psychiatric undergraduate training for my
Wayne medical student is presented as a means for
his disciplining himself in the medical way of
life, as a vital experience rather than as an in-
tellectual lesson to be memorized. This training
aims at every student’s preparing himself to see
that he necessarily applies psychological medicine
in his medical practice of every kind.
The pressure and the rapidity with which each
student must develop his medical character is
analogous to the requirements of the force and
accelerated mental growth which everyone under-
goes during adolescent years. Thus, the four
years of his undergraduate medical school living
may be seen helpfully as his enforcing within
himself a professional adolescence. The student
builds the foundation of his medical character
within this specified period of time, and needs the
kindest care of himself during this formative
period.
*Training myself in exact observation is a total im-
possibility except insofar as I am able to be aware
that all of my observation is self-observation, quite as
all of my consciousness is self-consciousness. I cannot
keep my mind out of its own activity. And as far as
interpreting my mind by “non-mental” means is con-
cerned, the statement of my Herbert Spencer about
that is well worded, “There is not the remotest possi-
bility of so interpreting it.” Anything which I construct
with the use of my hands can hardly suffice to account
for the existence of my hands. A body without a mind
obviously cannot account for mind; a mental body ac-
counting for mind is nothing but mind accounting it-
self.
October, 1957
1263
PSYCHOLOGICAL MEDICINE— DORSEY
Extended and enlightened self-care cultivates
best American citizenship. It holds the greatest
diagnostic and therapeutic promise for the under-
graduate medic, and it is most essential that this
promise be brought to performance. It is vain
for any student to usurp the name “physician”
without devotion to his own health. By increasing
his own power only can the student increase his
ability to live his patient well. Conversely, anyone,
even a physician, who is careless of his own health
cannot be convincing as a source of health con-
cern for his patient. This empowering kind of
self-sight is a personal health requirement for
the hard-working physician who may be killing
himself by trying to cure “somebody else.”
Deliberately and systematically striving for prog-
ress in the development of his own personal
strength and health during his own preparation of
himself to become a physician provides every un-
dergraduate with the possibility of identifying
himself as having a developing mind, as being
and having a human life, which needs kind care.
During his medical school years every student,
the creator and creature of his own power, can
benefit himself most from providing himself with
the most considerate attention to his own nature
and needs. His arousing himself from any leth-
argy into which he has fallen due to the mental
habit of self-ignoration, his seeing what goes into
the “making of the doctor,” will enable him to
discover what must go into the “making of the
well man.”
Hardness of medical character is possible only
where there is repudiation of the truth that one’s
“otherness” living is one’s very own. Such hard-
ness does not proceed from carelessness of inflict-
ing pain but from a want of self-consciousness, by
means of which awareness of pain is conferred.
It is a great awakening for the Imedical student
when he suddenly sees the innumerable ways in
which he can hurt himself without being aware
of it; and the innumerable ways in which his
organism betrays these self-hurts in organ break-
downs, visceral failures (skin trouble, kidney
trouble, heart failure, and other disorders).
The contribution which medical psychology can
make toward the more adequate understanding
of health, its preservation, and the means of pre-
venting its arrest, reflects the development of hu-
man insight, of human self-consciousness, within the
past sixty years. Thus I see and report the sanity-
preserving role of self-consciousness in all self-care ji
and self-development. The integration of the prin- e
ciple of inviolable integrity of every human being i
and the matrix of the medical curriculum, seems
to me to provide excellent opportunity for the 1
growth of “comprehensive medicine.” This health- l
producing integration involves the utilization of
what properly revered human individuality has
discovered about the emotional, and innumerably
repressed, aspects of human complaints. The (
desirable goal of furthering the physician’s com-
prehensive self-sight can be attained as it achieves |
more extensive living by every member of the i
medical discipline. The progress of this kind of |
development will depend largely upon the readi- 1
ness of each member of my psychiatric faculty |
to live what he sincerely claims to be most life ;
affirmingly.
Discoveries highlighting the healing force de- ;
rived from appreciating the dignity of the whole j
individual man make it possible to offer scien-
tific principles, as a helpful continuation of in-
tuition, in heeding the health requirement of full-
measured evaluation of the meaning of entire 1
individual human being. Every bit of this ad-
vancement is in the direction of the goal of
“comprehensive medicine.”*
Mental Health and Conscious Self Government
“In order that man may be persuaded to put
forth the intense effort required to change chaos
into order, he must feel that he has the necessary
stature for the asignment, at least the potentialities.
... It may appear absurd to philosophers, but in
our age of specialization it is not only man’s con-
cept of matter which must come from science, but
also man’s concept of himself. ... At the stage
of specialization of our knowledge, to determine
wtiat is specifically human in man requires a veri-
table cracking of the concept of man. This crack-
ing, in its turn, requires a concentrated effort of
specialists; as much as was required for the atomic
bomb. ... If the concept is cracked, the release
of spiritual energy will be voluminous enough to
make physical nuclear energy behave. It might be
powerful enough to light the lamps of peace and
keep them burning.”
Ana Maria O’Neill
The method of enlightened medical progress, as
does that of true democratic progress, lies I sub-
mit, in each citizen’s conscious development of
his wonderful ability to see his world as his own.
and care for his world as himself. To the extent
*Dr. Raymond W. Waggoner, professor and chair-
man of the department of psychiatry at the University
of Michigan, is outstanding for the excellent way in
which he identifies psychiatry with medicine.
1264
TMSMS
PSYCHOLOGICAL MEDICINE— DORSEY
at a citizen neglects his world, he neglects his
:alth. Self-government, conscious self-culture, is
e mind healing and strengthening way of life,
s Jefferson noted, “The laws and institutions
ust go hand in hand with the progress of the
jman mind.” The Declaration of Independence
self is a sublime expression of healthy psychology,
treatise upon the nature and needs of the human
ind. Wherever the dignity of individual man is
msciously lived, liberty, equality, health, and
lorality find expression as the joy of being human,
he Wayne medical student grows this kind of in-
ght as an integral part of his study of psycho-
igical medicine. He discovers for himself the con-
sction between his health potentiality and his
onderful government, the harmony of conscious
■If-care (self-government) and the physiological
:quirements of human life. As a precious by-
roduct he sees for himself the health-defeating
nplications in “state” medicine, quite as he has
[ways been able to see the analogous kind of
mtradiction implicit in “state” religion.
Conscious self-government has already been in-
oduced into mental hospital living as a success-
il means of instituting therapeutic, instead of just
ustodial, patient care.6 A conscious effort is
istained by each member of the department of
psychiatry to uphold this health significance of
conscious self-government. Dr. Elmer Hess, im-
mediate past president of the American Medical
Association, and honored as “the medical world's
mouthpiece,” made a discovery early in his prac-
tice: “The essence of self-interest is to behave in
an unselfish manner.” The wholesomely self-con-
scious physician does not practice his license with-
out his self, any more than he practices his medi-
cine without his license.
A precious wonder of my wonderful existence
is the truly heroic life of every doctor of medicine,
leading the hazardous career of a servant of the
poor in health, a courageous explorer of the actual
life of meaning, and an indefatigable researcher
upon the most essential meaning of life, Health.
References
1. The Pharos, 20(3) : 11-12 (May) 1957.
2. The Pharos, 20(3): 15 (May) 1957.
3. The Pharos, 20(3): 21 (May) 1957.
4. Dorsey, John M.: Surgical psychology. J. Michi-
gan M. Soc., 53:625-628 (June) 1954.
5. Psychische Behandlung. Gesammelte Werke, 5:289,
1942. London: Imago Publishing Company, Ltd.
6. Howard, Alvin R., and Tomsovic, Milan: Survey
of Patient Government. Information Bulletin, Medi-
cine and Surgery, Psychiatry and Neurology Serv-
ice, Veterans Administration, Washington, D. C.,
September 21, 1956.
CLINICAL MANIFESTATIONS OF ANXIETY
(Continued from Page 1254)
r is completely denied. Acting out of envy or
:alousy, intolerance or suspiciousness may be seen.
)r he may outgrow such manifestations and
imply be the most disagreeable person in the
oom. Or, as with Joseph and his brethren, at-
;mpt to commit murder.
The various mechanisms which I have touched
n: reaction formation, displacement, denial,
rejection, repression, conversion, are the
lost important ones involved in the psychic de-
elopment. They can be found in the normal, the
.eurotic, the psychotic. They are reactions to
nxiety. Through this, I have attempted to show
psychologic theory of mental health and mental
llness which conceives of these entities as being
he outcome of anxiety-motivated reactions to
isychologic threats presented by the person’s own
mpulses, which his early experience led him to
reat as dangers.
Pure anxiety, mild or great, normal or patho-
logic, remains a frequent occurrence throughout
life. Until it gives way to the more expanded
emotions or until the stimulus for it is removed, it
is one of the most painful and intolerable forms
of displeasure. Most anxiety reactions are nor-
mal everyday occurrences and are relieved spon-
taneously and individually; a smaller number call
for assistance by friends, physicians, clergy, or
others who help people in such situations.
Anxiety is the most frequent single symptom in
all medicine. The anxiety signal becomes the
most powerful motivation force in human life,
the power which organizes the character, the de-
fenses, the neuroses. It behooves physicians to
be alert to the presence of this symptom and to
become familiar with methods not only of allevi-
ating the symptom but also of understanding
and removing the causes of the symptom.
Ictober, 1957
1265
A New Approach to the Clinical Management
and Treatment of Behavior Problems
Progress Report
By John T. Ferguson, M.D.
Traverse City, Michigan
T7 OUR YEARS ago, fifty-seven patients from
the women’s halls and cottages left our hos-
pital. Last year the number was 199. The facts
behind these figures — the facts behind this 350
per cent improvement in chronic patient release
is the story of progress in the management and
treatment of abnormal behavior.
I want to tell that story. I want to tell where
we stand in the fight to eradicate mental illness — ■
of the progress being made in treatment of ab-
normal behavior — and the part you can play
in this effort.
In research every phase of behavior is being
studied — every phase from the behavior of a
single cell to the behavior of whole communities.
Every facet of psychopharmacology and physiology
is being studied and re-evaluated. The search for
new enzyme systems, new toxins and new chemi-
cals within the body has increased. Today re-
search is an all-crut effort, and from all of this
work something of value will undoubtedly ap-
pear. However, to date, the most useful and the
most practical information has come from the
clinical observations by private practitioners and
state hospital clinicians — from men interested in
their patients as people.
In most cases this honest, straight-forward type
of clinical research has met with much opposition
from the pure scientists and those individuals that
believe you can measure and weigh a man’s soul
as you would a chemical. It has met this op-
position and it will defeat it. This is true be-
cause in most cases we know neither the process
by which these new drugs exert their peculiar
effect upon human behavior nor the biochemical
abnormalities associated with the behaviors we
are treating. Consequently, this makes the purely
scientific evaluation of these new drugs, on a
strict comparison of percentages of diagnoses
Presented at the Michigan Clinical Institute, Detroit,
Michigan, March, 1957.
From Traverse City State Hospital.
helped, almost analgous to what might have
happened had the antibiotics been evaluated simi-
larly in a group of febrile diseases many years
before the development of the science of bac-
teriology.
Two months ago in Washington I participated
in a government-sponsored “Working Conference
on the Status and Improvement of Clinical Drug
Evaluation Reports.” It was not a publicized meet-
ing, but a small conference of thirty-five Canadian
and American doctors actively engaged in clinical
research with the new drugs. At that meeting the
committee members agreed that the new neuro-
pharmacologic drugs are not specific for any par-
ticular type of mental illness, but are primarily
for the management of abnormal behavior. This
group also agreed that the dose should be tailored
to the patient and that the best results were ob-
tained when the patient was given rehabilitative
help. In short, for the first time, this group
agreed that the Art of Medicine was not lost —
but was a vital part of a successful therapeutic
program.
Consequently, I’m glad I participated in that
meeting because it reaffirmed within me my belief
that the answer to mental illness lies with the
doctors in the front line. Doctors just like you
and me — doctors that see their patients as sick
humans, and not diseases.
I believe this because the fate of the menta’
patient is usually in the hands of the first physiciar
who sees the patient. The ability of this doctoi
to control or ameliorate the abnormal behavioi
that brings the patient to his attention is often th<
difference between the patient’s ability to remaii
at home and the need for commitment.
A few months ago I received a letter from ;
doctor in Charlevoix, in which he described ;
confused and disoriented eighty-two-year-old worn
an who was nude, incontinent and a terrific man
agement problem for her relatives. He sent th
letter because neither he nor the relatives wante>
1266
JMSM
BEHAVIOR PROBLEMS— FERGUSON
i commit her if it could be prevented, and he
ondered if we could help. I sent him a supply
f drugs and a copy of our paper that appeared
i the September, 1956, Journal of the Michi-
\n State Medical Society. Three weeks later
received another letter from him thanking me
>r my help and describing the improvement the
oman had made — above all, she did not need to
e committed.
This story is but one of several that we have on
le — and I take my hat off to all of these pioneer-
lg doctors, because they indicate that you — the
octors in the front line — hold the keys that will
nlock the mysteries surrounding mental illness.
rou hold the answers for decreasing our state hos-
ital population and the sociomedical problems
ssociated with hospitalization. It is my belief that
y the early detection and treatment of the ab-
ormal behavior that first brings the patient to
our attention, you can prevent many possible com-
litments from materializing.
This may seem like a tremendous challenge, but
; isn’t, because the management of a diabetic
atient or a cardiac patient requires much more
ime and effort than does the management of a
ase of abnormal behavior. However, in each case
be principle is the same, because with all three
ou are seeking to establish a balance compatible
fith the individual and his environment.
The better understanding of this balance tech-
ique in treating abnormal behavior is a good
xample of progress through failure, because this
ew approach was formulated as the result of
dverse findings with many of the new drugs,
/[any of us lost sight of the basic balances of the
ody and treated only one component of behavior.
Vith the tranquilizers we saw depression when
re removed overactivity — with the analeptics we
aw overactivity when we removed the depression,
lowever, we also observed that in most patients,
egardless of the outward behavior manifestation,
here was an element of the opposite behavior
resent and that the proper combination of a drug
or overactivity and a drug for underactivity would
iroduce better results than either drug when
sed separately. I cannot give you the number
f different combinations we have tried in our
esearch, but I can tell you from this work that
11 types of abnormal behavior can be changed
r controlled.
I have refrained from saying that the new drugs
)ctober, 1957
cure abnormal behavior because they don’t cure
—they merely make the patient more accessible
for other therapeutic measures that, previous to
administration of the new drugs, would have been
useless. That is one point that is not fully un-
derstood. The drugs open the treatment door
for the patient — how far he comes back into the
world of reality depends upon how much help
and encouragement he can be given.
Another point that is not fully understood is
the need for individualization of dosage. This is
true whether you are using small doses or large
— and unless it is done you will run into side re-
actions and difficulty. To continue unaltered the
same dose of a tranquilizer or an analeptic that
produces clinical change in a patient’s behavior
will only lead to trouble.
In this respect, there is a marked similarity
between the management of diabetes and the
management of abnormal behavior. Were you
to continue without change the original dose of
insulin needed to reduce a diabetic patient’s blood
sugar, you would encounter difficulties. Conse-
quently, you watch the blood sugar level, and,
as it changes, you prescribe that amount of in-
sulin needed to produce the blood sugar level
and clinical picture that is optimal for each pa-
tient. The same is true in treating abnormal be-
havior, although no special diagnostic or labora-
tory techniques are needed. As the clinical picture
changes, you must change the dosage as needed
until a balance state is reached.
To do this, which drugs should be used? The
logical place to find the answers is the literature.
However, loaded as it is with ambiguous and con-
tradicting statements, this makes a true study of
each drug impossible. During the past two years,
we have investigated thirty-nine of the new drugs.
Many of these are highly active and are useful in
special cases. For a chemotherapeutic program
that you can use successfully, I find that our rec-
ommendations of last year are very adequate and
should be repeated. Concentrate on one analep-
tic and one tranquilizer. Study them, know them,
use them and understand them clinically — sepa-
rately and combined. Let me show you what I
mean —
Figure 1 represents behavior problems as they
walk through your office door. From the shading,
one sees that some are outwardly very overactive,
others are quite underactive. Most are near nor-
mal.
1267
BEHAVIOR PROBLEMS— FERGUSON
Fig. 1.
Fig. 2.
Fig. 3.
If only a tranquilizing drug is used, results will
be similar to the dark area shown in Figure 2.
The most overactive will be helped most. The less
the overactivity, the less they will be helped.
For a tranquilizing drug, I use Serpasil, because I
consider it the least toxic and the safest to use
for increased motor activity and aggressiveness. It
has proven best for me with all overactivity, both
mental and physical.
If treatment is confined to an analeptic, results
will be similar to the shaded area shown in Fig-
ure 3. The more underactivity present, the better
are the chances for helping the patient.
For an analeptic drug, I use Ritalin, because
within therapeutic limits I have found it to be
without side effects. It has proven safest and best
for me with underactivity, both mental and physi-
cal.
Let’s go a step further and consider treatment
for both overactive and underactive behavior pa-
tients. The overactive patients are treated with
Serpasil and the underactive patients are treated
with Ritalin. From the clear area in Figure 4,
it can be seen that there is still a big segment of
behavior that is not being touched. If you look
at this another way, it is then that you see more
clearly how this untouched behavior segment has
both overactive and underactive components, each
of varying intensity.
It is definitely mixed (Fig. 5). How do you at-
tack it? (Fig. 6). First, you can set up your
results as percentages to see how many behavior
problems will be responding to Serpasil and how
many will be responding to Ritalin, after at least
a year. This is quite important because, in any
practice, the lasting benefits of the future are
far more important than are the spectacular cures
of today. Roughly, 10 to 15 per cent of all over-
active patients on Serpasil alone will be doing fine
after a year. About 5 to 10 per cent of all under-
active behavior patients will be all right on Ritalin
alone after a year. We see, then, that at the end
of the year, 75 per cent of the behavior problems
have not been touched — or will be showing
changes from their first improvements.
The reason for this is not an accumulation of
the medicines within the patient. It is an actual
change within the patient. Where this change
takes place with Serpasil and Ritalin, I do not
know, but I do know that as the behavior of an
individual moves toward normal, there is need for
less and less medicine. Most of you know what
I mean because you have used Serpasil for some
of your hypertensive patients — patients whose hy-
pertension was perhaps the clinical manifestation
of increased anxiety or tension. Within a week
or two, the blood pressure was down several point?
on maybe a dose of 0.1 to 0.3 mg. of Serpasil three
times daily. The patient felt like a new man. Life
was more bearable for him. For the first time in
years, he was living. You’ve heard it — and felt
good — until months later when the same patient
came in depressed or complaining of always being
sleepy. I have seen it happen on 0.1 mg. of Ser-
pasil daily. I have also seen this same patient add
10 mg. of Ritalin twice daily to his daily 0.1 mg.
of Serpasil and improve to a better mental and
physical level than at any time in the past ten
years. Therefore, to treat behavior problems
properly, each must be treated individually as a
mixture of overactive and underactive compo-
nents.
To illustrate what we mean, in Figure 7 we have
not only placed the two behavior components side
by side, but we have also shaded the areas to
show how, as the underactives awaken toward
1268
TMSMS
BEHAVIOR PROBLEMS— FERGUSON
Ritalin!
Ritalin
100
NORMAL
100
OVER ACTIVE
Serpasil
Serposil
UNDERACTIVE
Ritalin
UNDERACTIVE
Fig. 4.
Fig. 5.
Fig. 6.
•
A
A *
A
^ Jtk.
■
■
A
A
• A
A
■
? ? |
A
Fig. 7.
Fig. 8.
Fig. 9.
reality and the overactives “simmer down,” each
will not only need less and less of his original
medicine, but to arrive at an active tranquility
each will need to have the second drug added.
Figure 8 is the same as Figure 7, but with the
dosages added. In each section we have used a
dosage range rather than a mandatory figure. We
did this to stress the individuality of each patient,
as two patients with the same clinical behavior
pattern quite often require different dosage levels.
Here approximately 15 per cent of the over-
active group have no clinically recordable under-
active component. This type of patient will re-
quire larger doses of Serpasil than any of the
others. This dose range is usually 5 to 15 mg. of
Serpasil per day, although it may have to be
raised with a few overactive cases. Results with
this overactive group will be faster and smoother if
parenteral Serpasil is used.
A safe rule-of-thumb to follow for parenteral
Serpasil is this — “If the patient can be given 7.5
grains of sodium amytal, then 5 mg. of Serpasil
can be given. If not, then use 2.5 mg. of Serpasil.”
Either dose may be repeated every three to six
hours, if needed. On the underactive side, there
are approximately 10 per cent w'ho will require 60
to 90 mg. of oral Ritalin a day. This works
best when given 20 to 30 mg. three times daily.
Using 10 to 30 mg. of injectable Ritalin solution
intravenously with this underactive group will
give striking results in most cases. They can then
be maintained on the oral Ritalin.
It is from these two groups — the very overactive
and the very underactive — that state hospitals
secure most of their admissions. Proper treatment
of this type of patient, therefore, should reduce
materially the number of commitments each gen-
eral practitioner will be forced to make in the
future. It is a challenge to good medicine.
In the central group, very few patients will re-
quire as much as 1.5 mg. of Serpasil or as much
as 40 mg. of Ritalin daily. In fact, the 0.1 -0.5
mg. Serpasil and the 10 to 20 mg. Ritalin daily
dosage will be used in office practice more than
any other, as most patients will not be too far
from normal behavior when first seen. Using di-
vided doses will give smoother action. We like a
three times daily schedule. The medicine may be
October, 1957
1269
BEHAVIOR PROBLEMS— FERGUSON
given before, after, or with the meals. It may be
crushed and put in the food or beverage, if neces-
sary.
Although we show the range for the combined
use of both drugs, only a small part of your
treatment will start that way. In most cases,
there will be a dominant behavior. If it is under-
activity, start with Ritalin. If it is overactivity,
start with Serpasil. Then, as the dominant be-
havior starts to resolve, add small amounts of the
second drug. We find that this early addition of
small amounts of the second drug — 5 mg. of Rital-
in two or three times daily to the patient on Ser-
pasil, or 0.1 to 0.2 mg. of Serpasil added to the
patient on Ritalin — produces better results and is
easier on the patient and the doctor than to do
nothing until side reactions or bad effects appear.
To understand better this balance-technique
let us consider Figure 9. Behavior is like a teeter-
totter. Normal behavior fluctuates, but maintains
balance, even though one component may be dom-
inant. It is when one factor, such as overactivity
or underactivity, is clinically manifested that we
have abnormal behavior. It is the inability of the
individual to keep in balance — his inability to live
with himself and others — that usually brings him
to your attention.
If Serpasil is given in amounts sufficient to de-
crease the overactivity — would one expect that
this overactivity should reach normal and stop?
Of course not. It is like putting a rock on one
end of the teeter-totter to bring it down — and
expecting it to stop at center. Unless the dosage
is adjusted in proportion to the patient’s improve-
ment, it is only right to expect the drug to con-
tinue acting on the overactive component until
the negative remains clinically.
Now, if we add Ritalin to the point that this
new underactivity decreases, we again cannot ex-
pect the behavior to reach normal and stop. It
will again go on until the original overactivity
manifests itself, even though the patient is on the
original Serpasil dosage.
From this we see that we could continue adding
to each side as they went up and down; we could
add until we exceeded therapeutic limits. Don’t
do it the hard way; add the second drug when
the patient starts to improve. It will take less
drugs and less time.
After the patient is balanced for a month or
two, decrease both drugs in proportion; that is,
if he is on 1.0 mg. of Serpasil and 20 mg. of Ritalir
three times daily, cut the dose to 0.75 mg. of Ser-
pasil and 15 mg. of Ritalin three times daily. Dc
this every couple of weeks. In this way, it may be
possible to eliminate both drugs. If not, you wil
arrive at the proper maintenance dose.
The cause of abnormal behavior is not always
known. There will be times when a balanced pa-
tient will be temporarily upset or depressed. The
addition of extra amounts of Serpasil or Ritalin
for a short time will usually help the patient
through these periods.
In this respect, another comparison with the
control of diabetes is in order. If the diabetic over-
eats, he takes more insulin. If he fasts, he cuts
his insulin. A similar adjustment in relation to
the amount of mental strain, is needed in the
treatment of behavior problems. However, the
diabetic cannot make these adjustments unless the
reason is explained to him. Therefore, for best
results in behavior problems, it is necessary to
explain to the patient or his relatives the action
of each drug, the results expected from admin-
istration, and the symptoms which should be re-
ported to you, so that you may adjust the dosage
properly in order to reach the desired goal — active
tranquility.
This implies a condition wherein the individual
is mentally alert, yet calm and collected. It also
means the absence of abnormal behavior and the
inability of the individual to live with himself
and others.
It is at this point of therapy that most patients
have left the hospital and returned to society and
their loved ones. Consequently, it is at this point
that you — the patient’s family doctor — can take
over through some form of a parole system. We
feel this way, because, in most cases, you know
as much, or even more, about the patient’s en-
vironment than we do, and you are more than
capable of handling the medicines. Like the dia-
betic patient leaving the hospital, the mentally
ill patient must have good medical follow-up.
This is the weak link in our program today. We
have been able to increase the number of chronic
patients leaving the hospital by 350 per cent. We
have also been able to increase the percentage of
those that can remain out from 21 per cent to
68 per cent. However, our records show that 92
per cent of those that return to the hospital re-
(Continued on Page 1288)
1270
JMSMS
Evaluation of the Use of Reserpine
in the Psychoses
By A. L. Olsen, F.A.P.A., M.D., and
Harry Vander Kamp, M.S., M.D.
Battle Creek, Michigan
THE VETERANS Administration Hospital at
Battle Creek, Michigan has 2,055 patients,
all male, ranging in age from nineteen to eighty-
six years. Ninety-seven per cent have psychotic
diagnoses and eighty per cent of these are schizo-
phrenic.
During the past two years Reserpine has been
used at this hospital, and great changes have oc-
curred. The time interval that has elapsed is now
sufficient to warrant an evaluation of this medica-
tion. The use of the drug has been extensive
enough to warrant a critical appraisal. During
these two years a carefully controlled, subsidized
research project evaluating the effectiveness of this
drug has been completed. Further, a policy was
initially instituted whereby each physician on the
staff of the hospital had the privilege and re-
sponsibility of selecting patients from those on
his service who were to receive the medication.
An evaluation of the results obtained by these
physicians has been made. All this has afforded
a unique opportunity for a clinical evaluation of
the use of Reserpine at this hospital.
Many changes that this medication has brought
about seem truly amazing. Electroshock is now
given only to those patients where it has a specific
therapeutic effect, chiefly in cases of acute ex-
haustive psychoses, in depressions, and to catatonic
patients who would require tube feeding. Hydro-
therapy in the form of tubs and neutral packs is
now used only occasionally, whereas two years
ago it was used extensively. In order to accom-
modate the large number of patients it had to be
available both day and night. Lobotomies have
been discontinued. Many untidy patients are now
continent. The aged and senile are less confused,
better oriented, and memory impairment is less
pronounced. Many patients who have been on
the locked wards are participating in activities
of their own selection, and have the privilege of
From the Veterans Administration Hospital, Battle
Creek, Michigan.
October, 1957
being on open wards. The period of hospitaliza-
tion for many patients, who likely would have been
discharged ultimately without the medication, has
been definitely shortened.
In spite of these great changes and the definite
value of this medication in the treatment of these
psychotic patients, it still cannot be considered as
curative. The improvement most of the patients
have made is still very marginal. While many
patients show a change in emotional and feeling
tone and an attenuation of hostility and anxiety,
the psychiatrists have no difficulty in detecting
the psychotic process which is basically unchanged.
The more acceptable behavior is still very tenuous.
Many patients are able to adjust very well in
the hospital under a structured environment.
The majority of the chronic schizophrenic pa-
tients treated with Reserpine have failed to im-
prove sufficiently to be eligible for early hospital
discharge. Those who have left on trial visits
or who have been placed in the family care pro-
gram have needed much supportive therapy.
Some clinical complications from the medica-
tion, while not too frequent, can be serious and
disabling. A few patients have developed de-
pressive reactions. These have responded well to
withdrawal of the medication. We have had sev-
eral cases of acute vascular collapse. These,
however, have responded well to symptomatic
treatment. A more serious complication noted at
this hospital has been the reactivation of peptic
ulcer. Six patients have had severe gastrointestinal
bleeding and three have had acute perforations.
All of these required emergency surgical treat-
ment. These cases are often difficult to detect
because of the peculiar indifference to pain many
of these schizophrenics show. Constant vigilance
for detecting these complications has been nec-
essary and rewarding. While it is gratifying to
see the tranquilizing effect of Reserpine on patients
with assaultive, destructive and combative be-
havior, also the disappearance of the choreiform
1271
RESERPINE IN THE PSYCHOSES— OLSEN AND VANDER KAMP
movements in Huntington's disease, it is most
discouraging to see another neurologic deficit ap-
pear in the form of Parkinsonism.
The physicians at this hospital realized very
shortly after using Reserpine that it was very
difficult to predict which patients would respond
favorably prior to giving the medication; there-
fore, a carefully controlled study of 170 schizo-
phrenic patients was done. Some received Reser-
pine and others a placebo.* The double blind
technique was used. One group of these patients
represented the borderline psychotics and those
who were in good contact and on an open ward.
Another group were the acutely disturbed, dis-
playing periods of agitated violent, combative and
uncontrollable behavior. Another group were those
often described as “elopers.” Some of these were
in fairly good contact with reality; many were
actively hallucinating and revealed delusional
ideation. The fourth group represented the severe-
ly regressed patients. They had adjusted well to
a structured hospital environment and appeared
quite comfortable with their delusional ideation.
The results of this study show that the tran-
quilizing effect of Reserpine shortened the hospital
stay of many of the borderline psychotic patients
and those who were in good contact. In the ma-
jority of these cases the hospital stay was so short
that an accurate evaluation of the change in
psychopathology was not possible. In the acutely
disturbed patient, the personality disorganization
which had become progressively more severe was
at least partially halted. There was a definite
improvement in conceptual thinking. Hallucina-
tions and delusional idea — were diminished and
masked. These patients became better oriented
for time, place and person. Their speech was
more relevant and the effect more appropriate.
The tranquilizing effect of Reserpine is, indeed,
*Sandril and the placebo were donated by the Eli
Lilly Company.
amazing in this group. The eloper became less
seclusive, less resistive, less hostile and more co-
operative. The chronic regressed patient who was
well adjusted to his hospital environment showed
the least improvement.
A global evaluation of these patients reveals
that changes occur only in specific areas of psycho-
pathology. The response to Reserpine also showed
a pecidiar selectivity. Some patients made a good
response, others failed to make any improvement.
Even after completion of the study no definite
prognostic sign could be elicited which would in-
dicate which of these patients in a comparable
group would improve and which would not, prior
to a therapeutic trial with Reserpine.
It does seem logical to infer that this peculiar
selectivity and specificity represents a neurophysi-
ologic difference in these schizophrenic patients.
This in turn suggests a metabolic disorder, both
cellular and humoral in origin. It lends further
support to the concept that a biochemical factor
is involved in schizophrenia. Some recent re-
search on serotonin is suggestive of the nature of
this biochemical factor.
Our experience indicates that some patients re-
spond better to Reserpine, others to Chlorproma-
zine, others to a combination of these drugs. Some
of our patients who have failed to improve on the
drugs have subsequently made a very good im-
provement on insulin coma therapy. Some who
have failed to improve on insulin therapy have
done remarkably well on further treatment with
the tranquilizing drugs. The physical medicine
rehabilitation service, special services, individual
and group psychotherapy have been more valu-
able in the treatment program than ever and
should be utilized to the fullest extent. It is our
opinion that the older forms of therapy should
not be discarded. Each patient must still be in-
dividually evaluated. Certainly more research and
clinical experience in the use of these newer drugs
is needed.
The history is the backbone of clinical investigation.
* * *
Complete anacidity and a short history, unlike the
achlorhydria with a long history, strongly points a sus-
picious finger towards carcinoma.
It should be regarded as axiomatic that the harder it
is to recognize gastric carcinoma, the better the prog-
nosis.
* ■*■ *
Addisonian pernicious anemia is often confused diag-
nostically with carcinoma of the digestive tract.
1272
TMSMS
Management of Chronically Disturbed Patients
with Sparine
Q PARINE or Promazine hydrochloride is one
^ of the phenothiazine compounds that has
been significantly successful in the treatment of
acutely disturbed patients,1 especially in the treat-
ment of acute alcoholism.2 It has not been known
to have severe side effects, a fact which has been
attributed to the absence of the chlorine radical
on the phenothiazine nucleus. Chemically, this
is the only difference between chlorpromazine and
promazine.
Therefore, we thought it useful to administer
the drug to chronically disturbed patients with a
twofold purpose in mind: (1) to see whether it
would have a significant effect in calming chroni-
cally ill patients who had been previously treated
with any of the chemical or physical modalities,
and (2) to test it for undesirable side effects.
Fifty-nine disturbed patients from the chronic
female wards were selected on the basis of having
had previous physical or chemical treatment —
alone, combined or successively. Thus, each pa-
tient was her own control. By the process of
random selection, they were divided into two
groups. Thirty-one were placed in the Sparine
group and 28 in an EST group. This was to act
as an additional control. The ages ranged from
twenty-six to sixty-four years and the periods of
hospitalization extended from one and one-half
years to twenty-nine years. Eighty per cent had
the diagnosis of schizophrenia. The remainder fell
into the categories of chronic brain syndrome, in-
volutional psychotic reaction and manic-depres-
sive reaction.
Prior to treatment, blood pressures, pulse, and
temperatures were taken and recorded. Complete
blood counts were also performed. Finally the
patients were evaluated by the ward personnel.
A rating scale was used. It was divided into four-
teen subjects, such as sleeping habits, eating habits,
sociability, speech, et cetera, covering all con-
From Wayne County General Hospital.
The Sparine was supplied by the Wyeth Laboratories.
By Horace J. Prescod, M.D.
Philadelphia, Pennsylvania
Merlin C. Townley, M.D.
Eloise, Michigan
ceivable aspects of ward adjustment. Each subject
was subdivided in terms of degree of increasing
abnormality and numbered. Thus the lower the
number (and, hence, the total score), the better
the adjustment and vice versa. The lowest score
possible was fourteen. This represented a condition
good enough for convalescent leave. The highest
score possible was fifty; this represented the worse
possible adjustment.
The protocol was set up as follows: Each of
those on Sparine received 100.0 mg. of the drug
intramuscularly daily for four days. Oral medica-
tion was started at the same time. Only 100.0 mg.
tablets were used. For the first two days, each
patient received one tablet at bedtime. This was
increased to one tablet twice a day for two days,
then one tablet four times a day. Four hundred
milligrams a day was arbitrarily set up as the
maintenance dose. The amount was to be increased
or decreased as the individual required. The tests
extended over a two-month period. Complete blood
counts were done every two weeks.
Just before administering the intramuscular dose,
the blood pressure and pulse were taken and
recorded. They were taken again one hour after
the injections. In the hypertensive patients, the
pressure dropped as much as fifty points; in the
normotensive patients the drop averaged ten to
twenty points. Thereafter no particular pattern
could be ascertained, but there was a gradual, con-
tinued decline over the period of a month in
about 60 per cent. In the remainder, the blood
pressure started to return to normal subsequent to
the termination of the intramuscular injections.
There was only one significant side reaction at
that time — a rash at the site of the injection. A
few patients complained of weakness and drowsi-
ness initially. There were no incidents of syncope.
After the first few injections, there was no further
evidence of weakness. During the period of injec-
tions, it was noticed that most of the patients were
quieter and more co-operative, but with the shift
to oral medication there was an upswing towards
October, 1957
1273
MANAGEMENT OF CHRONICALLY DISTURBED PATIENTS— PRESCOD AND TOWNLEY
the former agitated behavior. A few patients did
not respond to the intramuscular injections, even
after four days, and required additional injections
extending up to a month.
At the end of two months the drug was discon-
tinued, except in those patients who seemed to
have benefited from it. Both groups were again
evaluated by the ward personnel. Twenty-three, or
almost three fourths, of the Sparine group showed
some improvement. One-fourth was unimproved
or worse. Almost identical percentages were ob-
tained for the EST group. Twenty-one, or exactly
three fourths of the EST group showed some im-
provement, as against seven or one fourth, who
showed no improvement. However, there was
one striking difference. In the EST group, one
patient improved dramatically (14.5 point de-
crease). This was a forty-six-year-old woman
with the diagnosis of schizophrenic reaction,
chronic undifferentiated type, who is now on
convalescent leave.
In terms of side effects, it was noticed that a
small percentage of the patients developed a mild
leukopenia (for our purposes a white cell count
below 5,000) . The white cell counts declined ap-
preciably in 17 per cent, but only one fell as low
as 2,550. No symptoms that could be associated
with this decline were noticed. All the lowered
blood counts returned to their former level within
a month after discontinuance of the drug. One
patient developed a serious macular rash, which,
although treated with Benadryl, became worse.
It was necessary to discontinue the drug on this
one patient. No other significant side effects were
noted. In particular, no patient developed seizures
which Barsa and Kline3 and Voegle and May4
observed independently in their studies.
Summary and Conclusions
Fifty-nine chronically disturbed female patients
who had previously failed to respond to either phy-
sical or chemical therapy, or both, were divided
into two groups on the basis of random selection.
Thirty-one were placed in the group to be given
Sparine and twenty-eight were placed in the EST
group. Thus each patient not only acted as his
own control, but also the EST group acted as an
additional control. Complete blood count, pulse,
pressure and temperature were taken prior to the
tests. In addition, each patient was evaluated by
the ward personnel.
The treatment lasted for two months and con-
sisted of intramuscular injections of 100.0 mg.
daily for four days and oral doses of 100.0 mg.
tablets starting from the first day and increasing
to 400.0 mg. daily. This was the average dose.
Blood pressures fell significantly within one hour
after the first intramuscular injection. There were
no instances of syncope. A slight majority con-
tinued a gradual decline during the first month;
the remainder returned to normal following cessa-
tion of the intramuscular injections. A transient
weakness and drowsiness were observed in a few.
A rash developed in one at the site of injection,
but this faded in time.
At the end of the two-month period, the patients
were again evaluated by the ward personnel. Al-
most three-fourths of the Sparine group showed
some improvement; the remainder were unim-
proved or worse. Exactly three-fourths of the EST
group showed some improvement. One of this
latter group improved enough to be placed on con-
valescent leave.
In terms of toxicity, 17 per cent experienced a
mild decline in the white cell count, but all re-
turned to normal within a month after the drug
was discontinued. There were no associated symp-
toms. In one case, a macular rash developed that
was so severe that it was necessary to discontinue
treatment. No other side effects, including seiz-
ures, were observed.
5 i
Bibliography
1. Fazekas, J. F.; Schultz, J. D.; Sulivan, P. D. ; and
Shea, J. G. : Management of acutely disturbed
patients with promazine. J.A.M.A., 160:46 (May
5) 1956.
2. Mitchell, Earl H.: Treatment of acute alcoholism
with promazine (Sparine). J.A.M.A., 160:44 (May
5) 1956.
3. Barsa, J. A., and Kline, N. S.: Promazine in chronic
schizophrenic patients. Am. J. Psychiat., 113:654
(Jan.) 1957.
4. Voegle, G. E., and May, R. H.: Epileptiform seiz-
ures under promazine therapy; occurrence in two
cases without history of former seizures. Am. J.
Psychiat., 113:655 (Jan.) 1957.
1274
TMSMS
Psychiatric Aspects of Gynecologic Care
By Somers H. Sturgis, M.D.
Boston, Massachusetts
TT MAY NOT be inappropriate to start this dis-
cussion of psychiatric aspects in gynecologic
practice with a reference to the importance of sex
at the very beginning of human life here on earth,
and I quote from Genesis Chapter I, verse 27 — “So
God created Man in His own image — male and
female created he them.” Man and woman, mas-
culine or feminine, we were brought into the
world, and the animals also came in two by two.
The biblical writer paid no heed to other species
that deviate from the bisexual pattern, such as
certain species of snails and mollusca that mature
in one hemaphroditic individual the dual poten-
tiality of spermatogenesis and ripening ova. But
in the higher species procreation remains bisexual
today as it was in the distant past. It is no mere
coincidence that our sex necessarily influences the
attitudes and attributes, the conditions and con-
flicts that govern much of our thinking and activi-
ties.
Psychiatrists point to three stages in sexual
maturation common to men and women. The
primary phase extends from before birth to the
first few years of infancy, and is characterized by
a neuter, ano-oral type of sexual satisfaction. Then
comes the second, homosexual phase, to be fol-
lowed sometime in adolescence by the mature
heterosexual era. Such development occurs equally
in both sexes, and the basic contours of person-
ality are often directed not only by the satisfac-
tory graduation from the homosexual to the het-
erosexual stage, but also by the adequacy of the
elemental maleness or femaleness of the individual.
I have sometimes speculated on why those indi-
viduals that appear to excel in any creative art or
craft — be it cooking, or weaving, or pottery, music
or painting, sewing, or even creating a new coif-
fure— are almost always males. Pick whatever pur-
suit you may, through the ages men have domi-
nated the techniques. To women alone, however,
even to the lowliest street walker, is given the gift
Presented at the 91st annual session of the Michigan
State Medical Society Detroit, Michigan, September,
1956.
of creation — the sublime ability to produce a liv-
ing, breathing bit of life itself. Why should there
be any wonder that her life, then, in the third or
mature stage of development should be wrapped
about the central theme of reproduction, the poten-
tiality for it or her demonstration or rejection of
such a God-given power?
If this be true, then, much of the mental as well
as physical ill health of the individual woman can
be properly understood only in the light of her
conscious or unconscious acceptance of her femi-
nine role. The menstrual function symbolizes this
role. Disorders of menstruation threaten the per-
sonality structure at its deepest level — that of fe-
maleness— and an awareness of emotional factors
in women’s complaints is recognized by all in the
field of gynecology. It is only surprising that in a
similar way we don’t have a special field of andro-
cology — for the ill health involved in the frustra-
tions implict in being a man can surely bring forth
many conditions that our genitourinary associates,
peering through their cystoscopes, may be all too
myopic to observe. Perhaps this field of andro-
cology offers a wide-open challenge to the ever-
increasing numbers of girl graduates from medical
schools in the future years.
Gynecology, then, means the science of women’s
diseases, and their adequate treatment calls for as
complete as possible an understanding of the indi-
vidual patient herself — her life-situation and her
problems. One cannot concentrate only on the
surgery of the pelvic organs and their pathology
and leave out the pituitary, the thyroid and adrenal
glands and the part they play in reproductive
physiology. Nor can one overlook the psyche — the
substrate that motivates and conditions all our
actions and responses. To be a thorough gyne-
cologist demands knowledge of the part played by
these three essential disciplines — pelvic surgery,
endocrinology and psychiatry. The purpose of this
paper is to emphasize the outstanding importance
of the psyche in all gynecologic complaints. One
of the best ways to illustrate this is, perhaps with
a few case reports.
October, 1957
1275
PSYCHIATRIC ASPECTS OF GYNECOLOGIC CARE— STURGIS
Case Reports
I would like to present three types of cases : first,
one with organic disease whose diagnosis was
obscured by the more obvious signs of a neurosis;
then a patient with important psychiatric implica-
tions in her clearly organic pathology; and third,
two cases with primarily emotional disturbances
presenting symptoms that suggested a somatic dis-
order.
We are often too prone to react in an unreason-
ing way to our patients’ personalities, especially
when the past history and negative physical find-
ings seem to support the hostility with which we
may have labeled the patient a neurotic. Once we
have even unconsciously committed an opinion of
this sort it may be difficult for us to shake it.
Case 1. — M. P. was a thirty-seven-year-old mother of
five who had a hysterectomy in (March) 1956 after a
period of observation of over three years for intractable
meno-metrorrhagia, having had five previous admissions
including four curettings.
At her first admission in 1953, her hematocrit was
32, all the usual studies for blood dyscrasia were in
normal range, and the dilatation and the curettage
showed normal proliferative endometrium. The almost
constant bleeding recurred shortly after, and for the
next year hormonal control was attempted but failed.
It was established by endometrial biopsy that ovulation
generally occurred in relation to monthly increases or
“hemorrhages” that punctuated the persistent flow.
Progesterone was thus found, as anticipated, to be
no help. Testosterone was tried both orally and by
injection. A course of Blutene was given. During this
time the patient’s personality presented so many out-
standing difficulties, and there was so little co-operation
in the outlined medical programs, that she was seen by
our psychiatrist and followed by the psychiatric social
worker.
The social history of this well-groomed and physically
attractive twice-married girl brought out that she, the
fourth of seven children, had always been expected to
do all the hard household work. Her menarche was
at age fourteen and menstruation thereafter was un-
eventful. She married at seventeen and had her first
child in a year. Her husband was killed in an accident
a year later. She left the child with her mother and
came for work to the city. A sister also came against
her wishes and she had the police force the sister to
leave town for promiscuous behavior. Later on, the same
sister is blamed for a court action that separated her
from her oldest child, who was then brought up by an
aunt. She married again, a bartender, and had four
children in the next eight years. Her home life has
been one of violent quarrels with her neighbors as well
as with her husband. He is said to accept only two
of the four children as his own. Her personality was
summarized by the psychiatrist as demanding, sarcastic,
belligerent and infantile, with many hysterical traits, yet
seductive and flirtatious. She showed hostility to all
those she dealt with; at home she would lock herself
in a closet or resort to face-slapping during violent
arguments. She was afraid of further pregnancies and
used the excuse of her bleeding to deny her husband,
or else a compulsive and feverish obsession to clean the
house, leaving her too tired for sexual activity. Like-
wise, the attempts to gain her co-operation in clinic
programs were repeatedly upset by missed visits, either
because she would say she was bleeding too hard to come
in for the planned injections, or she was too tired, or
had to clean house that day, and so forth. The psychi-
atrist’s opinion was that the major causes for her
anger and hostility were too complicated and she was
too disturbed for psychotherapy to offer any help, but
that the social worker could give her some supportive
treatment.
For a period of six months her bleeding was rela-
tively controlled, during which time she leaned heavily
on a sympathetic resident and the social worker. When
the resident left the hospital, however, the metrorrhagia
returned. We felt that she represented a complicated
emotional problem centered on fear of pregnancy and un-
resolved hostility to her feminine functions; yet, because
she was ovulating, an admission was advised for another
dilatation and curettage to rule out “irregular shedding”
of the endometrium. At this admission, she showed
normal secretory endometrium, but a medical consultant
found her serum iron to be down to 20 gamma per
cent (with a normal minimum of 80). Her hematocrit
was 27, and we reversed our diagnosis of primary emo-
tional causes in favor of the tentative hypothesis of pro-
longed serum iron deficiency and depletion as the major
explanation of menorrhagia. She was given a total of
2,400 mgs. of iron intravenously, and with transfusions
her hematocrit was brought to 37 after two weeks. For
two months she had less severe menstrual flow, then, in
spite of an acceptable serum iron level, her hemorrhage
recurred. Again, we were forced to conclude that her
psychiatric status was paramount; she was readmitted
for treatment of her blood-loss anemia. After consid-
erable discussion and further interviews with the psychi-
atrist, a hysterectomy was chosen as the best definitive
treatment, although pelvic examination was still essenti-
ally negative. It was during this experience that her
infantile behavior, her antisocial feelings and helpless-
ness were brought out. She did quite well, and one
month after the operation was doing a full schedule of
home work, albeit with many arguments and rages.
Comment. — This, then, appeared at first to be
the case record of an unhappy, maladjusted moth-
er of five, poorly equipped to handle the burden
of wifehood and motherhood, who seemed to have
developed uterine bleeding as a solution to her
fears of further pregnancy, in spite of a fairly
normal endocrine status. Our confidence in the
psychiatric etiology of this was shaken by the
demonstration of a severe deficit in her serum iron,
1276
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PSYCHIATRIC ASPECTS OF GYNECOLOGIC CARE— STURGIS
but restored by the recurrence of bleeding after
the deficit had been made up. In spite of the pre-
sumed emotional etiology, hysterectomy was ad-
vised eventually as the best solution to her prob-
lem. At operation, a different answer was found.
She had diffuse adenomyosis which offered a rea-
sonable organic explanation for her prolonged
bleeding, a pathologic entity never considered be-
cause of the emphatic, repeated display of emo-
tional insecurity and our too ready diagnosis of
her as a hopeless neurotic.
The next case represents those whose organic
disease is sufficiently confused by emotional factors
to interfere with the optimal therapeutic program.
Case 2. — Mrs. A. A., was a forty-eight-old married
woman with three daughters, who was first seen in
1952 in the clinic complaining of bladder weakness. In
addition to cystocele, she was found to have large
fibroids. Since there had been no hemorrhage, operation
was advised, but considered elective, and she was urged
to make an appointment within a few months. She did
not return, however, until uterine bleeding of seven
weeks’ duration occurred a year later, when she fainted,
became scared, and at her examination showed a hemo-
globin of 10 gms. per cent. The cystocele had increased,
and the fibroids were larger, and she promised to come
in for hysterectomy in three weeks, but missed her ap-
pointment because, she said, the small store that she
helped to manage was too busy at that time.
Three months later on her return, we learned that
her twenty-nine-year-old daughter had just undergone
a mastectomy for carcinoma and the fear of malignancy,
rather than persistent hemorrhages, had driven Mrs.
A. A. to come back. She was given an admission ap-
pointment for the following week but failed to keep
this date. Four months later she again returned and
a 6 cm. cystic structure was felt for the first time in
the right vault, independent of the fibroids. Unreason-
ably, she then wanted an operation done the very next
day. She did come in to the hospital in ten days and
psychologic tests preoperatively demonstrated the conflict
between her fears of the operation and her fears of
cancer. Her only defense had been to turn and run
away. Finally, through her daughter’s crisis, she found
she could master the worry about surgery by giving
way to the more overpowering fear of malignancy.
Through her operative convalescence, an almost sym-
biotic relationship between mother and daughter was
observed, with our patient rather passively enjoying
and taking part in the daughter’s acting out with hos-
tility her mother’s suppressed fears of going crazy.
Actually, the removal of a dermoid cyst and large fibroids
was attended by a surgical uneventful recovery.
Comment: Little need be added to this rather
classic case of a woman who suffered severe hemor-
rhages for four years from fibroids because she be-
lieved, first, that she would lose her mind follow-
ing hysterectomy, and, second, that she had cancer
anyway and operation would be futile. We were
unaware of the daughter’s controlling influence
until it became clearly apparent that it was the
younger woman who realistically faced mastectomy
and lived through her operation, that convinced
Mrs. A. A. to follow through with her own ap-
pointment for surgery.
Finally, the next two cases are from those whose
outstanding disorders are psychologic, but present-
ing somatic symptoms that primarily brought them
to the gynecologist.
Case 3. — Miss S. A. was a twenty-five-year-old single
girl of Greek Orthodox extraction who entered the
emergency ward at night complaining of right-sided
abdominal pain of twelve hours’ duration. She had a
leukocyte count of 15,000, a fever of 101° F., and
tenderness localized by her in the right lower quadrant
and in the right vault on pelvic examination. An oper-
ation for acute appendicitis was performed that night.
Exploratory laporotomy was entirely negative, however,
except for noting an acute hyperemia of the Fallopian
tubes. She was seen postoperatively by the psychiatrist
in an effort to understand better the background in
this case for the error in mistaking salpingitis for ap-
pendicitis.
This attractive dark-skinned girl quickly admitted to
her short temper, irritableness and “nerves,” which she
blamed on a mother who continually badgered her to get
married but scolded her for being out after ten o’clock.
Her past history revealed chronic indigestion, and a
normal menstrual cycle till the last flow, ten days before
admission, which had been preceded by an unusual
discharge, and continued longer than usual. She had
been going out with a married man of a different racial
origin and, although there was no hope of marriage,
she had recently had sexual relations with him. Only
very recently a girl friend of hers had become illegiti-
mately pregnant, and had been ordered out of the
house of her mother. The mothers of the two girls
had discussed this action, and Miss A.’s own mother had
said she would do the same if any of her three daughters
disgraced her in this way. Thus it was that the patient
became subconsciously fearful that the unusual flow
preceding her admision, followed by a fever and abdomi-
nal pain, was probably a consequence of a pregnancy
of her own. Unable to formulate this fear, yet desperate-
ly worried over the consequences, she apparently local-
ized her abdominal pain to the appendix region. Post-
operatively, cervical cultures were found positive for a
Neisserian infection.
Comment: No valid criticism need be sustained
for performing the negative exploration in such a
case where the risk of perforated appendix seemed
greater than the risk of the laparotomy. In retro-
October, 1957
1277
PSYCHIATRIC ASPECTS OF GYNECOLOGIC CARE— STURGIS
spect, one may argue that the history of sexual
activity followed by discharge, an unusual period,
then fever and abdominal pain should have pro-
vided enough suspicion to await cervical cultures.
When the strict orthodox upbringing and the coin-
cidence of the girl friend’s illegitimacy were
brought out, one can readily understand the mo-
tives behind this girl’s anxiety and the quick co-
operation with the night resident’s suggestive ex-
amination that pointed towards an acute appendix
as a face-saving solution.
Case 4. — Miss M. E. was a twenty-two-year-old stu-
dent nurse who came for relief of her monthly cramps
which were so disabling that she was falling behind in
her school work and was afraid she could not graduate
with her class. For the first thirty months after men-
arche at age eleven, she experienced no menstrual pain,
and her mother would ask her “any cramps yet?” When
she was fourteen or fifteen, she began to have severe
pain, nausea and vomiting that persisted with regularity
to the time she was first seen. Codeine alone was found
helpful. Other than a second degree retroversion, ex-
amination was essentially negative. She was given two
injections of 10 mgs. of estradiol propionate early in
her cycle, and for the first time in eight years experienced
no menstrual discomfort whatsoever. Ovulation was
then allowed to recur, and this was followed, as an-
ticipated, by the usual disability “worse than ever
before.” Oral stilbestrol, 1 mg. for three weeks failed
to produce any estrogen withdrawal flow. She was then
started on the “stepped-dose” regime first suggested by
Brown and Bradbury, receiving 2 mgs. of stilbestrol
the first week of her cycle, then 4- mgs. for a week
and finally 6 mgs. for a week. This regime was repeated
for three months in a row with complete relief and
psychologically acceptable uterine flows, and then the
fourth month ovulation was allowed to occur. Neither
papaverine, trasentine, valoctin or novatrin were at all
helpful when she had her dysmenorrhea. For the final
year of her training, however, for three out of every
four months the “stepped” stilbestrol regime eliminated
the pain and the absence from work, and she felt grate-
ful that she was thus able to graduate on time.
Shortly after graduation she was treated in the hos-
pital for acute peptic ulcer symptoms which yielded to
medical measures. In the spring of the next year she
married. After a year and a half of the concentrated
stilbestrol treatment she was told that this must be
terminated, and that the choices for her were either preg-
nancy or a pre-sacral resection. She felt too financially
insecure to have a baby and did not want to stop
working to have the operation. She compromised on
the use of stilbestrol only every other month, and agreed
to the condition imposed on this decision that she should
start psychotherapy.
It was difficult for her, at first, to gain confidence in
the therapist and accept the idea that she might have
pertinent emotional conflicts. After a relationship was
established, she described how she had to give in to
her intense pain in order to get her mother first, and
now her husband to take care of her as a helpless child.
She claimed she wished she did not have to work and
could afford a baby. Later on she expressed her re-
sentment toward the mother for pushing her into grow-
ing up too fast and her dissatisfaction in the childish- I
ness of her husband, thus placing too much responsibility
on her shoulders. She also felt that her dysmenorrhea
had served as an outlet to insure her the kind of care
she missed as a child. In these interviews, she began
to realize that she was taking refuge in her husband’s
inefficiency as the excuse for her feeling that she was
not yet sufficiently mature to be a mother. Nevertheless,
she became aware of a deep desire for a child. Seven
months after starting this therapy she voluntarily gave up
all further estrogen treatment. Her cramps had de-
creased sufficiently so that they no longer kept her
away from work. Her interest in accepting the respon-
sibilities of pregnancy continued to increase and she
was very pleased in five months to become pregnant.
Delivery was uneventful; she was happy looking after
the child and grateful for the therapist’s help in reach-
ing a decision to give up the hormone treatment and
become pregnant. It is of interest that she still con-
tinued to have cramps after the baby arrived, yet these
were not severe, and the following year she became
pregnant again.
Comment: There is little doubt that the rather
massive stilbestrol treatment did give this girl the
chance to conclude her training that was threat-
ened by her disabling cramps. The inevitable re- ‘
suit of the painless anovulatory flows was to make
her dependent, almost addicted to the estrogen.
Further one may well wonder whether the activa-
tion of her ulcer leading to a hospital admission
may not have been a somatic outlet in another
form for her conflicts, once the monthly cramps
had been taken away. She was, however, inteili- j
gent enough to make full use of the therapy inter-
views, and it was rewarding to note her progres-
sive improvement, her voluntarily giving up estro-
gens, and her happiness in finally becoming a
mother.
Discussion
These cases, of course, are not in the least un-
usual; every one with experience of the clinic or
office practice of gynecology can reduplicate them
or their like many times over. One cannot squarely
meet this challenge by refusing to recognize its
existence. The major problem for us lies in how
to deal adequately with it. What steps can be
taken to weigh in the balance the significance of
emotional conflicts in gynecologic complaints?
First, and most important, there is no single
1278
TMSMS
PSYCHIATRIC ASPECTS OF GYNECOLOGIC CARE— STURGIS
therapeutic approach that can offer as much suc-
cess for all functional disorders as the deep con-
cern, wise guidance and sympathetic understand-
ing that the dedicated clinician can devote to the
patient herself and her individual problem. This
means a careful history that includes background
data on family and siblings, the anxieties, ideals
and hates of childhood and adolescence. This takes
time. How few of us in a surgical specialty have
the time and the interest to try to learn about our
patients in this way! How little our training has
prepared us to be able to bring some order out of
the chaos of irrelevancies that may pour out dur-
ing the first examination! The best we can do
most of the time is to grasp those significant danger
signals that put us on our guard to think twice
before we schedule an elective operation, and to
insist on further knowledge before deciding on an
irreversible therapeutic course.
If we are fortunate to have the close collabora-
tion of a psychiatrist, many a needless operation
may be avoided entirely and other elective proce-
dures can be planned with optimal chance of in-
flicting the least psychologic trauma. I am con-
stantly impressed by the abundance of ordered
facts obtained in an hour’s interview by the skilled
and experienced psychiatrist. As an added aid,
I am deeply indebted to the knowledge provided
by our consultant psychologist through the use of
projective tests, the well-known Rorschach, the
thematic apperception test, draw-a-person and Sen-
tence-Completion tests. Finally, in surgical cases,
we have been rewarded by studying the pattern
of a patient’s recovery from anesthesia as a prog-
nostic sign of their future convalescence. Five
minutes or less of the surgeon’s time spent in the
recovery room will give him a telescoped view, as
it were, of the way his patient will be able to
handle the postoperative period. Those that moan
and groan, thrash about, demand more medica-
tion, resent and reject all proferred help while in
the twilight zone before full conscious mastery re-
turns— such patients are most surely going to be
difficult to handle, aggressive, complaining, infan-
tile and dependent. The others who seem to
summon up some deeper strength from their pre-
vious life experiences to accept the discomfort
with confidence that they are obtaining all possible
help — these patients will get well in progressive,
predictable manner.
In conclusion, I would like to make a few re-
marks about the importance, obligations and re-
sponsibilities of our specialty in relation to the
health of our nation which, as the American Medi-
cal Association repeatedly reminds us, is the best in
the world today. This is certainly borne out by
statistics on infectious diseases, and various mor-
tality rates. But there are few nationwide or
worldwide statistics on the incidence of gynecologic
conditions aside from malignancy. A more reveal-
ing index of the health of America’s women is pro-
vided by a truly disturbing accounting of sexual
unhappiness, broken homes, illegitimacy, septic
abortions and sterility. It is impossible to obtain
accurate figures, but estimates indicate, for in-
stance, that 20 million Americans are battling with
the frustrations of infertility; ten million others
have been involved in divorce action. Each year
there are over 100,000 children born out of wed-
lock, and the figure of 300,000 criminal abortions
annually has been considered a conservative guess.
The numbers of sexual deviates and delinquents
are unknown. Surely such figures speak eloquently
of a shocking degree of sexual immaturity and
inadequacy, of maladjustment and irresponsibility
of parents, a disturbing measure of mental ill
health of the women of our nation.
I do not believe the medical profession can shrug
off responsibility by claiming this state of affairs
is the concern of parents, church, or schools. I
think that our own specialty is particularly con-
cerned. In the age before specialization, the fami-
ly doctor was the guardian, teacher and friend of
his intimate clientele. He knew the family back-
ground, the hopes and worries of young parents
whose children he delivered and whose parents
he saw buried. With the priest or pastor, he
stood as a bulwark against abortions, divorce, and
illegitimacy. Today obstetricians and gynecologists
are perhaps best able to fill the same position. Too
often, however, obstetric or gynecologic care is
limited to the technical problem of the difficult
birth or pelvic repair. We are dealing daily with
the most intimate aspects of our patients concern-
ing their reproductive activities. It seems to me
we are obligated to try to face squarely the frustra-
tions and 'emotional problems that enter into al-
most all gynecologic complaints, as exemplified in
the case reports given here.
This is not a plea that gynecologists and obstetri-
cians should think themselves into the position of
(Continued on Page 1288)
October, 1957
1279
Medical and Psychiatric Collaboration
Importance and Possibility
TV/TENTAL HEALTH is the ability to meet and
■*" ■*" handle problems; to make choices and de-
cisions; to find satisfaction in accepting tasks;
to do jobs without avoiding them and without
pushing them on to others; to carry on without
undue dependency on others; to live effectively
and satisfactorily with others without crippling
complications; to contribute one’s share in life;
to enjoy life and to be able to love and be loved.
This is not just a matter of chemistry but of
training, education and practice in social rela-
tions.
Medicine and technology are perhaps the
glories of our civilization and culture. Possibilities
of industrial production are unlimited. The op-
portunities of leisure, the arts, physical recreation,
the enjoyment of nature, friends and the devotion
to others in nonremunerative activities has never
been so great. The possibility of freedom from
disease has never loomed so bright.
But what on the debit side? The darkness of
the depths and recesses of mental illness does not
receive the light, the warmth, the help of human
understanding which we possess, nor the interest
of fellowman which is healing, nor the financial
resources without which adequate treatment can-
not be given. The plight of the mentally ill in
our public hospitals is catastrophic, both financial-
ly and from the point of view of the suffering of
patients, families, relatives, children — the future
citizens. Six or ten million dollars for research
in mental illness is small change compared with
180 millions for general medical research, when
5 1 per cent of the hospital beds of our country
are devoted to mental illness, when only 5 per
cent of doctors are looking after patients in these
beds, and when there are eight to twelve million
people in need of psychiatric care. A five billion
dollar financial involvement and burden yearly
should not be treated lightly. Twelve million
Dr. Appel is professor of psychiatry, and chairman
of the department. School of Medicine, University of
Pennsylvania.
Presented at the 91st annual session of the Michigan
State Medical Society, Detroit, September 28, 1956.
By Kenneth E. Appel, M.D.
Philadelphia, Pennsylvania
children will sometime in the course of their
lifetime be relegated by our society to mental
hospitals. That is larger than the population of
Norway, Sweden, Denmark, Switzerland, almost
a quarter the size of England and France. Can
we afford such complacency? These are ulcers in
our social body that psychiatrists believe, in sig-
nificant measure, can be healed and even pre-
vented. We ask you and society to help in the
healing.
The form and appearance of the American
population is changing. Medicine through its
triumphs has enabled people to live longer. There
are thirty-three million people over fifty years
of age and seventeen million over age sixty. Yet,
American society has not looked with warmth and
favor on older people. America is the country of
the youthful, driving successful people. Industry
has not yet made places for the aging population.
Industry thus is in cultural conflict with medicine. |
Crowding and urbanization have made it difficult
for the older people. Crowded nursing homes
are not the answer, and neither are mental hos- i
pitals to which many of them now are sent. En-
feebled intellects in the elderly should not be met
by mental hospitals. Unfortunately, this is the
drifting, complacent outlet or terminus in many
instances. Some mental hospitals have 30 per cent
of their population in the elderly arteriosclerotic
and senile conditions. The aging population does
not need primarily psychiatrists and physicians.
They need nurses, of course, new kinds of social
workers, new types of counsellors and visitors, 1
vocations, hobbies and recreation.
The extent of emotional and mental illness and
its problems is significant and on the increase.
The statistics at present are that one out of twelve
babies born in this century will suffer severe
emotional disturbance so that at some time of
life it may enter a mental hospital. It is estimated
that there are between nine and thirteen million
people with nervous, mental or emotional troubles.
There are a million patients in our six hundred
mental hospitals each year. The resident popula-
1280
TMSMS
MEDICAL AND PSYCHIATRIC COLLABORATION— APPEL
tion is about three quarters of a million. Ad-
missions are around 350,000, of which over 100,-
000 are re-admissions, with over 200,000 new
cases. A quarter of a million patients are dis-
charged each year. This figure is increasing, as
are also the admissions. Increases seem to be oc-
curring in the senile and arteriosclerotic groups,
the alcoholic and probably also the schizophrenic.
There are, of course, no figures on the neuroses
in our population nor on the psychosomatic dis-
orders, nor character neuroses or psychopaths.
Halliday spoke of the lessening in Britain and
Scotland of various social “evils” before the last
war, such as improper feeding, impure milk, con-
taminated water, food which was not fresh, and
poor housing. There has been improvement in
the death rate, infant mortality, life expectancy,
decrease in infectious diseases and increase in
height and weight of children. On the other
hand, he felt that the psychologic health had been
worsening. As indices of community psychologic
ill health or social ill health, he pointed to a rise
in the infertility rate, the suicide rate, the nonin-
fectious arthritic rate, the gastritis-peptic ulcer,
exophthalmic goiter and diabetes rates.
There are 17,000 suicides annually in the
United States. There are 7,000 murders. There
were 1,800,000 eliminated from service in the
last war because of emotional difficulties. We
have 3J/2 million problem drinkers. There are
300,000 severe alcoholics. There are 50,000 nar-
cotic addicts. There are about two million serious
crimes committeed each year. Over a quarter of
a million children pass through the juvenile courts
each year, and the delinquency rate is rising. There
are almost 400,000 divorces.
Costs are staggering. Approximately one third
of the budget of one of our larger states goes for
the care of the mentally ill. State governments
pay 560 million dollars per year; the Federal
government spends 598 millions, including pen-
sions, for psychotic conditions. This makes a
billion dollars. Add one billion for loss in tax
dollars and three billion for loss of productivity.
This makes the mental health bill of the country
five billion dollars, which compares well with the
larger businesses of the country. For military re-
search, the figure has been a billion dollars, for
medical research 180 million, for agricultural
research 100 million, for mental health research
from 6 to 10 million per year. The salaries
October, 1957
paid psychiatrists in mental hospitals are woefully
inadequate. As to treatment, what can we expect
if the figure allowed for doctors’ salaries, nurses,
attendants, heat, light, plumbing, painting, food
and raiment is around $3.00 per day compared
with $12 to $18 a day in general hospitals? Of
course there are snake pits. Public education
about treatment instead of herding, regimentation
and custodial care is necessary. If better facili-
ties are not provided, certain groups will move in
and demand better socialized medical care.
Mental hospitals are piling up their population
at a rate of 16,000 a year. In ten years the cost
of increased facilities for these added patients
will be 2 billion dollars. The population is in-
creasing at the rate of 10 per cent in ten years, and
the mental hospital admissions have increased 40
per cent in the same period. We are on a tread-
mill. New methods of handling this problem can
and must be developed. A hospital providing in-
tensive treatment for acute cases in one of our
states kept patients thirty-two days as compared
with 676 days in the usual state hospital. Costs
were lessened in the acute hospital to $281 per
patient compared with $1,100 per year on the
average in State hospitals.
The overcrowding and understaffing in state
hospitals are tremendous. In a recent survey of
one of the state hospitals in a prosperous area of
the country, the hospital was found to be 49
per cent overcrowded. It was 75 per cent under-
staffed in doctors and registered nurses, and 50
per cent understaffed if nurses and attendants
were considered together. It was figured that if
doctors covered the patients each day, each patient
could be seen for twenty-one seconds. Other
comparisons were striking. If we take the fig-
ure that one out of twelve children will enter a
mental hospital some time in his life, that means
that 8 per cent of 150 million people, or twelve
million citizens of our country, will at some time
be patients in mental hospitals. This means that
we are going to carry a nonproductive popula-
tion larger than countries like Switzerland, Bel-
gium, Norway and Sweden. This represents not
just a medical challenge, but a social, economic
and humanitarian one. It certainly points to the
importance of research.
This may not be just a question of money, com-
fort or relief of friction and frustration. It may
be a question of survival. It is said that in fifty
years the United States will have a population
1281
MEDICAL AND PSYCHIATRIC COLLABORATION— APPEL
of 200 million people, while Asiatic countries will
have two billion. We cannot afford to neglect our
natural resources, and twelve million people in
mental hospitals in a generation are a wastage of
resources. There are indications that not only our
concepts of mental illness may need changing,
but that also our methods of treatment and pre-
vention need to be reviewed, revised and recon-
ceptualized.
“The statistics of severe psychiatric disorder form but
a segment of the mental health problem. They form
the background. . . . Every other bed in the nation is
occupied by these patients. Stress, strain and emotional
upheaval are the substance of which human life and
history have been made.* As Dr. Braceland says, it may
well be that they are more frequent and oppressing today
than ever before, with the competition and mobility of
modern society.
“It is not only the psychiatrist who must contend
with these forces and the aberrations they bring. ‘No
man is an Ilande, intire of itselfe,’ nor is any profession
or industry or any union of men. The welfare of society
is everybody’s business, and mental health subtends that
welfare as powerfully as any other factor generally rec-
ognized to do so. The exact stastistics of overt psychi-
atric disorder, of crime and delinquency, addiction and
other social illnesses are legion. In addition there is a
mighty aggregation of masked emotional disturbances
contributing to disorder relationships, work dissatis-
factions, absenteeism, accidents, marital and family prob-
lems and physicial illness itself.”
These are psychiatric problems, but they are
also social and economic ones. They are a medical
responsibility also. Nine or ten thousand psychia-
trists can never do the psychiatric job of this
country. If one-half of them are in state hos-
pitals, it leaves four thousand psychiatrists to take
care of the extra-mural psychiatry of a country of
160 million people. One thousand psycholanysts
cannot make much of a dent in this problem ex-
cept through teaching, research, public educa-
tion and the creation of optimism and public de-
mands for more psychiatrists and facilities. If
eighteen to twenty million patients go annually to
general hospitals; if over fifty million go to out
patient departments, then there are seventy mil-
lion people in our country who have close contact
with physicians, not including the private practice
of medicine. If 10 to 20 per cent of these have
important and even etiologically significant emo-
tional contributions or complications, then one
*The Mental Health and the Community, an ad-
dress given at the Mental Health Association of South-
eastern Pennsylvania, May 28, 1956.
1282
must add the millions of those seeing private gen-
eral practitioners, internists, pediatricians, to the
twelve million psychoneuroses and psychoses who
are in our general population — twenty million
people whose feelings, and emotions, are tremen-
dously important, contributing a hazard and
handicap to the pursuit of life, liberty, and the
enjoyment of health and satisfying activities. In
many, perhaps most of the psychologic or psychi-
atric problems of society, others than psychiatrists
must carry the teatment. This throws tremendous
burdens especially on the general practitioner,
who always has been and should be, I believe,
the backbone of medicine.
But medicine is too broad, too complicated,
for the individual physician. He needs the collab-
oration of others — - comprehensive medicine re-
quires an interdisciplinary approach - — general
practitioners, internists, psychiatrists, psychologists,
social workers, nurses, health aids, public health
and visiting nurses, volunteers, counsellors and
clergy. We probably need new professions we
have not dreamed of.
If feelings and emotions are so important in
the practice of medicine, we need more collabora-
tion of general practitioners and psychiatrists who
are supposed to be experts in feelings, emotions
and psychodynamics or the experimental factors
modifying and motivating behavior.
Frustration of basic needs produces tension
whether in the individual or society. If tensions
are overwhelming they produce catastrophic ill-
ness, such as mental illness, psychosomatic disease
or alcoholism. Typhoid fever, tuberculosis and
now polio have been largely conquered. Cancer,
coronary disease and strokes are the killers. The
latter two are tension illnesses, and who knows but
that destructive disequilibria in the body may not
be basically involved in cancer? Arthritis, high
blood pressure and stomach ulcers are on the
march. They are disabling forces in our society,
in our happiness, in our mental health. They
are in part, certainly, tension diseases. It is in
these areas that internal medicine and psychiatry
overlap and where collaboration sems most profit-
able.
How treat emotional disturbances, the more or
lesss permanent exacerbations of feelings such as
we find in anxiety states, neuroses, many psycho-
somatic conditions, personality disorders, and some
psychoses?
Psychotherapy, the guidance of one individual
JMSMS
MEDICAL AND PSYCHIATRIC COLLABORATION— APPEL
by another when there are emotional disorders,
has certain principles which many physicians have
known intuitively, and others from experience. It
is not esoteric. It involves the healing effect of
interest, the relaxing influence of patience, the
help of discussion, and the release of talking out
and getting things off one’s mind.
Psychotherapy is not merely an intellectual ex-
ercise as so many think, nor a matter of will
power. It is not a transference of ideas from doc-
tor to patient. It is not merely the development
of insight. It is not an argument. It is not ex-
hortation or a lesson in morality. It is not a battle
of wills. It is not an opportunity for the doctor
with his superior wisdom to improse his ideas
on the patient, make him feel inferior or humili-
ated. It is not an occasion for the doctor to
express his anger at the patient because of his
own frustration in treating the patient success-
fully.
Psychotherapy is an experience, and as such it
is a process of conditioning and growth. Like
growth much of it goes on unconsciously and
automatically. An automatic readjustment of the
emotional and social forces (which have been
conflicting and in tension) takes place. Psycho-
therapy is a social experience, that is, a relation-
ship with a doctor who wants to help his patient.
It is an experience, again I repeat, not an in-
tellectual exercise, in which the doctor’s attitudes
toward his patient are the most important levers
of therapy. The doctor should bear in mind cer-
tain needs of all people: the need for new ex-
perience, for security, for respect and a feeling
of individuality, and for responsiveness and under-
standing from another human being.
With the exhibition of attitudes of patience,
consideration, respect and responsiveness the pa-
tient will gradually identify with the doctor. The
doctor has a scientific, objective approach to
overwhelming situations and conditions. He is not
overwhelmed. He knows what to do. He has
plans of attack, through asking relevant questions
and exhibiting certain attitudes. The patient ab-
sorbs this point of view through identification with
the doctor, and gradually learns to meet problems
and difficulties by asking himself the same ques-
tions, and using the trial and error approach, with
repetition and practice.
The doctor sets the stage where his attitudes
permit the release of malignant emotional ten-
sions. When understanding of the complexities
October, 1957
of the human organism is so much beyond our
ken, there is a place for humility.
But getting well is more important than com-
plete understanding of all the causes of the illness.
In this connection, may I quote from Lord Grey:
“Nothing so predisposes men to understand as
making them feel that they are understood.”
Understanding, understanding of some of the
important concepts of modern psychiatry, of the
nature of emotional and mental illness and etiol-
ogy, can be of greatest influence. Pavlov and
Cannon have introduced important concepts for
medicine as well as psychiatry. So has Selye.
Stress is inextricably interwoven into life. Freud
has made more specific the implications of family
influences and childhood reverberations into adult
pathology. The work of Hebb and his co-workers
at Montreal, from the physiologic point of view,
forces on us new concepts of “mental” dysfunction.
Isolation from the support of customary sights and
sounds (stimuli) can produce psychopathology, for
example, hallucinations, paranoid tendencies and
delusions as are found in the mentally ill or after
the ingestion of toxic substances such as mesca-
line or lysergic acid. Gantt, Pavlov and Liddell
have produced nem’Otic animals by placing them
in situations where training and discrimination
conflict, and uncertainty and threats continually
present themselves. The fascist and totalitarian
brain washings and maneuvers to break ego func-
tion have used these methods.
Hebb, Liddell, Pavlov, Gantt, Cannon and Selye
introduced new concepts of pathology, stimula-
tion to our understanding, and a challenge to our
research and therapeutic resourcefulness whether
physiologic or psychologic. We are in a new world
in psychiatry and medicine just as atomic science
has introduced a new era in living and interna-
tional tensions. As Toynbee asks, “Can we develop
adequate response to the challenge?”
The discovery, mobilization and implementation
of new resources in people, whether by chemistry
and ataractics, kindness or constructive coopera-
tiveness, are important. Probably many more
people have recovered from serious mental and
emotional illnesses by ministrations of friends and
relatives and perhaps the fortunate turn of cir-
cumstances than we have any idea of. There is
probably a whole realm of psychiatry beyond that
of known statistics.
Research in psychiatry can be stimulated and
(Continued on Page 1292)
1283
Value of a Department of Physical Medicine
and Rehabilitation in a County Hospital
By Stanley Olejniczak, M.D., and
S. D. Jacobson, M.D.
Eloise, Michigan
T) HYSICAL medicine and rehabilitation is one
of the newest medical specialties and is recog-
nized as an integral part of medical practice. The
concepts and techniques of the specialty are now
being taught in many of the medical schools in
the United States. The American Board of Physi-
cal Medicine and Rehabilitation was established in
1947. Growth of the specialty was accelerated dur-
ing World War II when physical medicine became
a major service in the hospitals of the armed forces
and in other governmental institutions.
Physical medicine employs physical agents in the
diagnosis and treatment of the disease. As the
specialty has developed, it has come to include the
fields of physical therapy, occupational therapy
and rehabilitation.
Physical therapy utilizes physical and other ef-
fective properties of light, heat, cold water, and
electricity and employs different forms of thera-
peutic exercise, massage and manipulation.
Occupational therapy is medically prescribed. It
not only tends to improve the functional ability
of the patient, but also gives him a knowledge of
productive hobbies and trades.
Rehabilitation involves teamwork. It employs
various forms of physical medicine and psychoso-
cial adjustment and retraining. Its goal is to
achieve the maximum functional independence
and to prepare the patient physically, mentally,
socially, vocationally and economically to lead the
fullest life possible within the limits of his disa-
bilities.1
There is a growing need to establish more de-
partments of physical medicine and rehabilitation
in institutions caring for the chronically ill and
disabled. Recent advances in medicine and sur-
gery have been accompanied by a steady increase
in the number of permanently disabled people
Dr. Olejniczak is Director of Physical Medicine and
Rehabilitation, Wayne County General Hospital, Eloise,
Michigan.
Dr. Jacobson is General Superintendent and Physician-
in-Chief, Wayne County General Hospital, Eloise, Michi-
gan.
whose lives are saved. With saving of increased
number of lives, life expectancy has increased.
Two thousand years ago the average length of life
was about twenty-five years. At the turn of the
century it was forty-nine years. Today it is sixty-
six years. In 1900, one person in twenty-five was
sixty-five years of age or older; it is estimated that
in 1980 the ratio will be one in ten.2
In 1910, 26.5 per cent of the nation’s popula-
tion was over age forty-five and required more
than one-half the nation’s medical services. By
1 980 it is estimated that the number of persons
over forty-five will constitute nearly one-half of
the population.2
The increasing number of older people in our
population makes the problem of chronic disease
continually more pressing. It is estimated that
there are over seven million persons in the United
States disabled by diseases of the heart and arteries;
6.850.000 with rheumatism and arthritis; 2,600,000
with orthopedic conditions.3
During World War II, 19,000 amputations were
performed among our military personnel but over
120.000 major amputations were performed dur-
ing the same period among our civilian popula-
tion.3 It has been estimated that 2,500 men became
paraplegic as a result of the war, while 15,000
civilians became paraplegic during the same
period.4
Since the majority of patients in a county hos-
pital are in the older age group and chronically ill
and disabled, it would seem extremely important
that a department of physical medicine and re-
habilitation be established in these institutions.
This new medical specialty concerns itself with
dynamic medical and psychosocial care. Many
chronically ill and disabled patients who receive
such care are restored to a high level of physical
and mental function. Although a department of
physical medicine and rehabilitation in a county
institution would provide treatment for patients
with acute conditions, it is mainly concerned with
1284
TMSMS
DEPARTMENT OF PHYSICAL MEDICINE— OLEJNICZAK AND JACOBSON
Activities in the Department of Physical Medicine and Rehabilitation
rehabilitating patients with chronic disease. The
department could furnish therapy that would lead
to return of a normal life in the community, of a
significant proportion of the chronically ill and
disabled, now vegetating in our county institutions ;
at least it could develop in the minds of many of
these patients a higher level of self-sufficiency and
independence. Patients sent for custodial care
could be screened on admission to determine if
they might be rehabilitated. Successful screening
procedures and proper rehabilitation techniques
would reduce the cost of care of these patients
and lessen the demand upon the limited number
of professional personnel.
A department of physical medicine and rehabi-
litation in a county hospital could conduct educa-
tional programs with actual demonstrations to
stimulate agencies and organizations in the com-
munity to develop social services and work oppor-
tunities for the disabled. By educating the com-
munity to new concepts and methods of rehabilita-
tion it should make it easiter to return larger num-
bers of patients to the community to become self-
supporting and self-sufficient.
In the Department of Physical Medicine and
Rehabilitation at Wayne County General Hospital,
the major objective is complete physical rehabilita-
tion, which means training the patient in the ac-
tivities of daily living for complete functional
independence.
In this program the psychosocial problems are
investigated and, if the patient is employable, ar-
rangements are made, in conjunction with the
Office of Vocational Rehabilitation, for vocational
training or for job placement. If, however, a
patient in the older age group does not desire to
work or if employment is not feasible, the home
situation is explored and the members of the
family are properly informed of the disability and,
in many instances, patients are accepted by their
families after completion of the program in the
Department of Physical Medicine and Rehabilita-
tion. In every case in which the home situation is
favorable, even if the patient is severely disabled,
the family is informed of the progress of the
patient and the possible date of his discharge from
the hospital so that the proper arrangements can
be made in advance for taking the patient back
October, 1957
1285
DEPARTMENT OF PHYSICAL MEDICINE— OLEJNICZAK AND JACOBSON
into the home. We try to stress the role of the
relatives in meeting the needs of the patient. Even
if the patient is able to stay at home for only a
few months, we feel that the program is worth
while. If the period of hospitalization is too long,
the family may lose interest in the patient even
though he has regained his functional indepen-
dence or requires only minimal assistance; even
though he easily be taken care of by his family,
he may become a permanent resident of the insti-
tution. If employment is not feasible and if the
family is not willing or able to provide for him.
patients who have been rehabilitated to indepen-
dence are transferred to a ward for the chroni-
cally ill, where much less nursing service is required.
Activities for total rehabilitation at Wayne
County General Hospital were accelerated in July,
1955, by the appointment of a physiatrist in charge
of the Department of Physical Medicine and Re-
habilitation. A rehabilitation team has been or-
ganized and weekly conference initiated, with
presentation of patients. Evaluations are obtained
from the departments of surgery, medicine, psy-
chology and social service; the patients are pre-
sented and their problems discussed at the confer-
ence and realistic program of rehabilitation is
outlined.
Since inaugurating the program, a number of
patients with various disabilities have been success-
fully rehabilitated, some only physically and others
completely. The largest single group consisted of
amputees. In twenty-nine patients the amputa-
tion was below the knee, five bilaterally below the
knee, and ten above the knee. Two amputations
were the upper extremities, one above the elbow
amputation, and the other below the elbow.
Three paraplegics were successfully rehabilitated
after gaining functional independence in activities
of daily living with the aid of braces, crutches and
wheelchair. They were discharged home and now
two are awaiting to return to work in a factory,
and one to enter shelter workshop for vocational
training. Another paraplegic, who also walks with
braces and crutches for short distances and has a
good home situation, was sent to business college.
He is provided with hand controls for his car and
drives fifty miles to attend classes every day.
Recently a quadriplegic, with a spinal cord in-
jury at C-6 level, was discharged to her home to
assume some of the responsibilities of housewife
and mother. She was trained t6 perform some
Rehabilitation patient treated at Wayne County Gen-
eral Hospital.
activities of daily living and to control bladder and
bowel function, and was furnished with a wheel-
chair and hydraulic lift. She had no active motion
in either hand. Her brachioradialis was utilized
lor closing and opening of the hand by extension
of the wrist after insertion of a bone block between
the first and second metatarsal bones, fusion of the ij
interphalangeal joints in slight flexion, and teno- ;
desis of the flexor digitorum longus and attach- I
ment to the radius. She was provided with a splint
lor the left hand, and after being trained was able
to feed herself, brush her teeth, comb her hair
and even write.
Several hemiplegics that were discharged from
the hospital were provided with short or long I
double upright braces for the involved lower ex-
tremity and a special sling for the involved upper i
extremity.
We have found that it is important to start I
patients on a program of rehabilitation , as early j
as possible. Patients usually go through a period
of psychologic readjustment to their disability. If
realistic programs of physical rehabilitation are in-
stituted soon after the acute phase, the adjustment
period is usually shorter and more successful. The \
patient undergoing rehabilitation, if properly mo-
tivated from the. beginning, thinks of how to live
with his disability and* how to make the most of
what is left of his functional abilities. If a patient,
after the acute phase of injury, is placed on a ward
1286
JMSMS
DEPARTMENT OF PHYSICAL MEDICINE— OLEJNICZAK AND JACOBSON
or the chronically ill and rehabilitation postponed,
ie may gradually become dependent on institu-
ional life, losing all incentive. Leading a depen-
lent life, the patient’s disability may gradually in-
rease in severity. For example, contractures of
oft tissues, weakening of muscles or decubital
dcerations may develop. These complications re-
ard the process of rehabilitation. Many paraplegic
md hemiplegic patients and amputees have been
lospitalized for many years at Wayne County Gen-
eral Hospital and have adjusted themselves to
institutional life. They have contact with the out-
side world by radio and television. A forty-year-
old paraplegic with injury of the cord at the level
of the 10th dorsal vertebra has been hospitalized
for twenty-eight years, twenty-one years in this
institution. He is almost constantly in bed and
only on special occasions has he been able to sit
in a wheelchair. He has developed subluxation
and complete fusion of both knees. After several
fractures, one of the lower extremities was am-
putated. Through the years he has had numerous
decubiti. He is above average intelligence, but
when approached with a definite plan for rehabi-
litation, he flatly refused, stating that he was too
old and would not be able to accomplish anything.
His situation results from doing too little, too late.
There are other hemiplegic patients and amputees
who have been hospitalized for shorter periods,
who have the same attitude towards possible re-
habilitation. They are all afflicted with the same
type of “hospitalitis.” Many attempts have been
made to work with these patients to make them
more independent and although they have agreed
to start the rehabilitation program, they have put
little effort into it. Many times when improvement
in function was noted, the patient would imme-
diately refuse to continue the program and would
start to have various complaints. Investigation of
these complaints usually resulted in negative re-
ports.
We may cite one case to illustrate how the De-
partment of Physical Medicine and Rehabilitation
can screen patients who are sent to the institution
for custodial care to determine which ones may be
successfully rehabilitated or at least made func-
tionally independent.
A thirty-three-year-old woman was sent to Wayne
County General Hospital from another institution after
being hospitalized there for six months for custodial
care. Her diagnosis on admission was transverse myelitis
of unknown etiology with involvement of all extremities.
She had a sacral decubitus about 5 cm. in diameter and
had no control of bowel or blader function. The pa-
tient was on a Stryker frame. A careful examination
revealed all muscle groups in the extremities were at a
fair minus to fair level. A program was instituted to
re-educate her and strengthen her muscles. Training
of bowel and bladder control was begun. Gradual
ambulation was started after endurance in sitting and
standing was improved. The patient was very difficult
to manage and uncooperative at the beginning of the
program and would not even feed herself, stating that
she had no hope for recovery. However, when she
was removed from the Stryker frame, she was persuaded
to feed herself in the sitting position. She was informed
of the possibility of her becoming independent and of
returning to her family. The patient then became more
cooperative and put more effort into the prescribed
exercises and activities of daily living. After three and
one-half months on a program of rehabilitation, the
patient regained bowel and blader control and was able
to ambulate with crutches. She gained fifteen pounds
in weight. The sacral decubitus gradually healed with-
out the necessity for surgical intervention. On a re-
turn visit, one month after discharge, she stated with
tears in her eyes that she was the happiest person in
the world, because she was now able to take care of
her children and be back with her family.
Rehabilitation can be successful even in the most
severely disabled patient, if the program is planned
realistically with practical goals.
A patient, a forty-three-year-old white man, who had
been afflicted with multiple sclerosis since the age of
eighteen, was referred to the department from the In-
firmary Division. With progression of the disease and
confinement to bed over the years, he had developed
severe spasticity and gradual paralysis of both lower
extremities, severe flexion contracture deformities and
a dislocation of the left hip. Both his legs were flexed
in a fixed position on his chest with knees almost touch-
ing his chin. He had lost bowel and bladder control,
necessitating the use of a perineal catheter. A large
sacral decubitus had developed. Disarticulation of both
lower extremities at the hips was carried out. Follow-
ing surgery, the patient started to use a wheelchair,
participate in social life, move around and visit with
older patients. To the casual visitor he was the happiest
man in the world, always smiling and joking. To in-
crease his activities it was decided to change the perineal
catheter to the suprapubic area. The sacral decubitus
is healing gradually and after debridement it appears
that no other surgical procedure will be necessary.
The patient is being trained in wheelchair activities and
to participate in activities of daily living with the goal
of attaining full functional independence. Plans are
being made for this patient to return to his parents’
home. Fie will be provided with a special wheelchair,
a bedside commode, and an overhead bar. He will re-
October, 1957
1287
DEPARTMENT OF PHYSICAL MEDICINE— OLEJNICZAK AND JACOBSON
quire very little assistance, whereas previously it was
impossible for his parents to care for him at home.
Since he had some experience in drafting, the Office of
Vocational Rehabilitation is planning to assist him in
obtaining a homebound job.
The chief function of a Department of Physical
Medicine and Rehabilitation in a county institu-
tion is to attempt to obtain total rehabilitation of
the physically disabled through integration of dif-
ferent services. It is necessary to a “team” ap-
proach among the personnel working with the
patient.
Patients who successfully complete programs of
physical rehabilitation are either sent back to their
previous jobs or placed on job training in order to
become productive members of society. Elderly
patients who cannot be re-employed, even though
they have gained physical independence, can be
sent home or to nursing homes to lessen the bur-
den of nursing care in the hospital.
Successful programs of rehabilitation will release
beds for new patients which is vital to the institu-
tion and means savings of thousands of dollars to
the community. The human aspects of rehabilita- i
tion, such as restoration of dignity, self esteem and
happiness, cannot be assessed in dollars.
References
1. Krussen, F. H.: Physical medicine and rehabilita-
tion for the clinician. Philadelphia: W. B. Saun-1
ders, 1951, p. 2.
2. Rusk, H. A.: The broadening horizons of rehabili-
tation and physical medicine. Arch. Phys. Med., |
30:26-28, 1949.
3. Rusk, H. A.: Dynamic therapeutics in chronic
disease. Postgrad. Med., 5:278-287 (April) 1949.
4. Rusk, H. A. : Meeting the needs and life problems
of the paraplegic patient. New York: Institute of
Physical Medicine and Rehabilitation, New York
University-Bellevue Medical Center.
BEHAVIOR PROBLEMS
(Continued, from Page 1270)
turn because of faulty administration of their
medicine by relatives and friends — none had gone
to their family doctor as we had recommended.
It is within the power of each of you to further
the work that we, in your state hospital system,
have undertaken. We have broken the treatment
barrier so that you can now successfully control,
ameliorate or reverse most of your abnormal be-
havior problems.
Therefore, I ask you individually, and as a So-
ciety, to consider the problems of prevention and
follow-up, and the part you can play in making
this a better world in which to live.
PSYCHIATRIC ASPECTS OF GYNECOLOGIC CARE
(Continued from Page 1279)
pseudopsychiatrists. Many of our cases do need
experienced and trained psychiatric care; these
we should be quick to recognize. Many more,
however, are desperately looking for the kind of
sympathy and understanding, the psychologic sup-
port given by the old-fashioned family physician,
and this is the help we are in a favorable position
to offer. Recognition of this by those in our
specialty may, in the long run, become the great- :
est contribution any group of clinicians can give i
to the mental and physical health of the women of
our country.
1288
JMSMS
he Importance of Differentiating Petit Mai
rom Other Forms of Minor Seizures
1
HE introduction of electroencephalography as
an aid to neurologic diagnosis has helped con-
derably to differentiate various forms of minor
:izures. Prior to the use of electroencephalo-
raphy, the term petit mal was employed to cover
wide variety of epileptic seizure phenomena
hich last only a short period of time, usually up
) three to four minutes. The increase in knowl-
dge about seizure patterns and their presumed
By E. Rodin, M.D.
Ann Arbor, Michigan
The petit mal seizure is characterized clinically
by abrupt loss or diminution of awareness, which
interrupts the patient’s stream of thought or motor
activity for a period of ten to forty seconds. The
patient may merely have a vacant staring expres-
sion of his eyes or there might be in addition some
slight blinking of the eyelids, at the rate of three
blinks per second. In other instances there may
also be some visible nodding of the head or mild
TABLE I. DIFFERENTIATION BETWEEN PETIT MAL AND PSYCHOMOTOR OR TEMPORAL LOBE SEIZURES.
DIAGNOSTIC CASES
PETIT MAL SEIZURES
‘PSYCHOMOTOR”— “TEMPORAL LOBE” SEIZURES
Aura None
Consciousness Lost or severely impaired
Motor Activity None or some jerking of eyelids at the rate
of three jerks per second. At times also
rhythmic jerks of the head or arms
Duration 10-40 seconds
Postictal Patient is fully oriented may be amnesic
for seizure
During seizure 3c/s spike-wave in all head areas
EEC
During interval
Etiology
Age of onset
Interictal emotional
disturbances
Most effective drugs
Frequently minor
Hereditary, idiopathic
Around three years
Frequently normal
Tridione, Paradione, Milontin, Ampheta-
mines, Diamox
Frequent, consists of a great variety of somatic, visceral or sensory
phenomena
Lost or severely impaired, but at times retained. “Mental Di-
plopia ”
Chewing, smacking or swallowing motions, performance of complex
automatic acts. At times no motor activity visible
1-2 minutes
Is confused, drowsy, possibly aphasic, may be amnesic for seizure
Seizure pattern complex, either high voltage 6c/s activity most
pronounced in the temporal areas, or focal slow wave activity in
temporal areas, generalized slow wave activity. And other types
of seizure patterns
Usually focal abnormality in one or both temporal areas
Usually acquired, although hereditary factors may be present in
addition
All ages, but more frequent in adolescence and adulthood
Frequently marked
Dilantin, Mesantoin, Phenurone, Mysoline, Phenobarbital
>rigin has allowed the separation of various groups
>f minor seizures. The two largest groups are true
>etit mal and minor seizures of the “psychomotor”
>r “temporal lobe” variety. The patients who
>elong to either group are usually sufficiently
lifferent in their clinical manifestations, electro-
:ncephalographic findings, etiology of seizures,
irognosis, and response to therapy, so that the
finician should try to make an accurate distinc-
ion between them. The main differences are sum-
narized in the accompanying table. Since neither
>f the terms “psychomotor” seizures or “temporal
obe” seizures is completely satisfactory, both terms
ire used at present more or less synonymously.
From the Neuropsychiatric Institute, University of
Michigan, Ann Arbor, Michigan.
October, 1957
to moderate bilateral jerkings of the arms and,
occasionally, the legs. This is usually also at the
rate of three jerks per second. The seizure ends
abruptly and the patient immediately afterwards
continues what he had been doing prior to his
attack, without mental confusion.
The electroencephalogram reveals during the
seizure the classic 3c/s spike-wave pattern de-
scribed by Gibbs and Lennox in 1937. This usual-
ly starts suddenly in a bilaterally symmetrical and
synchronous manner involving all head areas, and
terminates abruptly when the patient becomes re-
sponsive again. The more pronounced the spike
component of the discharge (especially if multiple
spikes are present which are followed by a wave) ,
the greater the likelihood that the previously men-
1289
PETIT MAL AND OTHER MINOR SEIZURES— RODIN
tioned clinical myoclonic components of the seiz-
ure are pronounced or that the patient suffers in
addition from grand mal convulsions. The patients
with petit mal, as defined here, are usually chil-
dren or young adults and are as a rule extremely
sensitive to such activating procedures as a period
of hyperventilation, small doses of Metrazol. or
intermittent photic stimulation. The sensitivity to
hyperventilation is usually to such a degree that
this may be conveniently demonstrated in the clini-
cian's office and a positive diagnosis can be estab-
lished. even without electroencephalography, on
basis of the typical clinical picture alone. Xo
other seizure type is as easily reproduced by a two
to three minute period of deep breathing as is
petit mal.
hile petit mal seizures are thus reasonably
simple in their pattern, the "psychomotor" or
"temporal lobe" variety of minor seizures is fre-
quently rather complex. The attack may start with
immediate loss of consciousness or. more frequent-
tly. with an aura. The aura — which is. of course,
actually the onset of the seizure — may consist of
a variety of visceral sensations, the most common
being a knot or lump in the stomach which rises
to the throat. Following this there is frequently
dizziness, which may be a sensation of lightheaded-
ness or of impending blackout or mav be a true
subjective or objective vertigo. After this, loss of
consciousness frequently ensues. In other instances,
the patient may experience a sudden fear sensa-
tion before blacking out or may be aware of altera-
tions in space perceptions, of a dreamy sensation,
or have an olfactory, visual or auditory hallucina-
tion. The patient may remember these clearlv
after the attack or may only be aware of having
had a hallucinatory experience the content of
which he is unable to recall. During the attack
the patient usually retains his posture: he may
continue his activities in an automatic fashion or
may "freeze to a chair, table, or kitchen stove.
There are. frequently, lip smacking, chewing mo-
tions of die jaw. and swallowing motions. These
may be very pronounced or only faintly visible.
Other motor activities, if the patient does not re-
main "frozen, may include repetitive and rather
purposeless movements of the upper or lower
extremities, such as plucking at clothes, waiting an
arm. stamping a leg. or die like. The variety of
these acts is practically infinite in die various pa-
tients. although die seizures are usually alike in
any given patient. This phase of the seizure lasts.
usually, one to two minutes during which time the
patient is totally unresponsive.
Following this, the patient becomes gradually
more responsive and during the recuperation is
likely to show signs of mental confusion, drowsi-
ness or nervousness. The patient may be physi-
cally or verbally abusive, may complain of a head-
ache and. if the seizure arose in die dominant
hemisphere, frequently exhibits a noticeable
aphasia. This consists initially of a complete ina-
bility to talk and an inability to name objects: if
the patient can say anything at all it is fill-words
like, "ah. ah,” “ves,” “you know,” “shucks.” and
the like. Later, as cerebral recovery progresses,
the patient becomes more fluent but may still be
confused as to time and place. This postictal state
lasts up to five to ten minutes. Although one is
able to communicate with the patient during this
time and may even receive seemingly rational
answers, especially if there is no aphasic compon-
ent. the patient may later have complete amnesia
for the entire sequence of events and ten minutes
later may even vigorously deny having had a seiz-
ure at all. In other instances, there may be am-
nesia only for some aspects of the seizure and.
especially during a "dreamy state” or hallucina-
tory experience, the patient may be aware of his
surroundings as 'veil as of the content of the hallu-
cination. This is the state which Hughlings Jack-
son termed “mental diplopia.”
The electroencephalogram during one of these
attacks shows a variety of seizure patterns. There
may be a high voltage 6c s rhythm present, most
pronounced in the temporal areas, or diffuse slow
wave activity or focal spike and sharp wave activity 1
may appear in one temporal area. At times the-
electroencephalogram may be so distorted by
movements of the patients that the seizure patterns
can not be seen clearly at the time of the attack:
but during the postictal confusion state there is
frequently a pronounced slow wave focus in the f
temporal area on the side where the seizure arose.
This slow wave focus may persist up to several ,
hours, depending on the severity of the seizure. In i
contrast to patients with petit mal, who frequently j
have normal interictal records, the electroence-
phalogram in the majority of the “psycho-
motor" or "temporal lobe" seizure patients shows j
abnormalities, usually located in one or both tem-
poral areas, even in the resting state. Hyperventi-
lation is not as effective in producing a seizure
as in petit mal. and if a seizure is precipitated ii
JMSM:
1290
PETIT MAL AND OTHER MINOR SEIZURES— RODIN
isually does not occur during the hyperventila-
ion effort but rather about thirty to sixty sec-
nds after cessation of the overbreathing. While'
j ietit mal occurs usually in children and adoles-
ents, psychomotor seizures occur most commonly
n adolescents and adults, although no age is
mmune.
If the above criteria are kept in mind, a differ-
ential diagnosis can usually be established on clini-
al grounds alone. It may, however, be difficult
! o differentiate some minor seizures of the “tem-
)oral lobe” variety from hysterical attacks. This
lifficulty is increased markedly if the seizure shows
mly minimal or atypical motor components and
especially if it does not pass through the entire
.equence of events described above but ends, for
nstance, after the aura. In such cases, it is highly
mportant to observe an attack in the labora-
ory while the electroencephalogram is recorded.
Seizure patterns in the electroencephalogram dur-
ng the attack are diagnostic of the convulsive na-
:ure of the disturbance.
The differentiation of petit mal from other
forms of minor seizures is not only of academic
interest, but is also of immediate concern for the
management of the patient. Petit mal, with or
without grand mal convulsions, is nearly always
on a genetic hereditary basis and almost never on
the result of birth injury, encephalitis, brain tumor,
or trauma. The hereditary factors may not be
obvious if one directs attention only to the pres-
ence or absence of grand mal seizures in the sib-
lings and parents but they become soon apparent
f habitual fainting spells, febrile convulsions,
‘worm fits,” seizures after alcohol ingestion, et
eetera, are also taken into account. Lumbar punc-
:ure and pneumoencephalography can be dis-
oensed with in the classic case.
The prognosis in regard to the disappearance of
oetit mal seizures in adolescence and early adult-
hood is fair, although the petit mal attacks may
)e superseded by grand mal convulsions and, later
n life, “temporal lobe" seizures may also develop.
\s long as there is only pure petit mal present, the
ntellectual and emotional development of the
:hild is likely to be reasonably normal. Behavior-
vise, the patients do not present, as a rule, any
narked difficulties unless their seizures come so
requently that one can speak of a petit mal status.
Hre patients may then present, clinically, either a
Jsychotic or a hysterical picture. The drug treat-
nents of choice are: Tridione, Paradione prefer-
Dctober, 1957
ably each of these two 'drugs should be combined
with Dilantin in order to forestall the develop-
ment of grand mal convulsions), Milontin, Am-
phetamines, Diomax or Prenderol. A ketogenic
diet is occasionally also of benefit. There are no
operative procedures available which are of any
help.
The other forms of minor seizures have different
implications. Any minor seizure which is not petit
mal is likely to have demonstrable organic patho-
logy as its basis. Although hereditary factors fre-
quently play a role, there is an equally large factor
of acquired pathology. This may be on the basis
of birth injury, other head trauma, early encephali-
tis, a porencephalic cyst, or other congenital mal-
formation in children; of brain tumor, cerebral
degenerative, or vascular disease in adult patients.
Contrast radiographic studies, like pneumoence-
phalography or angiography, have to be carried
out in many instances for final diagnosis. In chil-
dren and adolescents the intellectual development
may be normal, but more or less severe emotional
disturbances are usually present. Hyperactivity,
excessive mood swing, unmanageable and unruly
behavior, inability to concentrate, temper tan-
trums, and excessive masturbation are frequently
outstanding features. If the seizures also involve
the middle and posterior portion of the temporal
lobe, with resulting auditor)7 and visual hallucina-
tions, the patient may present a clinical picture
suggestive of either severe hysteria or psychosis.
The above mentioned emotional difficulties are
also commonly seen in adult patients with frequent
minor seizures of this type and suicide attempts
occur often in this group of patients. The prog-
nosis of spontaneous improvement of the seizures
during adolescence and adulthood is rather poor,
and most patients are able to make only a margi-
nal social adjustment, despite some happy excep-
tions. "Epileptic deterioration” is most frequently
observed in patients with this type of seizure
pattern.
The seizures are often very difficult to control
pharmaceutically. The drugs which are relatively
effective are: Dilantin. Mesantoin, Mysoline,
Phenobarbital, Phenurone, or mixed preparations
like Mebaroine, or Phelantin. A ketogenic diet is
of no apparent value. If there is a definite uni-
lateral focus, limited to the anterior portion of one
temporal lobe, surgical resection of this part of
the temporal lobe may lead to good results after
medical management has failed. The surgical
1291
PETIT MAL AND OTHER MINOR SEIZURES— RODIN
approach, however, should be limited to patients
with no evidence of separate involvement of the
other temporal lobe and where a conservative
regime, of adequate medication and a sympathetic
psychotherapeutic approach directed toward les-
sening of tension, has failed.
Summary
1. The difference between true petit mal and
other forms of minor seizures is emphasized. True
petit mal occurs usually in childhood and consists
of “absences” without warning. These last usually
between ten and forty seconds and are not fol-
lowed by mental confusion. During the seizure
some rhythmic blinking of the eyelids, nodding of
the head, or slight jerking of the arms or legs
may be noted. The EEG shows usually a classical
3c/s spike-wave pattern and is frequently normal
in between seizures.
2. The most common form of other minor seiz-
ures is the “psychomotor” or “temporal lobe”
variety. These seizures frequently have a warning.
They last about one to two minutes and are fol-
lowed by a two to five minute period of mental
confusion. During the seizure, itself, complex
muscular movements may be carried out and a
variety of sensations may be experienced, with
complete or incomplete amnesia afterwards. The
EEG shows complex patterns during the seizure
and in the interval a focal abnormality, involving
one or both temporal areas, is frequently present.
3. Petit mal is one of the classic forms of
“idiopathic” or “genetic” epilepsy. Lumbar punc-
ture and pneumoencephalography can be dis- |
pensed with if petit mal is present alone or accom- »
panied by grand mal seizures which are not pre- j(
ceded by an aura.
4. Other minor seizures are usually of the
acquired type; hereditary factors, if present, are
somewhat less important than in petit mal. Diag-
nostic procedures, like pneumoencephalography
and/or angiography must often be carried out to
exclude a mass lesion.
5. Petit mal patients do not present, as a rule,
overt behavior problems ; patients with other forms
of minor seizures frequently do.
6. The more useful drugs in petit mal are Tri-
dione, Paradione, Milontin, Amphetamines, Dio-
max and Prenderol; other forms of minor seizures
respond better to Dilantin, Mesantoin, Mysoline,
Phenobarbital or Phenurone. If all medical man-
agement has failed and if the focus of pathologic
activity is limited to the anterior portion of one
temporal lobe, surgical ablation of this area may
be of benefit.
References
1. Gastaut, H.: The Epilepsies, Electro-Clinical Cor-
relations. American Lecture Series No. 204. Spring- :
field, Illinois: Charles C Thomas.
2. Penfield, W., and Jasper, H. : Epilepsy and the
Functional Anatomy of the Human Brain. Boston:
Little, Brown and Company, 1954.
3. Lennox, W. G.: Science and Seizures. New York, 1
London: Harper and Brothers, 1946.
4. Gibbs, F. A., and Gibbs, E. L.: Atlas of Electro-
encephalography; Epilepsy, Volume 2. Cambridge,
Massachusetts: Addison-Wesley Press, Inc., 1952.
MEDICAL AND PSYCHIATRIC COLLABORATION
(Continued from Page 1283)
facilitated by physicians. It has lagged far behind
other branches of medicine.
Psychiatrists and physicians can collaborate in
treatment. Beyond this they can help to change
the public attitude toward mental and emotional
illness which to a great extent is understandable,
curable, and preventable. Physicians can help re-
move the stigma that is a primitive, prerational,
cultural inheritance. One only has to think of
Adams, Jefferson, Lincoln, Newton and Darwin
to realize that severe emotional disturbances do
not occur alone in weaklings.
Finally, a benevolent tolerance, criticism and
helpfulness in the realization of the great handicap
under which psychiatrists, especially in public hos-
pitals, labor will help relieve or lighten a stagger-
ing burden which our society is often needlessly
carrying.
1292
JMSMS
yledicine and Labor in These
Changing Times
.
By Walter P. Reuther
Detroit, Michigan
^7" OUR INVITATION to contribute this year’s
installment to the distinguished series of Biddle
-ectures before the Michigan State Medical So-
iety comes as a signal honor to me as an in-
ividual and to the Union I represent, the United
lutomobile Workers. As an individual, I shall
lways be profoundly grateful for the fact that in
948, after being almost mortally wounded by
shotgun blast through the window of my home,
was put back together again. I know it was
nly through the skill and dedication to service
4 the physicians who gave my case immediate
ttention, in many cases at great inconvenience
0 themselves, that I am not only still alive today,
>ut can function as a physically whole person,
"or the rest of my life, I shall carry with me
;reat respect, affection and appreciation for the
nany doctors whom I came to know as a pa-
ient during those critical days.
I share with many Americans a deep sense of
low much better life has become as a result of
he striking advances in medicine. Millions of
leople are today living with diseases that would
lave meant certain death only a few decades
igo. The major infectious diseases have been vir-
:ually conquered. Rehabilitation of amputees and
laraplegics borders on the miraculous and offers
new hope for millions of victims of the major
Tronic diseases. Almost certainly there lies ahead
1 break through in our understanding of how
:ancer destroys the processes of life, the dis-
:overy of new methods for the detection and
ireatment of cancer and heart disease, and the
ipplication of new tools and understanding to
:he conquest of mental disease. These must be
:hallenging and rewarding times to be a physician.
These advances have made modern medicine
nherently more expensive. The worker has had
:o find ways to allocate more money to health
Biddle Lecture presented at the ninety-second annual
session of the Michigan State Medical Society, Grand
Rapids, Michigan, September 25, 1957.
Inasmuch as Mr. Reuther, because of illness, could
aot be present at the session for which the lecture was
scheduled, his address was read by Leonard Woodcock,
/ice president of United Automobile Workers.
October, 1957
care, to pay and arrange for it in advance and
to share its cost. Health insurance has become
nothing less than essential and its further de-
velopment inescapble. And in the process, labor
and medicine have become more dependent on
each other than ever before.
I think it can be said fairly that while medical
societies may have entered prepayment reluctant-
ly in order to avert government medicine, labor
entered voluntary health insurance reluctantly
because a government program was not available.
The original motivations of both medicine and
labor are now of only academic interest. What
is far more important is that both are actively in-
volved in prepayment and our common problem
is to make it work.
To accomplish this we face some troublesome
and unsettled questions — the scope of health in-
surance; setting of fees and methods of remunera-
tion that are adequate, on the one hand, and
equitable on the other; finding ways for health
insurance to contribute to the best development
of good medical care. Whenever two groups are
thrown together as are medicine and labor some
friction will be generated. I am not too worried
about the friction generated by these problems. I
hope that this meeting will lead to a better under-
standing between organized medicine and or-
ganized labor. Such understanding is absolutely
essential for the fullest development of medicine
and for the sound financing of health care.
I would like to tell you a little about unions,
because I fear that normal sources of information
in the community often do not give an accurate
or balanced picture of the trade union movement.
Through most of history the balance has been
heavily weighted against the working man as an
individual. Workers came to organize unions in
order to get a better share of the good things of
life. Only through association could he aspire
to make real economic progress not only on the
wage front but in terms of the broader gains of
economic security, justice and dignity.
Unions are now looking at the length of the
1293
MEDICINE AND LABOR— REUTHER
work week and again, as when labor campaigned
to reduce the twelve hour day, we find that
leisure is supposed to be O.K. for others but that
it leads merely to licentiousness in workers. Evi-
dently, this is one argument that hasn’t changed
much with the times. As wage payments are not
enough to assure economic security when the
worker is too old or unable to work, labor turned
to various forms of social insurance — pensions,
when the worker became too old to work and too
young to die; unemployment insurance, guaran-
teed annual wage plans, compensation for work
injuries and other such programs. It was neces-
sary to protect the worker against hazards to his
health and safety on the job and this was why
some of the early labor health centers were estab-
lished.
I think that our Union in particular draws its
effectiveness and inherent strength not only from
struggling for a better life for its members but
from its moral concern that labor’s gains must
be accomplished together with, and not at the
expense of, the community. Our members today
have cost-of-living elements in their pay. We,
nevertheless, are concerned with the rising cost
of living. It was no publicity stunt when last
month I called upon the presidents of the major
automobile companies to join with us in the first
steps to reverse the tide of inflation.
It is possible to make economic gains without
democracy and in some parts of the world ad-
vancement has been achieved at the expense of
freedom. One of the great challenges of today
is to prove the compatibility of economic security
and political liberty. I believe our union to be
the most democratic in the world. Our members
are free to criticize and they do criticize; our
members can remove their leadership, and they
do it at times; our members can reject proposals
advanced by their leadership and they do so;
and recently we have created an independent
body entirely outside of the union structure to
which members can have recourse with their
complaints about the union.
We have, it is true, pioneered in many new
social programs through collective bargaining;
pensions, supplemental unemployment benefits,
higher levels of disability protection and so forth.
Almost every one of these programs was original-
ly characterized as “destructive of the American
way of life.” All are now regarded as worthwhile
to the worker, good for the company, helpful to
the economy and good for the country as a whole.
The fact that society now acknowledges the value
of past gains has not inhibited many people from
criticizing each new proposal in the same old way.
Practical bargaining gains like these that have
been hammered out over the bargaining table re-
flect the best joint thinking of management and
labor and have made a great contribution to the
prosperity of America. Be assured that this prog-
ress is not at an end.
Our position also derives its strength because
demands advanced in collective bargaining arise
out of workers’ basic needs. Ultimately the con-
tribution of labor leadership depends on its ability
to know what workers want and need as accurate-
ly as possible. When the UAW takes a position
on a large issue it does so only after it has made a
careful study of the problem and after the issues
have been thoroughly considered and debated by
a convention of over 3,000 delegates, freely elected
by secret ballot from among the rank and file of
the Union. Our collective bargaining negotiations
with the major automobile companies are pre-
ceded by a whole series of meetings at which
elected delegates from plants all over the country
have had an opportunity to discuss and act on
these demands.
However much the newspapers, may criticize
each new demand that the Union makes, the fact
is that once the membership, through democratic
processes, decides that demands arise out of real
needs and they are economically sound, they will
back them up — even at great sacrifice. In 1950,
when the Chrysler Corporation refused to pro-
vide funded pensions, the Chrysler workers stayed
out on strike for 104 days to nail home this is-
sue of funding. And when Henry Ford II in-
sisted that the workers would prefer a stock par-
ticipation plan instead of the guaranteed annual
wage that they were demanding, the Union quick-
ly offered to put the question to a test by secret
ballot. At this point, Ford management promptly
withdrew its proposal and began to bargain in
earnest.
I am little concerned about the lack of under-
standing on the part of some in medicine toward
labor and a tendency to disparage the legitimate
abjective of the trade union movement. The pres-
ident of a local medical society recently attacked
our proposal for a shorter work week. He said
this was leading in the direction of a “no work
week” and characterized the objective of union-
1294
.TMSMS
MEDICINE AND LABOR— REUTHER
sm as “security, idleness and play.” As for se-
:urity, millions of Americans, including doctors,
vant and need ecomonic security. Security isn’t
:heir only goal but it is an important one. It
foesn’t rank first and neither do idleness and
day rank second and third for any group of
hinking Americans, including unionists. Ameri-
;an labor is not only concerned with a fair share
>f economic gains for the working man but, with
ill Americans, we are concerned with the great
aroblems of peace, abundance and democracy,
[f the medical profession accepts only a carica-
ture of these aspirations it will only harm itself
in failing to understand the issues that motivate
the majority of the people. If it tries to under-
stand these motivations it will realize that the
quest for security is not at odds with medical
practice any more than is the quest for health.
People need good programs of economic and
health security. Such programs can be worked
out in a manner that will enhance medical prac-
tice rather than harm it and to the satisfaction
of the medical profession as well as to the public
at large.
When workers have complaints about their
medical insurance they are more likely to come to
the Union that has negotiated the insurance plan
than to the Medical Society. Our members bring
us many complaints about medical insurance. The
worker wants to know why, after paying his
premiums, he has to lay out substantial amounts
to the doctor when he has an operation. He wants
to know why he can get x-ray tests only when
hospitalized. He wants to know why so many
medical services are not covered by insurance.
He wants to know why the insurance so often
fails him in serious illness.
The Union screens out unjustified and exces-
sive demands for service. It plays a very import-
ant role in telling the worker, in relation not only
to his insurance but to his labor-management con-
tract rights — when his demands and grievances
have no merit or cannot practically be realized
or corrected. But I cannot conscientiously quar-
rel with union members when they want prepay-
ment to cover a bigger segment of health care
for a longer period of time, and not be limited
to bills for the hospital and the surgeon, or when
they demand real value for their insurance money.
These are not ideological problems; they are prac-
tical. They can be answered. The question in
America, as far as millions of wage earners are
concerned, is not whether they are going to have
adequate prepayment programs. The question is,
“How?”
The president of the American Medical As-
sociation recently deplored labor demands for
full payment of all items in medical care. He
accused labor, by setting this improperly high
standard, of disparaging the performance of ex-
isting plans. This charge doesn’t even come close
to the real issue. We are not, as Dr. Allman seems
to think, arguing about extending insurance from
covering most of the cost of health to covering
all of it. Present insurance plans, at best, cover
only one-third of the average family’s health
service bill, and we are trying to get benefits ex-
tended to cover about another third of health
needs. The present deficiencies, rather than ex-
cessive demands by labor, constitute the main
problem in health insurance today.
Workers not only want more and better pre-
paid health coverage but they are willing to pay
for it. They know that truly comprehensive care
costs more. Although they are concerned with
rising costs and with some abuses and inefficiencies
in existing programs, they are not trying to reduce
doctors’ incomes, as has at times been charged.
The fact that employers pay premiums in full
or in part has led to the false assumption that
workers will make unreasonable demands for
health coverage because, somehow, they are not
paying for it. They are, because employer con-
tributions are monies the worker could otherwise
get in cash or other benefits. This is perfectly
clear at the bargaining table, where a certain
amount of money is applied to the hourly wage
rate, a certain amount to health security, a
certain amount to pensions, and so forth. The
money that employers contribute to these pro-
grams is just wages, in a form to best serve a
social purpose. Doctors have made great gains
out of the fact that the workers have earmarked
a portion of their wages as social wages. This has
permitted a greater economic allocation to the
cost of hospital and medical care, if only by the
fact that in this collective way workers as a
whole have been able to pay for medical care that
they could not have paid for on an individual
basis. The trouble is that this has led some
doctors to assume that the insurance has increased
the worker’s ability to pay, and they charge more
for their services. As a result, we have found that
the dollar paid by the employer and the worker
October, 1957
1295
MEDICINE AND LABOR— REUTHER
under the health plan is not worth as much as
the dollar paid out of pocket at the time the
service is performed. Those who are responsible
for the development of prepayment must assure
the beneficiary that he will receive full value for
his prepayment monies, if we are to increase the
allocation of our national income to personal
health services.
To the extent that medical societies entered pre-
payment to avert legislation, they were relatively
less concerned with finding the best possible way
for prepaying medical care. Rather than to
hammer out a whole new set of insurance prin-
ciples that could be properly applied to medical
care, they adapted the ready made doctrines of
casualty insurance. Inappropriate as they are,
they have been sanctified as “first principles”
which now conceal the lack of medical orientation
of too many of our health insurance programs. I
really don’t believe that the average doctor, with
his deep interest in medical services, is ready to
adopt the insurance industry’s concepts of losses
rather than benefits, indemnity rather than serv-
ice, financial devices to inhibit use, to eliminate
the small claim and to exclude predictable ex-
penses rather than preventive care, early diagnosis
and easy access to health services.
I fear that medicine is in danger of compound-
ing these errors when it flirts with major medical
programs like that at General Electric. What-
ever its current vogue, major medical epitomizes
the complete capitulation of medicine to insur-
ance.
A great gap exists today between the advanced
state of medical science and the kind of medical
care received by the bulk of working people. This
gap does not exist in the field of medicine alone.
For the first time in the history of civilization we
have the tools with which to conquer poverty and
hunger and disease and ignorance and man’s
other ancient enemies. For the first time mankind
has the know-how and the scientific and technical
tools to master his physical environment. This is
the first time that it is no longer necessary for
people to be hungry, for people to be naked or for
people to be denied the essentials of life. Our
great task and the great challenge before the free
people of the world is to find a way to harness
the power of science and technology, not to make
H-bombs, not to destroy human life, but to ad-
vance the well-being of the human family.
You can go out into the Ford plant where they
can make an engine block in 14.6 minutes. There
are no manual operations involved. This plant
is already obsolescent. Television sets are manu-
factured by automation, without a human hand
touching the product. On the drawing-boards
they have new machinery that will make the
equipment they use today look like museum
pieces. I was told the other day that there is a
machine that can capture the tone qualities from
a recording by Enrico Caruso. That machine can
sing, with Caruso’s voice, a song written twenty
years after his death.
This is the world in which we live. Machinery
is taking tremendous steps forward in terms of
creating greater and greater abundance, with less
and less manpower.
Now what are we going to do with this tech-
nological revolution? If we gear it to the needs
of the people, if we use this power with a sense
of social responsibility, we can build a greater
new world with all its poverty and hunger and
unnecessary suffering from disease removed. Un-
less we use this power sensibly and sanely in the
interests of all of the people, then these machines ;
instead of building a better world, can dig oui i
.
economic graves.
This is the problem in America today. The
search for new answers must have its application
in medicine as well as in all the other fields o
man’s struggle. While men may differ as to hov
best to close the gap between our potential anc
its realization — between the kind of medical can
that is within the competence of the medical pro
fession to provide and what is now generally avail j
able — we cannot and must not stand still. I
progress is to be made, bold experimentation i <
needed. Old concepts must be re-evaluated am !
adapted, and new ones must be developed. Man
fear change; but change is inevitable.
A wise society, however, tries to guide chang ]
in relation to certain principles. In medicine thes |
principles recognize that while practice is firml
based on science, it is still an art. Scientific prc
gress has increased the patient’s bewilderment 2 '
what is happening to him when he seeks medic; I
care. Far from eliminating the need for a clos
personal relationship between the patient and h
doctor, it has made the doctor-patient relationshi
all the more important. Where a continuin
doctor-patient relationship does not exist,- as
now too often the case with many Americans,
should be established. Where it exists it shoul
1296
JMSV
MEDICINE AND LABOR— REUTHER
e preserved and enhanced. Let me dispel a
ogeyman. Anyone who has thought about medi-
al practice knows that it is essential to preserve
ae personal relationship in medicine. No one
rould knowingly advocate impersonal, assembly-
ne medicine. But let us not stretch the valid
eed for doctor-patient rapport to apply to the
/ay in which a pathologist gets paid for his
ervices. It is very difficult for me to see how the
loctor-patient relationship is in any way impaired
iy the adoption of a modem plan for transferring
noney from the patient’s pocket to that of the
loctor.
An improved standard of medical practice is
engthening the already long and arduous period
)f education through which the modern physician
las to go — college, medical school, internship,
-esidency — which can take him into his thirties
Defore he begins to earn a reasonable living. The
doctor can never stop studying if he is to keep
aace with evolving medical knowledge. We must
find ways to increase his opportunities for con-
tinuing education and research. Most important,
I recognize the weight of life and death respon-
sibility that bears constantly on the physician.
Certainly these considerations must be fully re-
flected in the financial rewards for the practice of
medicine.
In all planning for medical care, quality must
receive the highest possible priority. Our Union
wants no compromise with quality; we are not
looking for bargain basement medicine. In this I
am sure our aims conform with yours. The
arrangements to provide and pay for care must
not conflict with the objective of high quality
care; rather they must reinforce it. But we can-
not accept the contention that quality is auto-
matically lowered by any change at all in the
currently prevailing pattern for practicing medi-
cine or paying for it.
In present practice quality may be sacrificed
by the heavy concentration on episodic illness to
the neglect of preventive care. One of the greatest
challenges in medicine is the opportunity to de-
tect cancer and other fatal diseases at a stage
when these killers can be easily disarmed. How
many doctors are attuned to preventive medicine?
How widespread is the application of these new
techniques for early disease detection? How high
is the unnecessary fatality count today?
It is because I believe we are in essential agree-
ment on broad principles that I am confident we
can find solutions to the problems concerning us.
Recent progress in prevailing community health
insurance has been too slow. As a matter of fact,
there is considerable regression from earlier prin-
ciples of prepayment. Because of this, pressure
has been building up in unions to set up their
own medical care programs. Some unions have
done so. The Mine Workers have made a great
contribution in building and staffing ten modern
hospitals and clinics.
The UAW decided not to launch a separate
union medical care program. It has taken the
much more difficult course of working with the
rest of the community. Setting up a union pro-
gram would be pulling out of existing hospital-
medical programs the group that now carries the
major share of the financial load. It would frag-
mentize medical care in the community and ulti-
mately leave thousands and thousands of families
in a kind of no-man’s land with no real pro-
tection. We support the community approach
because we believe that labor in a free society can-
not solve its problems in a vacuum — that we can
make progress only if we co-operate with men and
women of good will in the whole community to
find answers for the problems of all the people.
We have consistently bargained for and sup-
ported community plans such as Blue Cross and
Blue Shield. In our negotiations we have not
asked for special favors, but have sought to im-
prove the community-wide contracts available to
all. . The prevailing pattern of our health service
benefits throughout the country amply demon-
strates our determination to improve and support
community-wide plans.
For years we have been urging existing plans
to experiment with substantially broadened bene-
fits. As we have said on many occasions, we will
support experimentation which is soundly con-
ceived and medically oriented and which effec-
tively removes the economic barriers to medical
care. We would hope, for example, that the
Michigan Medical Service Plan would provide
benefits like those developed under Windsor
Medical Service by the Essex County Medical
Society in Ontario.
We are also convinced that further experi-
mentation is necessary ; that is why the UAW is
backing the development of the Community
Health Association which, under medical leader-
ship, will be experimenting not only with
broadened prepayment benefits, but also with
October, 1957
1297
MEDICINE AND LABOR— REUTHER
medical care organization. In this new program it
is contemplated that benefits will be comprehen-
sive in scope including preventive care, and re-
habilitation, and that the care will be provided
by physicians in group practice. We are not going
to coerce people into joining this plan. Every
individual in every group will have free choice
of plan, so that each family may elect to be a
member of this plan or some other program, like
Blue Cross-Blue Shield. For over five years, this
principle of free choice has been a feature of the
UAW’s collective bargaining contracts with the
auto industry. In California, Ford, Chrysler and
General Motors workers individually choose be-
tween Blue Cross and Blue Shield on the one
hand and the Kaiser Foundation Health Plan on
the other. The Union firmly believes that its
efforts in the provision of medical care must be
to expand choice, not restrict it.
Earlier this year, more than forty prominent
physicians, about half of them from Michigan,
came together at the invitation of the CHA to
advise on how to establish and maintain a high
level of medical care under its program. Even
physicians who expressed serious reservation;
about the proposed program approached the dis-
cussions with an objective attitude and were most
generous with their advice and suggestions. This
certainly is in the best tradition of the medical
profession, and of democracy, where free men of
good will join together to find ways of meeting
human needs. In other areas and in earlier times,
the use of ostracism and sanctions against new
plans proved not only unedifying but ineffective.
This spirit on the part of Michigan Medicine
holds promise of a mature and constructive ap-
proach, not only to the possible development of
new medical care programs, but to the perfection
and extension of existing plans.
Interpolation by Leonard Woodcock: I under-
stand that at this convention you have approved a set
of proposals on medical insurance. From accounts in
the newspapers, it would appear that you have made
real progress and have taken a sound approach to such
important matters as affirming the service principle,
extending the range of service benefits, and raising the
income ceilings and making them work. And I am
also happy to hear you have reaffirmed the all-important
community-rating principle.
Obviously, we must reserve final assessment of your
new program until it is more fully developed. Naturally,
too, we shall want to know what it will cost. I can,
however, endorse the direction that has been taken.
If we lived in a totalitarian state the kind of
problems we have been discussing would be
handled by decree. This is not the way we do
things in America. While the processes by which
we advance in a democracy are infinitely more
arduous, our experience has shown that sound and
practical solutions to all our problems can be
found.
I personally believe that America is, in truth,
the last best hope of freedom in this very troubled
world of ours. We are blessed, as no other people
in the world, with great natural resources, with an
extremely efficient economy, with a highly produc-
tive agriculture — we are really blessed as no other
people in the world are blessed.
But I think we need always to keep in mind —
doctor and labor leader, banker, farmer, business
man and factory worker — we need always to
realize that fundamentally the struggle in the
world between the forces of freedom and the forces
of tyranny is not a struggle for geography but is
essentially a struggle for the hearts and the minds
and the loyalties of the people of the world.
And freedom will win that struggle, not by the
size and destructive capacity of its H-bomb. We
need, because of the necessities and the realities
of the world situation, to be strong militarily to
meet the threat of Communist aggression, but we
must always understand that military power is but
the negative aspect of the total struggle against the
forces of Communist tyranny. In the long pull,
freedom will win only if it can attract to its side
hundreds of millions of uncommitted people, and
they are going to judge freedom in a large measure
by what we in America do with the opportunities
that freedom gives us. They are going to judge
us, not by our industrial indexes, although they
are very impressive; or by the fact that the Ameri-
can economy yielded in excess of four hundred
billion dollars in gross national product last year,
although that was impressive. They are not going
to judge us by the level of our technology or by
the speed of our jet planes or the number of new
shiny Chevrolets that General Motors turns out
on its many assembly lines, although all of these
economic facts are very impressive.
They are going to judge us by the true measure
of the greatness of any civilization; by the social
and moral capacity of the society to translate
material values into human values, to reflect tech-
nological progress in human progress and human
happiness and human dignity.
1298
JMSMS
The Challenge
What does this next year hold for us Doctors of Michigan?
To specifically prognosticate is impossible, but certain funds,
statements and happenings in the past few months allow us
to make reasonable assumptions. Recent piecemeal infringe-
ment of our basic philosophy of the practice of medicine by
third parties alarms me and I feel that as a united profes-
sion we must make our stand and fight for what we think is
right — right for the people we serve.
You will note that I said “fight for” and not “fight
against,” as so often Doctors are berated. We know this
criticism is mistaken but we must let all people know we
are fighting for their free choice of a physician. This must
be our basic belief, as it has been down through the centuries.
This doctor-patient relationship, voluntarily established by
the patient who chooses a physician and by the doctor who
assumes responsibility for the patient’s care must be main-
tained. No third party must be allowed to arbitrarily set
up restrictions that would alter the basic relationship. These
freedoms of patients and doctors are closely allied; take
away one and eventually all may be lost.
We must emphasize that we are fighting for this free
choice of physician, a “status quo” if you like, for the
benefit of the people; of people in all walks of life, and not
for the benefit of the Doctor. Actually, the physicians lot
might be easier under third party control, whether it be
governmental, hospital, or pressure groups. Hours could be
shorter, vacations more often, and retirement benefits more
secure. However, we know, under previous existing plans
of this type, that the caliber of medical care suffered; that
the “art of medicine” quickly died out, and that people who
could, preferred paying for their private physician in addi-
tion to the “Plan’s” cost. This free choice is not nebulous or
irrelevant. It is something deep and sincere in peoples’
hearts and it is something that we all must fight for.
By this time the results of our Market-Opinion Survey on
Pre-Paid Health Care have been given to our House of
Delegates, and decisions and directions have been given to
the Board of Blue Shield and to us Doctors.
With the help and backing of each of you, your Officers
and Councillors will see that your mandates are consum-
mated. The horizon may be hazy at this time, but I am
confident that we can achieve what we desire.
President Michigan State Medical Society
October, 1957
1299
Editorial
MENTAL HEALTH AND MENTAL ILLNESS
Mental illness has long had a “stigma” at-
tached to it that presents serious obstacles to the
treatment and rehabilitation of psychiatric pa-
tients. This stigma seems to suggest that the
causes of mental illness are shameful, evil and
unnatural. In fact, relatives of mentally ill patients
often refuse to admit the illness is mental and
take the patient to the internist, gynecologist or
neurologist or any other doctor, rather than the
psychiatrist. And, finally, when it is evident to
them that the illness is mental, they rationalize
that the mental condition must be caused by a
head injury, brain tumor or some other physical
cause. It is only recently that people are be-
ginning to break through this stigma and view
mental illness in its proper sphere.
As this proper understanding of mental illness
by the public becomes more accepted, the more
the general practitioner will take his proper role
as the first line of defense against mental illness.
This is evidenced by the American Psychiatric
Association and the American Academy of Gen-
eral Practice, forming a joint committee this past
year to stimulate interest in this project. We,
in Michigan, must encourage the men in general
practice to visit and give help in our mental hos-
pitals, as well as to encourage general hospitals
to create psychiatric facilities and wards, within
their framework.
Your Mental Health Committee has been in
favor of county medical societies creating mental
health committees and has offered assistance to
county medical societies in developing programs
in the field of mental health.
The Committee maintains its deep interest in
teen-age crime and juvenile delinquency. It judges
that a carefully selected commission of twelve to
fifteen members to study the issues involved is
probably the best long term approach to the prob-
lem.
The Committee strongly endorses the resolution
approved by the House of Delegates of the AMA
and recorded in the Journal of the American
Medical Association, Vol. 163, p. 52 (January 5,
1957). This resolution points out that certain
types of alcoholic patients should be accepted by
general hospitals as medical cases and so treated.
Hospital staffs are urged to cooperate in this
program.
The articles appearing in this issue may stimu-
late interest in further communications covering
specific areas or topics in the field of Mental
Health. The Committee will attempt to answer
any such requests emanating from the readers of
this Journal. We are grateful to the State Medi-
cal Society for the opportunity to participate in
this issue of the Journal.
Ivan A. LaCore, M.D., Chairman
Mental Health Committee
PRACTICAL CITIZENSHIP
The Michigan Medical Service — Blue Shield — - j
and its program are a direct exposition of the
place of the doctor in the eyes of the public and
in the work of the public and the state. At the
annual meeting of the Michigan State Medical \
Society in Pontiac in September, 1931, the House
of Delegates adopted a resolution authorizing the
appointment of a committee to study the costs
of medical care. Under this authorization, Carl
F. Moll, M.D., of Flint, the president at that time,
appointed a study committee consisting of: W. H.
Marshall, M.D., Flint, chairman; F. A. Baker,
M.D., Pontiac; L. G. Christian, M.D., Lansing;
B. U. Esterbrook, M.D., Detroit; C. S. Gorsline,
M.D., Battle Creek; and F. C. Warnshuis, M.D.,
secretary ex officio.
The committee organized and developed a study ,
plan. Nathan Sinai, D.P.H., of the University of
Michigan, was the director of this study. A sur-
vey was made of every item of medical and health
expense for a group of approximately 40,000
people in various areas of the state over a period
of a year’s time. The study of the major com-
mittee included a trip to Europe and especially
England, an analysis of all the information, pub-
lishing of a book in June, 1933, and the outlining
of a “Mutual Health Service” which was published
in The Journal in May, 1934* The Mutual
Health program suggested by this committee failed
of adoption by the House of Delegates, but it
*See footnote on next page.
1300
JMSMS
EDITORIAL
served as the basis upon which other workers in
various parts of the state developed plans and
programs, and ultimately Michigan Medical Serv-
ice evolved. It is interesting to note that of the
original committee three are still alive: L. G.
Christian of Lansing, C. S. Gorsline of Battle
Creek, and Fred A. Baker of Pontiac.
Throughout the years, our State Medical So-
ciety officers, many of whom have passed on, de-
voted time, effort, material and all sorts of re-
sources and personal sacrifice in working out a
program to relieve the high and catastrophic costs
of medical care. Michigan Medical Service was
the result of research and study by these devoted
pioneers working in a totally new field of en-
deavor, apparently far removed from the practice
of medicine. In the November issue of The Jour-
nal we will report another effort along a kindred
line. During this year the State Medical Society
has conducted a mammoth Market Opinion Sur-
vey involving almost half a million of our state’s
citizens, trying to find what they wish in the nature
of pre-paid medical care — and if they want it. We
have also surveyed the medical profession to de-
termine their desires and their willingness to work.
These reports will be presented in the November
Journal.
Through the years it has always been the ex-
perience that leaders, pioneers, and forward think-
ers are ready to work and to devote not only
:heir spare time but their very important business
lours, days and weeks which should be devoted to
heir practice, to planning and organizing. Had
t not been for these men, medical societies would
lave died years ago. During this current year
md at the last meeting of the House of Delegates,
fecisive action has been taken more clearly to
lefine and more distinctly to outline the provisions
or care to our patients, and to protect our own
utal interests in preservation of the private prac-
ice of medicine. This work has been done by
nany dedicated and conscientious physicians.
* After the publication of the book in June, 1933, Dr.
2. S. Gorsline retired from this committee and three
■thers were appointed: Stuart Pritchard, M.D., of
tattle Creek, I. W. Green, M.D., of Owosso, and
'hil Riley, M.D., of Jackson. The readjusted commit-
ee, with Henry Luce, M.D., of Detroit, as Speaker of
he House, was responsible for the Mutual Health Serv-
:e program. Later, Ferris Smith, M.D., of Grand
fapids, and Ralph Pino, M.D., of Detroit, became
lembers of this same study committee, and it was due
3 Ralph Pino’s untiring efforts that the study continued,
le was chairman when the final work was being done
;ading to the establishment of Michigan Medical Serv-
:e.
Ictober, 1957
The course has been outlined; the final and
ultimate result, even more than in the past three
decades, must depend upon the cooperation and
the effective services given by all of our mem-
bers. It is up to the general mdmbership of the
Society now to carry through and see that the
plans and obligations are extended and consum-
mated; that the pledges and promises of the Mich-
igan State Medical Society as expressed by our
leaders and our House of Delegates are metic-
ulously performed; that the preservation of our
dignity and of our laboriously established good-
will through the years is a truly devoted picture;
and that there will be no misuses or untoward
burdens. Our public is at attention and every
member is obligated to carry though as a duty to
his patients and his confreres.
FEDERAL LEGISLATION
Congress has now adjourned. The senators and
congressmen are at home and available for con-
versation and contacts; in fact, they are anxious to
make these contacts with their constituents. There
are some things the medical profession is especial-
ly interested in which could be discussed with
them, or letters could be written to them. Of
utmost importance is the Jenkins-Keogh bill. Bills
of this nature have been in the Congress for
over ten years without much progress, but now for
the first time a hearing has been announced to
start on January 7, 1958. All of our members
probably know what the Jenkins-Keogh plan is.
It is a program to allow self-employed profes-
sional persons to set aside a portion of their in-
come in pension plans and defer income tax pay-
ments until those plans materialize in later years
as endowments or pensions. At that time they
will be taxed according to the prevailing tax.
The plan is one of simple justice. All industrial-
ly employed and most salaried persons are in posi-
tion to take advantage of this reduction in tax
now through laws that have been in effect for
years, whereby the employer can invest money,
which he otherwise would be paying as salary to
his employee, in income-producing securities des-
ignated to be paid after retirement age in the
nature of a pension. Tremendous amounts are
being saved now for our friends and many of our
neighbors who are in industrial employment. There
is no reason professional persons should not be
granted the same privilege. Letters to your friends
in Congress do sometimes produce results.
1301
EDITORIAL
THE CROSSROADS
The House of Delegates at the Annual Session,
September 23 and 24, 1957, decided the future of
the Blue Shield in Michigan. Our subscribers
have indicated their desire for extensions of the
service contracts. Management of Michigan Medi-
cal Service has developed a series of contracts of-
fering the various types of care on full payment,
deductible, or coinsurance basis, as the individual
group may require.
These sendees can all, or each separately, be
given successfully, if and when the doctors of
Michigan decide they are willing and ready to
render the care and to recognize the contract pro-
visions. Such must be done or no group medical
care program can succeed. Approximately half
of the service contracts are to be renewed within
a few months. Labor has protested : ( 1 ) the over-
utilization and misutilization leading to extra costs
and increased rates, (2) has announced its goal
of government medicine, and (3) has organized
a “Community Health Association” prepared and
ready to issue medical sendee contracts if and
when their leaders or they themselves may de-
cide.
The Michigan State Medical Society in an
utterly new field put our Blue Shield plan in
operation with over seventy thousand subscribers
in a very few months. Our doctors must realize
that can be done again — the way has been shown.
Remember Michigan Medical Service is not
a rich “insurance” company. It is ourselves, an
integral part of the Michigan State Medical So-
ciety. No matter what any group may be induced
to demand, the future of prepaid medicine is now
in the balance. The decision must be made cor-
rectly if independent practice is to prevail.
Think it over, doctor — the vote of your dele-
gate in September must be proven correct or it
could be a vote to submit to control by pressure
groups at home or politicians in Washington.
WHAT DO YOU MEAN— “NON-PROFIT”?
One of the chief distinctions between medically
sponsored prepayment plans — such as Blue Shield
— and the commercial health and accident insur-
ance companies, is that Blue Shield is conducted
on a “nonprofit” basis, whereas the insurance com-
panies are frankly business enterprises operated to
earn a profit for their owners.
To state this difference is not to imply any
criticism of either. The insurance companies have
a long and honorable history of public service and
they are an important part of America’s business
community.
Blue Shield, on the other hand, serves largely
as an agency of the medical profession, perform-
ing a community service. Initiated by the medical
profession, with the help of local industry, labor
and civic leaders, Blue Shield is designed for
one purpose only: to help people pay for medical
services whenever the need for such services arises.
Blue Shield has succeeded in pioneering the
medical care prepayment movement because the
profession has guided it and supported it. Blue
Shield’s working capital was the pledge of the
participating physician to deliver the medical
services that Blue Shield has promised on his
behalf.
In some cases, the participating physicians have
accepted a fraction of scheduled Blue Shield pay-
ments in order to tide an infant plan over its early
trials. In every case, local professional leaders
have given their local Blue Shield Plans incal-
culable hours of service as trustees and advisers.
None has ever accepted one penny of compen-
sation for such service as a committee member
or trustee. As an agency of the medical profes-
sion, created for the sole purpose of facilitating
the doctor’s job of service to his patients, there
has never been any need (for any third party)
to make a profit out of the Blue Shield trans-
action.
Blue Shield’s success is measured by the pro-
portion of its income dollar that is expended for
services to subscribers, the smallness of its operat-
ing costs and the quality of its doctor-support —
not by the size of its reserves or its net earnings.
These earnings — these profits, if you will —
belong to the subscriber.
“Nonprofit” does not mean no profit. Much
less does “nonprofit” mean a profit-less operation
“Nonprofit” in Blue Shield means that the earn-
ings of the Plan belong to the subscribers whe
support the Plan.
The symptom-complex which is officially designate*
as pernicious anemia may, in many of its features a!s(
betray malignancy of the stomach, and particularly o
the right colon sector.
* * *
A neoplasm may attain a considerable size withou
causing serious obstruction of the right colon.
1302
JMSM
NO KNOWN CONTRAINDICATIONS
permits high dosage,
more effective diuresis in more patients
The low incidence of side action with
Rolicton (brand of amisometradine) per-
mits high dosage, extending the range of
effective diuresis to a greater number of
patients than was previously possible.
Laboratory studies demonstrate that
Searle’s new oral diuretic, Rolicton,
causes positive diuresis with an essen-
tially balanced excretion of water, sodium
and chlorides.
Settel1 studied the effect of Rolicton
in forty-seven patients and found no
serious side effects. Assali, who observed
the action of Rolicton in five patients
with severe toxemia of pregnancy, states2
that side actions are essentially non-
existent. Side actions of such low inci-
dence, together with its diuretic efficacy,
suggest a high order of usefulness for
Rolicton.
One tablet of Rolicton, b.i.d., is usually
adequate to maintain patients free of
edema after the first day’s dosage of four
tablets. Some patients respond well to
one tablet daily. G. D. Searle & Co.,
Chicago 80, Illinois. Research in the
Service of Medicine.
1. Settel, E.: Rolicton® (Aminoisometradine), a
New, Nonmercurial Diuretic, Postgrad. Med.
27.186 (Feb.) 1957.
2. Assali, N. S.: Personal communication. May
28, 1956.
SEARLE
)CTOBER, 195'
Say you saw it in the Journal of the Michigan State Medical Society
1303
Michigan's Department of Health
Albert E. Heustis, M.D., Commissioner
ASIAN STRAIN INFLUENZA
There are four main types of influenza viruses titled
A, B, C, and D. Within each type, various new strains
develop from time to time. Currently, we have a new
strain that has developed within type A. This new
strain or variant of type A influenza virus was first
identified from a case of influenza that was part of an
outbreak of the disease in Asia. As a result it was
designated as the Asian or Far East strain. Public
fancy immediately labeled influenza resulting from this
variant of type A influenza virus as “Asiatic Flu.” This
is unfortunate, because it gives the public the impression
that they are faced with an invasion of a rare exotic
type of disease. That which is more unfortunate is
that it carries with it the fear of the unknown. It would
have been better had the new strain been called just
another variant of type A influenza virus, which is
actually all that it is.
This new strain of type A influenza virus has certain
characteristics that help to remove fear once the truth
concerning it is known. It causes a relatively mild
disease, has few complications, and results in almost
no fatalities.
Symptoms. — One of the characteristics of any “touch
of the flu” is that its onset is abrupt with few or no
premonitory symptoms. The time lapse from exposure
to illness among susceptibles is frequently less than
twenty-four hours. The fact that a group of people
working or living together in close quarters become ill
at the same time seems to breed hysteria away beyond
the importance of the affliction. The symptoms can
be any or all of the following: fever, chills, headache,
sore throat, cough, and soreness in the back and limbs.
Although the temperature may reach 102 to 103° F.,
the illness is short-lived and lasts only two to three days.
However, it leaves the patient exhausted and feeling
that he has gone through an illness of long duration.
Treatment. — No medicine as yet known will cure in-
fluenza. The antibiotics are useless and could be harm-
ful, and should be used only if complications, such as
pneumonia, appear imminent. The only thing to do
is to go to bed and let nature work for you. Another
advantage of bed rest is that the patient is not cir-
culating and spreading the virus. By the same token a
person with the “flu,” Asiatic, Far Eastern or other-
wise, should not have visitors — solely for his own good,
since visitors bring in bacterial contaminants that can
result in serious secondary infections for a person already
ill from influenza.
Precautions. — When influenza of any type is prevalent
in a community, the air is so laden with flu viruses
that it is impossible to avoid getting into the path of
coughs and sneezes of those already infected but not
yet “sick enough” to go to bed.
There are, however, a few precautions that can be
taken. One can avoid a maximum exposure by avoiding
crowds, insofar as possible. Proper rest and proper
food are of major importance in overcoming bacterial j
invaders that are actually the cause of mortality in
influenza.
Prevention.- — The influenza vaccine we now have is
not of any value in preventing so-called Asian or Far
East influenza, since it does not contain any substances
that will result in the development of antibodies against
this new variant of influenza virus type A.
It does, however, appear likely that a vaccine designed
specifically to combat this variant will be available at
some later date. This vaccine, when available, will of-
fer about 70 per cent protection. It is probable that
the supply will be limited. However, there are no in-
dications at this time that this new strain of influenza
virus type A has any of the deadly characteristics of
the influenza virus that was so devastating during 1918-
1919.
Sensible, sane, sanitary living should suffice. Certainly,
there is no reason for panic.
POLIO NOTE
Of the 235 cases of poliomyelitis reported this year,
only forty-five are paralytic and the remaining 190, are
reported as nonparalytic. Normally paralytic and non-
paralytic are about 50-50.
NEW LOCAL HEALTH DIRECTORS
John S. Wisely, M.D., became Director of the Lena-
wee County Health Department on August 1.
Earl Hasty, M.D., was appointed Director of Dis-
trict Health Department No. 2 as of July 1.
Dorothy V. DuVall, M.D., was named Director oi
the Chippewa-Luce-Mackinac Health Department, ef-
fective August 2.
A. B. Mitchell, M.D., formerly Director of the Allegan
County Health Department, became Director of the
combined Shiawassee-Livingston District Health Depart-
ment on August 1. The Shiawassee County office is in
the Courthouse at Corunna and the Livingston office
is in the Courthouse Annex in Howell.
More babies are being born in hospitals and with : j
doctor in attendance than ever before, Health Informa 1
tion Foundation reports. In 1935, only 37 per cen
were born in hospitals and 13 per cent of all births weri
unattended by doctors. In 1956, almost 95 per cen
were hospital-born, and doctors attended 97 per cent o
all births.
1304
JMSM:
Tastiest way to dissolve sore throat symptoms
(hydrocortisone-bacitracin-tyrothricin-
NEOMYCIN-BENZOCAINE TROCHES)
Adult or juvenile, your patients with sore throats
will welcome a course of HYDROZETS. These
newest Merck Sharp & Dohme troches offer anti-
inflammatory, anti-infective and analgesic proper-
ties that promptly alleviate distressing mouth or
throat irritation whether caused by infection,
mechanical injury or allergic reaction. And
HYDROZETS taste so good, it’s hard to believe
they’re medicine.
Formula: Each HYDROZETS Troche contains —
2.5 mg. ‘H YDROCORTONE’ to reduce pain, heat
and swelling; 50 units Zinc Bacitracin, 1 mg.
Tyrothricin and 5 mg. Neomycin Sulfate to com-
bat gram-positive and gram-negative bacteria; and
5 mg. Benzocaine for rapid soothing analgesia.
Other indications: As adjunct therapy in aphthous
ulcers, acute and chronic gingivitis and Vincent’s
Infection.
Supplied: Vials of 12 troches.
MERCK SHARP 8c DOHME
DIVISION OF MERCK a CO.. INC., PHILADELPHIA 1. PA.
jCTOBER, 1957
Say you saw it in the Journal of the Michigan State Medical Society
1305
In Memoriam
Ray S. Morrish, M.D., Flint
physician and surgeon and promi-
nent civic leader, died August 13,
1957, at the age of sixty-nine.
Doctor Morrish was president of
the Michigan State Medical So-
ciety in 1945 and was a former
secretary and president of Genesee
County Medical Society. He was
also active in numerous medical
groups and was a former president
of the Flint Academy of Surgery.
Dr. Morrish’s grandparents came to Michigan from
England in 1850 and settled in Flint Township. The
family had a farm which is now part of Bishop Airport.
He received his doctor of medicine degree from the
University of Michigan in 1912.
During World War I, he entered the Army Medical
Corps as a lieutenant. He served a month at Ann Arbor,
then became assistant commander at the Base Hospital
at Camp Shelby, Mississippi, where he rose to the rank
of major.
Returning to Flint, he began a series of postgraduate
studies in surgery, tuberculosis, traumatic surgery and
tumors and malignancies.
He taught residents and interns at Hurley Hospital
from 1931 to 1940 and also classes at Wayne State Uni-
versity and the University of Michigan. He was director
of general surgery at Hurley from 1931 to 1940.
Dr. Morrish limited his practice to surgery. He was
on the staffs of Hurley Hospital and St. Joseph Hospital
and was acting assistant surgeon for the Veterans Ad-
ministration from 1919 to 1938.
Serving on the board of directors of the Genesee Red
Cross Chapter from 1924 to 1951, Dr. Morrish was its
chairman from 1939 to 1946. He was also chairman of
a fourteen-county Red Cross regional co-ordinating com-
mittee.
Dr. Morrish was a fellow of the International College
of Surgeons and was certified as a specialist in general
surgery by the International Board of Surgery.
Aura Andrews Hoyt, M.D., of Battle Creek, for twen-
ty-four years health officer of the community, died Au-
gust 8, 1957, at the age of seventy-seven.
Dr. Hoyt graduated in medicine at the University of
Michigan and, after his internship in New York City,
practiced in the west for one year before returning to
Battle Creek.
After his retirement as health officer in July, 1944,
Dr. Hoyt entered private practice and continued as
director of public clinics conducted by the health depart-
ment.
Charles W. Heald, M.D., Battle Creek physician, died
of a heart ailment August 6, 1957, at the age of eighty-
one.
Before entering the medical profession. Dr. Heald at-
tended the Battle Creek College and afterward engaged
in religious work for the Seventh-Day Adventist Church,
serving in various communities as assistant to pastors.
He later attended the American Medical Missionary
College of Medicine, graduating in 1906.
Dr. Heald was born in Fairfield, Iowa, July 7, 1876.
Alvin J. Swingle, M.D., Benton Harbor physician and
surgeon, died August 1, 1957, of a heart attack. He
was forty-six years old.
Born September 15, 1911, Dr. Swingle graduated from
Ohio State University Medical School in 1937 and
began his practice of medicine in Mandan, N. D. Upon
entering the U. S. Medical Corps, World War II, he
rose to the rank of lieutenant colonel and was a member
of a surgical team in the European theater.
After the war. Dr. Swingle taught surgery at Mar-
quette University, before coming to Benton Harbor in
1949.
Dr. Swingle was active in civic and fraternal affairs.
He was a member of Lake Shore Lodge 298, the Masons;
the DeWitt Clinton Consistory, Commander of the Sala-
din Temple. He was a member of the Kiwanis Club and
active member of Saron Lutheran Church, St. Joseph.
Frederick G. Novy, M.D., Ann Arbor, died August 8,
1957, at the age of ninety-two.
Born in Chicago, Frederick Novy received his early
schooling there. He served on the University of Michi-
gan faculty for forty-nine years, heading its bacteriology
laboratory from 1902 until his retirement in 1935. His
last two years of active service were as dean of the
medical school.
In 1891, he established the first credit course in
bacteriology in any American university.
Dr. Novy brought to the new laboratory his training in
Germany and France under Louis Pasteur and Robert
Koch, and a demand for strict attention to scientific
procedure. He discovered and named many micro-organ-
isms, among them Novyi, which causes relapsing fever.
He developed antisteptics and in 1903 introduced new
methods for cultivation of blood parasites — methods still
used today.
Dr. Novy was a pioneer in the study of allergies and
laid the groundwork for modern antihistamines. Much
laboratory apparatus he invented still bears his name.
All three of his sons are doctors of medicine and his
two daughters are married to physicians: Robert L. of
Detroit; Frank O. of Saginaw; Frederick G. of Berkeley,
California; Mrs. Warren C. Lambert of Marquette and
Mrs. Archibald Diack of Portland, Oregon.
1306
JMSMS
new physiologic iron chelate lor
maximum
hematologic
response — avoids interruption of
therapy
due to g. i. irritation
-guards against iron
poisoning from accidental overdosage
FERROUP
(Iron Choline Citrate*)
for the clinical and
experimental proof, write for
complete literature
chelated iron for effectiveness
plus “built-in” tolerance and safety
TABLETS — 3 tablets supply 120 mg. of iron DROPS-Each cc. provides 16 mg. of iron
and 360 mg. of choline base. Adults: 1 or 2 and 48 mg. of choline base. M.D.R. for in-
tablets t.i.d.: Children, 1 tablet t.i.d. fants and children up to 6 years is 0.5 cc.
SYRUP- 6 teaspoonfuls supply 120 mg. of Supplied: Tablets: Bottles of 100 and 1000;
iron and 360 mg. of choline base. Adults: 2 Syrup: Pints and gallons; Drops: 30-cc.
to 4 teaspoonfuls t.i.d.: Children, 2 tea- dropper bottles,
spoonfuls t.i.d.
Decatur, Illinois
EATON <£ COMPANY
*U. S. Pal. 2,575,63 1
'CTOBER, 1957
Say you saw it in the Journal of the Michigan State Medical Society
1307
♦ ♦♦♦♦♦
NEWS MEDICAL
MEDICAL AUTHORS
Jack Kevorkian, M.D., Pontiac, is the author of an
article entitled “Rapid and Accurate Ophthalmoscopic
Determination of Circulatory Arrest,” published in the
Journal of the American Medical Association, August
10, 1957.
William D. Robinson, M.D., Ann Arbor, is the author
of an article entitled “Current Status of the Treatment
of Gout,” published in the Journal of the American
Medical Association, August 10, 1957.
J. Reimer Wolter, M.D., Ann Arbor, is the author of
an article entitled “Innervation of the Corneal En-
dothelium of the Eye of a Rabbit,” published in AMA
Archives of Ophthalmology, August, 1957.
Klaus Hergt, M.D., and John L. Langin, M.D., Bay
City, are the authors of an article entitled “Serum
Transaminase Determination,” published in the Jour-
nal of the Medical Sciences, January, 1957.
Albert D. Reudemann, Jr., M.D., Detroit, is the au-
thor of an article entitled “Automobile Safety Device —
Headrest to Prevent Whiplash Injury,” published in the
Journal of the American Medical Association, August
24. 1957.
W. D. Robinson, M.D., of Ann Arbor, is author of a
special report, “Current Status of the Treatment of
Scalps,” which appeared in JAMA of August 10, 1957.
A. D. Ruedemann, Jr., M.D., of Detroit, is the author
of an interesting article under “Clinical Notes” in The
Journal of the American Medical Association, August
24, 1957. The subject of the note is “Automobile Safety
Device — Headrest to Prevent Whiplash Injury.”
J. R. Simpson, M.D., et-al, authored an original ar-
ticle, “Serum Lactic Dehydrogenase — a Diagnostic Aid
in Myocardial Infarction” which appeared in JAMA
of September 7, 1957.
Vance Fentress, M.D., and D. J. Sandweiss, M.D., of
Detroit, are authors of an original article, “Segal’s Tube-
less Gastric Analysis with Azure, a Resin Compound,”
which appeared in JAMA of September 7, 1957.
* * *
Seminar on Chronically 111. — The State of Michigan
Office of Hospital Survey and Construction called and
sponsored a three-day meeting, a seminar on the chroni-
cally ill, at Haven Hill Lodge on May 26, 1957. The
opening meeting on Sunday evening, May 26, featured
a talk and a discussion on Michigan’s changing health
picture led by Vlado Getting, M.D.. of the University
of Michigan School of Public Health. This was a dis-
cussion of the health picture which is changing from
one of acute illness to one of chronic illness within local
communities; and hospitalization and medical care in
the future is going to have to be aimed along these
lines more than it has been in the past. Dr. S. J. Axel-
rod from the University of Michigan Department of
Public Health reported on his survey of medical fa-
cilities in Michigan, which had been primarily devoted
to the Ingham County area, in which a rather detailed
study had been made. It was a report of available serv-
ices, recommendations to be made later. There were
some inaccuracies noted in relations to numbers and
types of units, but, in general, it was a most informa-
tive report.
The rest of Monday was devoted to discussions in
groups in relation to the problems of community care
for the chronically ill. The group was broken into four
separate study groups, which discussed the problems in
general, each bringing in their report; in the evening,
these reports were all consolidated into three main
phases: (1) improved methods of care, (2) improved
methods of economics, and (3) prevention of and edu-
cation for chronic disease. The recommendation of most
interest to the medical profession was the urging that
medical personnel accept more responsibility regarding
the problems of chronic illness and the long term pa-
tient within the community, and that this be considered
not only an individual patient problem but also an
interesting community problem.
In the groups, most of the discussion centered upon
methods of improved care, finances including prepaid
insurance, and prevention or education to prevent chron-
ic illness. It was suggested that the community should
recognize that the chronically ill or handicapped repre-
sent an honorable state and not one to be frowned
upon, and that the number of such individuals in the
hospitals is a reflection on the moral, physical, social,
emotional and economic environment of the community.
The problem of assimilating the chronically ill as part
of the community is an interesting problem, and the
answer is not necessarily in brick and mortar and hos-
pital beds, but in a better organized community ap-
proach to the problem and better use of home care.
Discussions revolved around the doctors’ offices oi
clinics, general hospital care, the chronic disease hos-
pital, nursing homes, and home care. The final recom-
mendation was for the development of ( 1 ) a pilot pro-
gram to cover all of the aspects of the community ir
relation to the problems of the chronically ill, and (2)
a pilot or trial program for further development anc
experimentation in relation to prepaid insurance.
* * *
The International College of Surgeons has announcer
two European congresses. One met in Vienna, Octobei
(Continued on Page 1310)
1308
JMSM!
CORN OIL is a Prime Source
of UNsaturated Fatty Acid
Numerous clinical
studies emphasize
its efficacy in the
reduction and
control of serum
cholesterol levels
Physicians are quite aware of the rapidly
growing appreciation of the role of dietary
lipids in health and disease. Accumulating
metabolic studies throughout the world indi-
cate that serum cholesterol levels may be
influenced more by the kind than by the
amount of the dietary fat.
Unsaturated fats tend to depress serum cho-
lesterol levels in many patients, whereas sat-
urated fats may have the opposite effect.
Medical references on this subject, as well as
other findings concerning unsaturated fatty
acids in nutrition, may be found in the book,
“Vegetable Oils in Nutrition.”
Mazola Corn Oil is an excellent source of
unsaturated fatty acids... 85% of its com-
ponent fatty acids are unsaturated . . . average
values being 55% linoleic acid, 30% oleic
acid. Mazola is unadulterated corn oil in its
natural form . . . not flavored, not blended,
not hydrogenated. Well tolerated, easily
digested, readily absorbed, Mazola is also
an excellent carrier for fat soluble vitamins.
Mazola Corn Oil is widely used for salad
dressings, in frying, cooking and baking...
and thus may be included palatably in great
variety as a replacement for part of the daily
fat intake.
COMPARATIVE COMPOSITIONS OF FOOD FATS AND OILS
Fatty Acids os Percentage of Total Acids
Fat
Ave.
Range
Butter
46-48
Coconut oil
' —
75-88
m Corn oil
13
11-15
Cottonseed oil
26
21-30
Lard
43
Linseed oil
■
6-12
Margarine
23
15-23
Olive oil
—
8-16
Peanut oil
17
14-22
1 Shortening
25
17-45
Soybean oil
15
11-18
Tallow (beef)
53
—
Oleic
Ave. Range
Linoleic
Ave. Range
Linolenic
Ave. Range
Arachidonic
Iodine Value
— — 4.0 —
1.2 —
— 5-8
— 23-40
22-36
27
46
62
54
62
25
42
13-31
59-77
53-86
44-65
43-79
18-58
56
47
10
5.8
29
5
55
4
1. 0-2.5 —
46-66
34-57
15.6
10-27
5-1 1
4-20
20-37
3-12
28-62
5.3
— 0.0-0. 6
0.5
5.1
0.5
30-64
0.1 -0.9
0.2-0. 6
0.3-10
Ave.
Average Range
0.2
26-42
—
—
7-10
—
126
113-131
—
105
90-117
0.5 (2.1)
—
53-77
—
_
170-204
0
81
74-85
_
—
80-88
—
98
90-102
0-0.5
78
59-80
—
130
100-143
0.5
—
40-48
Iodine numbers are an accepted measure of the degree of unsaturation of vegetable oils.
TO PHYSICIANS interested in the study and manage-
ment of high cholesterol blood lefels. this most recent
monograph will provide helpful information. It is free
on request. Write to: Corn Products Refining Company,
17 Battery Place, New York 4, N. Y.
CORN PRODUCTS
REFINING COMPANY
17 Battery Place,
New York 4, N. Y.
CTOBER, 1957
Say you saw it in the Journal of the Michigan State Medical Society
1309
NEWS MEDICAL
ACETYLCARBROMAL TABLETS
• Proved safe and effective by 6 years’
clinical use.
• Soothes the central nervous system,
produces calmness without hypnosis.
• Non-toxic, non-cumulative, non-addict-
ing, no known contraindications.
(Continued from Page 1308)
18-20, 1957, and the other will convene in conjunction
with the World’s Fair in Brussels, May 15-18, 1958. The
Vienna Conference was under the auspices of the Vien-
na section of the International College of Surgeons, and
under the direction of Dr. Felix Mandl and Professor
Leopold Schonbauer, both of the surgical department
of the University of Vienna. The meeting brought to-
gether the German, Austrian, Dutch, Swiss, and other
sections. About seventy-five papers were presented. The
sessions were held in the Billroth-Haus in Vienna. In-
formation about the May meeting is available at the
headquarters’ office, 1516 Lakeshore Drive, Chicago 10,
Illinois.
* * *
The doctor draft law went out of existence on June 30
after nearly seven years on the federal books. Figures
collected by the selective service headquarters show that
forty-five priority 1 and priority 2 physicians and twenty-
seven dentists remain in the 1-A pool, and 337 phy-
sicians and 101 dentists in the same priorities, were de-
ferred for vocational essentiality, and 1,768 physicians
and 555 dentists in priorities 1 and 2 hold deferrment
as 4-F’s.
* * *
Poliomyelitis Literature. — The National Foundation
for Infantile Paralysis maintains a listing of all articles
on poliomyelitis published in the United States and
abroad, and publishes it monthly. The June listing
just received, contains 104 titles, of which Michigan
furnished two: “Mechanisms of Persistent and Masked
Infections in Tissue Culture,” Annuals New York Medi-
cal Society, April, 1957, by W. W. Ackerman, University
of Michigan Virus Laboratory, Ann Arbor, and “The
Nature of the Formalin Inactivation of Poliomyelitis
Virus,” Journal Immunology, June, 1956, by E. A. Timm,
I. W. McLean, Jr., C. H. Kupsky, and A. E. Hook,
Parke-Davis, Detroit.
* * *
• Does not impair mental or physical
function.
• Orally effective within 30 minutes for
sustained action up to 6 hours.
• Economical.
Indications: Tension, nervousness,
anxiety and muscular spasm.
Supplied: White round tablets
Acetylcarbromal 5 g r. in bottles
of 100, 1000.
Write for samples and literature
There's Always A Leader
MALLARD, inc
3021 WABASH, DETROIT 16, MICHIGAN
The August number of the Blue Shield Medical Care
Plans Newsletter devoted almost two pages to quota-
tions from The Journal of the Michigan State
Medical Society for June. It quoted extensively from
the articles by L. Fernald Foster, M.D., President of
Michigan Medical Service, George W. Slagle, M. D.,
President-Elect of the Michigan State Medical Society,
and J. C. Ketchum, Executive Vice President of the
Plan. In closing the article, the editor remarks: “Each
year when the Blue Shield issue of Michigan Medical
Journal appears, it stands as one of the outstanding
examples of productive professional relations. The same
kind of annual Blue Shield edition could well be made
a part of every state medical publication so that all
doctors, everywhere, might understand more fully and
completely the role of physicians in further developments
essential to the continuation of voluntary health care
coverage under the leadership of physicians.”
* * *
Top Trophy to Michigan. — Michigan Blue Cross-Blue
Shield was named winner of the top trophy for its 1956-
(Continued on Page 1312)
1310
Say you saw it in the Journal of the Michigan State Medical Society
JMSMS
NASAL
(HYDROCORTONE® WITH PROPADRINE® AND NEOMYCIN!
Anti-inflammatory-
Decongestant — Antibacterial
MAJOR ADVANTAGES: New synergistic anti-inflammatory, decongestant
and antibacterial formula. High steroid content assures effective response
f. .
Topically applied hydrocortisone1 in therapeutic
concentrations has been shown to afford a sig-
nificant degree of subjective and objective im-
provement in a high percentage of patients
suffering from various types of rhinitis. Hydro-
spray provides Hydrocortone in a concentra-
tion of 0.1 % plus a safe but potent decongestant,
Propadrine, and a wide-spectrum antibiotic,
Neomycin, with low sensitization potential. This
combination provides a three-fold attack on the
physiologic and pathologic manifestations of
nasal allergies which results in a degree of relief
that is often greater and achieved faster than
when any one of these agents is employed alone.
INDICATIONS: Acute and chronic rhinitis, vaso-
motor rhinitis, perennial rhinitis and polyposis.
SUPPLIED: In squeezable plastic spray bottles
containing 15 cc. Hydrospray, each cc. sup-
plying 1 mg. of Hydrocortone, 15 mg. of
Propadrine Hydrochloride and 5 mg. of Neo-
mycin Sulfate (equivalent to 8.5 mg. of neo-
mycin base).
MERCK SHARP A DOHMC
DIVISION OF MERCK ft CO.. INC.
PHILADELPHIA I, PA,
REFERENCE: 1. Silcox, L. E„ A.M.A. Arch. Otolaryng. 60:431, Oct. 1954.
>CTOBER, 1957
Say you saw it in the Journal of the Michigan State Medical Society
1311
NEWS MEDICAL
ULTRAS O U N D,
FOUND BENEFICIAL
BURDICK UT-1
ULTRASONIC UNIT
Clinical reports, both here and abroad,
have been in agreement on the value of
ultrasound in the following conditions:
Traumatic Injuries • Osteoarthritis • Periarthritis
Fibrositis • Painful Neuroma • Rheumatoid Arthritis
Bursitis • Radiculitis • Scars
A compilation of detailed clinical reports
and ultrasound technics is available upon
request from the Burdick Corporation.
The Burdick UT-1 Ultrasonic therapy
unit is a tested result of pioneering in
this field. It features a coupling signal
that warns when contact is inadequate
for effective treatment. The right-angled
applicator and flexible cable add ease to
operation. Burdick also has a smaller,
portable machine — the UT-4. We will
be happy to demonstrate both machines
to you at your convenience.
The UT-1 and UT-4 are
sold through 296 qualified
medical supply houses
throughout the United
States. Over 1,500 Burdick
sales representatives are
backed by complete serv-
ice facilities for all Bur-
dick equipment.
THE BURDICK CORPORATION
MILTON, WISCONSIN
Branch Offices: CHICAGO • NEW YORK
Regional Representatives:
ATLANTA • CLEVELAND • LOS ANGELES
THE G. A. INGRAM COMPANY
4444 Woodward Avenue, Detroit 1, Michigan
Say you saw it in the Journal of th
(Continued from Page 1310)
57 public relations program at the annual Blue Cross-
Blue Shield Public Relations Institute held at the
University of Wisconsin, August 15, 1957. The Michi-
gan Blue Cross-Blue Shield entry, one of fifty submitted
by the eighty-six Plans in the United States, Canada
and Puerto Rico, was selected Grand Winner in the
overall judging on the basis of its “systematic realiza-
tion of planned objectives.” Louis Graff, Director of
Public Relations and Advertising of Michigan Blue
Cross-Blue Shield, accepted the award at the Annual
Award Dinner.
In accepting the award, Graff said: “Few institutions
conceived in the public interest, as is Blue Cross, have
a greater moral challenge to bridge the- gap between
health problems, which are apparent to everyone, and
financial solutions which are exceedingly complex, often
obscure.” . . . “Our basic task in communications,”
he added, “is to convince the public that we understand
the emotional and economic worry associated with hu-
man illness. And more than that, to demonstrate
through our combined creative restlessness that we in
Blue Cross are still pioneers in finding solutions to these
problems.” . . . “Inescapably,” Graff concluded, “our
public relations task tie us to the welfare of the com-
munity and to the well-being of the individual.”
Those judging the entries were: Harry E. Clark,
Family Week Magazine ; Alton D. Farber, J. Walter
Company; and, Robert Cunningham, Editor, Modern
Hospital.
* * *
The National Disease and Therapeutic Index, a re-
search project of Taylor, Harkins and Lea, Inc., Phila-
delphia, has published its first report in July, 1957, a
mimeographed copy of twenty-one pages. This report
covers neoplasms as seen by practicing physicians. This
survey is a unique research project designed in the hope
of providing a continuous flow of reliable basic facts
on medical practice in the United States. Each of the
panel of more than eight hundred participating physi-
cians reports on all private patient visits during, a forty-
eight-hour-period, once each quarter. Approved sta-
tisticians 'then take the information and analyze it.
The study was sponsored and supported by four lead-
ing ethical pharmaceutical manufacturers: Ciba, Eli
Lilly, Smith, Kline and French, and the Upjohn Com-
pany. The study started in February, 1956, apd from
February 1 through December 31, they collected in-
formation on a total of 91,801, patient visits. Of this
91,801, 2,536, or 2.8 per cent, were recorded with
diagnosis of neoplasm. 35.2 per cent were benign neo-
plasms, 9.1 per cent were neoplasms of unspecified
nature, 1.5 per cent were malignant neoplasms of the
buccal cavity and pharynx, 10.2 per cent were malig-
nant neoplasms of digestive organs and the peritonium,
4.7 per cent were malignant neoplasms of the respiratory
system, 1 9 per cent were malignant neoplasms of breast
and genito-urinary organs, 12.1 per cent malignant neo-
plasms of other and unspecified sites, 8.2 per cent were
malignant neoplasms of lymphatic and hematophytic
tissue.
(Continued on Page 1314)
Michigan State Medical Society
1312
.TMSMS
For—
quick symptomatic relief
or prophylaxis in
urinary tract infections
SUROMATE
patch
THE TRIPLE SULFA
Sulfadiazine .... 100 mg.
Sulfamerazine .... 100 mg.
Sulfacetamide .... 100 mg.
An improved combination including sulfacetamide
. . . efficient antibacterial of exceptional solubility.1
Offers wide-spectrum activity with low dosage,
minimal danger of crystalluria or sensitization.2
Preferred to antibiotics because drug resistance or
superinfection is less likely.3
with the DOUBLE PLUS...
Ext. Hyoscyamus
(alkaloids 0.155%)
5.75 mg.
Antispasmodic action of hyoscyamus quickly
relieves pain, irritation, burning, urgency.4
Potassium Citrate .
200 mg.
Alkalizing and diuretic effects of potassium citrate
enhance sulfonamide solubility and safety.4
Supplied: Bottles of 100 tablets.
1. Kerley, L., and Headlee, C. P.: J. Ara. Pharm. A. (Scient. Ed.)
45:82, 1956. 2. Lehr, D.: Special Exhibit, Mod. Med. 23:111, No. 2,
1955. 3. Editorial, J.A.M.A. 160:210, 1956. 4. Bastedo, W. A.:
Materia Medica, Pharmacology, Therapeutics and Prescription Writing,
ed. 4, Philadelphia, W. B. Saunders Company, 1937, pp. 514, 101.
THE E. L. PATCH COMPANY
STONEHAM, MASSACHUSETTS
)CTOBLR, 1957
Say you saw it in the Journal of the Michigan State Medical Society
1313
NEWS MEDICAL
Important
Announcement of
Arteriosclerosis
Treatment
GEROT PHARMACEUTIKA, own-
ers of United States Letters Patent
#2-776-973 issued January 1957 to
Gerhard Gergely of Vienna, Austria,
have licensed MEYER AND COM-
PANY of Detroit, Michigan, to syn-
thesize and market 3, 7-dimethyl-xan-
thine double salt in the United States
of .America.
3, 7-dimethyl-xanthine double salt with
oleic acid and magnesium, a stable
compound marketed in Austria since
1950 under the name “Perskleran” and
used in the treatment of ARTERIO-
SCLEROSIS is being marketed by
MEYER AND COMPANY under the
trade name of “Athemol.”
The product is now available in tablet
form.
Literature and clinical samples are
available on request.
MiYiE. AND
COMPANY
Pharmaceutical Manufacturers
16361 Mack Ave.
Detroit 24, Michigan
(Continued from Page 1312)
Peripheral Vascular Disease. — A 16-millimeter film in
color with sound has been prepared showing the wide-
spread occurrence of peripheral arterial and venous
circulatory disease. A recent survey shows more than
4,808,000 known cases in the United States alone. More
than a million new cases arise every three years, of which
from 50 to 65 per cent are considered more or less
permanent and requiring periodic or continuous treat-
ment. The film runs thirty-two minutes. Arrangements
for showing the film can be made by writing to Medical
Film Guild, Ltd., 506 West 57th St., New York 19, or
Arlington Funk Laboratories, 250 E. 43rd St., New
York 17. Please advise if you have available the neces-
sary projection equipment, and at least thirty days’
notice should be given.
* * *
Influenza 1957.— In co-operation with the United
States Public Health Service, Wyeth Laboratories has
produced a book with twenty-nine mimeographed pages
giving the complete story of the Asiatic Flu, discus-
sing diagnosis, testing, prevention, and treatment of the
disease. One hundred and fifty thousand copies of the
booklet are being distributed to the medical profession.
It may be had upon request to Joseph E. Dooley, Pub-
lic Relations, Louis N. Gilman, Inc., 1528 Walnut St.,
Philadelphia 2, Pennsylvania. This book contains a very
interesting history of influenza, known in ancient times,
which has produced many pandemics, the most famous
one being in 1918 which took 20,000,000 lives.
* * *
Liaison Committee with University of Michigan. —
The Michigan State Medical Society has a liaison com-
mittee with the University of Michigan, consisting of
Bradley Harris, M.D., chairman; F. E. Ludeig, M.D.,
R. B. Nelson, M.D., and G. C. Wilson, M.D., esnsti-
tuting a Subcommittee on the University Hospital. The
Committee has presented problems of the young doctor
entering practice to the internes and residents. The
presentation was based on the following summation,
especially covering the philosophy of the University
Hospital and the referring physician:
UNIVERSITY HOSPITAL AND THE LOCAL
REFERRING PRACTITIONER
A. Introduction
B. Reasons for patient referrals
1. The attempt of the local practitioner to gel
better and more complete medical care for his
patient.
2. To help provide medical material for study foi
the medical school, interns and residents.
3. Many times the local practitioner desires re-
evaluation of chronic illness, hoping that there
may be something new for his patient.
4. To provide more complete surgical treatment
for his patient when such treatment is nol
available in his community.
5. Out-patient consultation, such as N.P.I., neu-
rology, tuberculosis, allergy, blood diseases, etc
6. Many times the local practitioner desires more
adequate treatment regimes that he may con-
tinue at home.
(Continued on Page 1316)
1314
Say you saw it in the Journal of the Michigan State Medical Society
JMSMf
She’s nervous — and depressed at the same time: “I just can’t
get interested in anything.”
You feel that a “tranquilizer” will probably relieve her nervousness
— but not her depression. On the other hand, stimulants will relieve
the depression — but may magnify her nervousness.
In this type of patient, a clinical trial with Dexamyl* often produces
gratifying results. ‘Dexamyl’, a “normalizing” agent, relieves both anxiety
and depression and imparts to your patient a sense of cheerfulness,
optimism and assurance. A combination of Dexedrine* (dextro-
amphetamine sulfate, S.K.F.) and amobarbital, ‘Dexamyl’ is
available as tablets, elixir and Spansule* sustained release
capsules (two strengths).
Made only by Smith, Kline & French Laboratories, Philadelphia.
*T.M. Reg. U.S. Pat. Off.
■I
October. 1957
Say you saw it in the Journal of the Michigan State Medical Society
1315
NEWS MEDICAL
EVERY WOMAN
WHO SUFFERS
IN THE
MENOPAUSE
DESERVES
"PREMARIN®
widely used
natural 3 oral
estrogen
AYERST LABORATORIES
New York, N.Y. • Montreal, Canada
5646
1316
Say you saw it in the Journal of th.
(Continued from Page 1314)
7. Many referrals come to University Hospital be-
cause certain counties direct patients to the
hospital on the order of the Director of the
Poor, by a supervisor, where no doctor may have
seen the case. In such instances, there has
been no local practitioner.
8. Some referrals are made to the University Hos-
pital because the local practitioner wishes to rid
himself of a nuisance patient.
9. Doctors of Osteopathy refer many patients to
University Hospital.
(a) Twenty per cent of medical care in the
State of Michigan is now given by D.O.’s.
This means that the D O. is replacing the
general practitioner in many areas through-
out the State of Michigan.
(b) For your information, there are approxi-
mately 1,800 practicing D.O.’s in the State
of Michigan, as compared to around 8,000
M.D.’s. At this time, there are 260 Michi-
gan residents now taking courses in Osteo-
pathic schools. As an example, the County
of Oakland has 180 practicing Doctors of
Osteopathy. All of these refer patients to
University Hospital.
C. Resident and Intern relations with the patient
1 . Remember that most patients have complete
faith in their local practitioners.
2. Use care while speaking in front of the patient
about the treatment he has received from his
local practitioner. While the treatment may
not have been that you would have used your-
self, it should not be mentioned as inadvisable
treatment in front of the patient.
3. Careless words can cause dissatisfaction of the
patient with his local practitioner and even
instigate a malpractice suit against the local
practitioner.
D. How to help the local practitioner.
1. Get out reports as promptly as possible.
2. In case of sudden death or serious complica-
tions, contact the local practitioner by phone or
telegraph.
3. Be sure patient is properly instructed as to the
treatments and medications that he must con-
tinue. If the patient is given this information,
have him contact the local practitioner as soon
as possible after his discharge, so that he may i
take over.
4. Many children have reports sent only to the
Crippled Children’s Commission, so that just
writing a letter is not sufficient; giving the in-
formation to the patient or the patient’s family
is most important. (
5. Particular care must be made with Children
with diabetes and allergies and other serious
illnesses. Otherwise, it may be a month before
the report gets to the local practitioner.
6. Remember that in two or three years, you will
be the local practitioner.
* * *
Asian influenza vaccine is being put on the market
and should be in plentiful quantities by cold weather
The AM A Board of Trustees have appointed a commit-
tee on influenza to implement the international and
operational phases of the AMA program. This com-
mittee is the present committee on National Civil De-
fense which consistes of Harold C. Lueth, M.D.; Cortii
F. Enloe, Jr., M.D.; Henry Poer, M.D.; Max L
Lichter, M.D., Detroit; Roscoe L. Sensenich, M.D.
(Continued on Page 1318)
JMSMf 'C
Michigan State Medical Society
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E. GRAND RAPIDS — J. E. Tipping, 1044 Keneberry Way, S.E.
GTOBER, 1957
Say you saw it in the Journal of the Michigan State Medical Society
1317
NEWS MEDICAL
BAND-AID
TRADE MARK
Plastic Strips
• ELASTIC PLASTIC
• FLESH COLORED
• STAYS CLEAN
• THIN, SMOOTH PLASTIC
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Ccnffenientltf located
in (jrand dtapid*
• Hospital Equipment
• Pharmaceuticals
• Office Equipment
• Physicians’ Supplies
• Trusses
• Surgical Garments
• Physiotherapy Equipment
Medical Arts Supply Company
233 Washington S. E. Phone GL 9-8274
Grand Rapids 2, Mich.
Medical Arts Pharmacy
20-24 Sheldon S.E. Phone GL 9-8274
Grand Rapids 2. Mich.
(Continued from Page 1316)
and Claude W. Steele, M.D., to whom have been added
two members of the board: Hugh H. Hussey, Jr., M.D.,
and James E. Apple. This committee is busy at work.
They have recommended that emergency medical service
committees of each state medical society be qualified to
cope with the special influenza problem.
* * *
Tuberculosis appears to be on the
increase among elementary school age
children. Despite a 16 per cent drop
in active and probably active tubercu-
losis cases reported for the state as a
whole, the number of children under
age ten found to have active or prob-
ably active tuberculosis rose 10 per cent
in 1956 over the figure for 1952, when
this breakdown in tuberculosis cases
was first made. The greatest increase
occurred among children aged five through nine.
In 1952, the Michigan Department of Health re-
ported a total of 4,066 active and probably active tuber-
culosis cases, of which 329 were children under ten. In
1956 there were 3,402 active and probably active
tuberculosis cases, including 362 children under ten.
These figures may reflect the rise in birth rate which
followed World War II. They also suggest that the
sources of tuberculosis infection for children are not
being reduced significantly.
The Medical Economics publication, beginning Sep-
tember, 1957, is issuing a new volume for young doc-
tors preparing to practice medicine — internes, house
physicians, residents, and senior medical students. About
thirty-five thousand of them are now receiving the new
edition prepared especially for them. Much of the ma-
terial in the regular Medical Economics publication will
be used, plus a special lead article, entitled “What
Practice Set-up Will Suit You Best.” This will use
charts, tables, and occupy about twenty pages of text
There was also an article about down to earth advice
on the relative merits of solo practice, expense sharing,
partnerships, group practice, and salaried work. Special
articles will appear each month and will take up the
particular problems in the young doctor’s horizon, how
to find a location, how to get a hospital connection, how
to set up an office, how to establish fees, et cetera. We
believe this will be a very acceptable addition to the
young graduate’s training.
* * *
The American College of Physicians has arranged for
eight postgraduate courses beginning in October. These
are open to members and nonmembers at various fees.
The first course lasted five and one-half days, October
7-12, 1957, at the University of Pittsburg, Pittsburg,
Pennsylvania. The second course was from October 14-
18, 1957, at the Medical College of Virginia, Rich-
mond, Virginia. The third, on October 21-25, 1957,
was held at the University of Wisconsin Medical School,
Madison, Wisconsin. The fourth, October 28 to Novem-
(Continued on Page 1320)
1318
Say you saw it in the Journal of the Michigan State Medical Society
JMSMS
* •
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without question, to wliht extent it could
help you in your daily practice. L-F\
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This unit is right for any anp all applications
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Investigate this safe, efficient diathermy unit
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NAME
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CITY/STATE-
CTOBER, 1957
Say you saw it in the Journal of the Michigan State Medical Society
1319
NEWS MEDICAL
(Continued from Page 1318)
ber 1, 1957, will be held at Tufts University School of
Medicine at Boston, Massachusetts. The fifth, Novem-
ber 1 to 3, 1957, will be at the University of Pennsyl-
vania Graduate School of Medicine, Philadelphia Gen-
eral Hospital, Philadelphia, Pennsylvania. The next,
November 18-22, 1957, will be at the National Institutes
of Health at Bethesda, Maryland. The seventh, Febru-
ary 10-14, 1958, is scheduled at Duke University School
of Medicine, Durham, North Carolina, and the eighth,
February 17-21, 1958, at the University of South Cali-
fornia School of Medicine, Los Angeles, California. The
work at these various schools will be various basic sub-
jects and a complete program may be secured from E. R.
Loveland, Executive Secretary, 4200 Pine Street, Phila-
delphia, Pennsylvania.
* * *
The Ophthalmology Scholarship Fund of the Guild of
Prescription Opticians of America. Inc., has announced
five additional young physicians who are just beginning
their residence training in Ophthalmology. This is a
three-year course and the fellowship will amount to
$1,800, paid monthly, over the three years of residency.
None of these new fellows is from Michigan; one is
from Erie, Pennsylvania, one from Nova Scotia, one
from Ontario, one from Georgia, and one from Florida.
This brings to eleven the number of recipients. Next
year’s awards will bring it up to the total of eighteen
fellowships which the Guild expects to continue in oper-
ation, new ones being appointed as old ones finish their
course.
* * *
Management of Mass Casualties. — The army has an-
nounced that special courses for the management of
mass casualties are to be conducted during the fiscal
year of 1958. The following dates have been selected:
September 9-14, 1957 ; December 2-7, 1957; March 24- j
29. 1958; and May 12-17, 1958. The AMA Council
on National Defense has allotted a quota of two repre-
sentatives for each course. Those interested in attend-
ing the courses should write directly to the Council on
National Defense, American Medical Association, 535
N. Dearborn St., Chicago, advising which course is de-
sired. Since there is limited space, they will be handled
on a “first come — first served” basis.
* * *
Dr. James Maxwell, Professor of Otolaryngology of
the University of Michigan is again giving a course
of lectures at the Graduate School of Medicine of the
University of Florida, January 27 to February 1, 1958,
midwinter session, Miami Beach, Florida.
* * *
The 22nd Annual Convention of the American Col-
lege of Gastroenterology was held at The Somerset,
Boston, Massachusetts, on October 21, 22, and 23. In
addition to the many individual papers presented,
(Continued on Page 1322)
Active relief
in
cough
both allergic and infectious
HYDRYIM
• allays bronchial spasm • liquefies tenacious secretions • suppresses allergic manifestations
The ingredients of Hydryllin Compound are proportioned to provide high therapeutic response.
Each 4 cc. (one teaspoonful) contains:
Aminophyllin
32.0 mg.
Chloroform . . .
Diphenhydramine
8.0 mg.
Sugar ......
Ammonium chloride
30.0 mg.
Alcohol 5% (v/v)
8.0 mg.
2.8 Gm.
G. D. Searle & Co., Chicago 80, Illinois.
Research in the Service of Medicine
1320
Say you saw it in the Journal of the Michigan State Medical Society
J MS M’S
Tfie nwAt mmilmt E C6
Change leads by turning a knob, with "Instoinatic” (amplifier-
stabilizing) action automatically clone for you as you turn the knob
. . . mark patient’s name, data, date on record while its still in the
instrument, using a built-in writing surface . . . reload new chart
paper by lifting a cover, dropping in the roll, running motor . . . pick
up and carry the instrument to a hospital ward or patient’s home, as
easily as you would a brief case.
You can do every one of these — and a dozen more time-and-
effort-saving things— when you use the new Sanborn Model 300
VISETTE electrocardiograph. This remarkable, moderately priced
instrument has been designed to fulfill a single purpose: convenient
’cardiography with no sacrifice in diagnostic accuracy. Here is an
ECG that weighs only 18 pounds — no more than a portable type-
writer; that occupies barely more space on the top of your desk
than an 8V2" x 1 1" letterhead; that encourages patient’s pre-test
"peace of mind”, by its attractive, modern design; that shuts itself
off, when the cover is closed; that grounds itself when a button is
pushed; that keeps electrodes, paste, cables and accessories from
getting lost, by storing them in a cover compartment.
In short, the VISETTE is the electrocardiograph for your
practice today. Call the "Sanborn man” in or near your city for
all the facts on the new 300 VISETTE. He’ll be glad to demon-
strate, in your office and at your convenience, the most convenient
ECG you’ve ever used. Or, write for descriptive literature, with
details of 15-day Trial Plan.
SANBORN COMPANY
175 WYMAN ST., WALTHAM 54, MASSACHUSETTS
CTOBER, 1957
Say you saw it in the Journal of the Michigan State Medical Society
1321
NEWS MEDICAL
for modern
control of
salt retention
edema
CUMERTILIN*
(Brand of Mercumatilin, Endo)
Tablets
• effective oral diuretic with no sig-
nificant gastrointestinal irritation1
• Suitable for long-term mainte-
nance therapy.
• eliminates need for injections in
certain cases, lengthens interval
between injections in others
• basically different in chemical
structure, extending the therapeu-
tic choice in organic mercurials
DOSAGE: 1 to 3 tablets daily as required.
SUPPLIED: As orange tablets, in bottles
of 100 and 1000. Also available —
CUMERTILIN Sodium Injection, 1- and 2-cc.
ampuls, in boxes of 12, 25, and 100; and
10-cc. vials, individually and in boxes
of 10 and 100.
1. Pollock, B. E., and Pruitt, F. W.: Am. J. M
Sc., 226:172, 1953.
THE G. A. INGRAM COMPANY
4444 Woodward Avenue, Detroit 1, Mich.
(Continued from Page 1320)
there were panel discussions on Chronic Ulcerative Coli-
tis, Diseases of the Esophagus, Peptic Ulcer and the
Management of Massive Gastrointestinal Hemorrhage
in Patients with Liver Disease.
On October 24, 25 and 26, immediately following
the Convention, Dr. Owen H. Wangensteen, Minneap-
olis, Minnesota, and Dr. I. Snapper, Brooklyn, New
York, were again the moderators of the Annual Course
in Postgraduate Gastroenterology, held at The Somerset
and in the Joslin Auditorium of the New England Dea-
coness Hospital.
Honorary Fellowships were presented to Dr. Chester
S. Keefer, Boston, Massachusetts, Dr. William W. Frye,
New Orleans, Louisiana, Dr. Stafford L. Warren and
Dr. Rafe C. Chaffin, both of Los Angeles, California. |
* * *
OASI Disability Check. — The number of persons
under the new amendment to the Social Security law
has grown very rapidly. During August there were
more than a hundred thousand disability workers whc
received checks under the Old Age and Survivors Insur-
ance Disability Payment program. That was the first
group to receive these benefits. The program went intc
effect in July and these payments are for that month.
* * *
Meetings Abroad. — The eighteenth International Con-
gress of Ophthalmology will meet in Brussels Septembei
8 to 12, 1958. Elaborate programs have been arranged
but anyone who wishes to go should make his reserva-
tions immediately in Brussels because the 1958 World’:
Fair will be there and the city will be crowded with
visitors.
The Pan American Association of Ophthalmology, cele-
brating its eighteenth year with some 2,000 member:
representing the Western Hemisphere, will hold its Sec
ond Cruise Congress on February 1-14, 1958, on boarc
the steamship Queen of Bermuda. The itinerary in
eludes a stop of a day each at San Juan, Puerto Rico
Ciudad Trujillo, Dominican Republic; Kingston, Ja
maica; Port Au Prince, Haiti; and Nassau, Baham:
Islands. Elaborate meetings and reports and program
will be conducted on the cruise on board ship anc
with meetings in each of the cities visited. For informa
tion, address Frank H. Constantine, M.D., 30 West 59tl
St., New York 19, New York.
The Fifth International Congress of Internal Medicini
will be held in Philadelphia on April 24-26, 1958. Abou
1.000 Americans and about 400 overseas physicians ari
expected to attend. Membership is open and thosi
eligible are invited to make application; papers will bi
considered. Consult Frank W. Allan, M.D., 605 Com
monwealth Ave., Boston 15, Massachusetts.
* * *
The Internal Revenue Department has issued report
showing that in the year 1953 there were 145 person
with one million dollars income. That had increased t<
201 in 1954. The 1954 records are the latest availabli
and they show that only 1.3 per cent of all taxpayers
543.000 persons, made as much as $20,000 in 1954, bu
(Continued on Page 1324)
1322
Say you saw it in the Journal of the Michigan State Medical Society
JMSM
Thirst, too,
in
PREVENTIVE GERIATRICS
a FIRST from TUTAG !
Now — 20 to 1 Androgen-Estrogen
(activity) ratio* !
Each Magenta Soft Gelatin Capsule contains:
Methyltestosterone 2 mg.
Ethinyl Estradiol .... 0.01 mg.
Ferrous Sulfate 50 mg.
Rutin 10 mg.
Ascorbic Acid 30 mg.
HI 2 1 meg.
Molybdenum 0.5 mg.
Cobalt 0. 1 mg.
Copper 0.2 mg.
Vitamin A 5,000 I.U.
Vitamin D 400 I.U.
Vitamin E _ 1 I.U.
Cal. Pantothenate 3 mg.
Thiamine Hcl. 2 mg.
Riboflavin 2 mg.
Pyridoxine Hcl 0.3 mg.
Niacinamide 20 mg.
Manganese .. I mg.
Magnesium .5 mg.
Iodine..... 0.15 mg.
Potassium 2 mg.
Zinc I mg.
Choline Bitartrate 40 mg.
Methionine 20 mg.
Inositol 20 mg.
Write for Latest Technical Bulletins.
‘REFERENCE: J.A.M.A. 163: 359, 1957 (February 2)
jjgl DETROIT 34, MICHIGAN
October, 1957
Say you saw it in the Journal of the Michigan State Medical Society
1323
NEWS MEDICAL
(Continued from Page 1322)
those people received more than 10 per cent of all
income and paid nearly 25 per cent of all federal
income taxes on individuals. This figure includes only
taxable income. Only 3.7 per cent of all taxpayers re-
ceived from $10,000 to $20,000 of income in 1954, but
that group received 10 per cent of all income and paid
about 12J/2 per cent of the federal taxes. 29 per cent
of all taxpayers received from $5,000 to $10,000. They
received 39 per cent of all income and paid about 35
per cent of the taxes. Stated in another way, 66 per cent
of the taxpayers received less than $5,000 of income.
They accumulated 41 per cent of income and paid 28
per cent of the taxes. (USNWR)
* * *
Doctor Draft. — S. S. Director Lewis B. Hershey has
announced officially that doctors and dentists under age
thirty-five, otherwise potential inductees in selective
service, are not to be drafted. The medical draft law
has been discontinued and if these particular men should
happen to be on any draft board call list, they are not
to be inducted. This applies to any young man holding
the degree of Bachelor of Medicine, as well as M.D.,
D.D.S., D.M.D.
* * *
Practice of Medicine by Hospitals. — The internal
revenue bulletin for August 26 reports some peculiar
rulings on the practice of medicine by hospitals. A non-
doctor anesthetist served two hospitals, one on a salary
basis and the other on a fee basis. The Internal Revenue
Service held that services to the hospital are as an
independent contractor rather than an employe, because
working conditions are not those of the usual employer-
employe relationship. Further, the ruling makes it im-
plicit that the services rendered are not medical since
the anesthetist is not a physician and therefore his earn- I
ings are regarded as the product of a trade rather than
a profession for tax purposes. In another ruling, it was
held that an anesthetist who works exclusively for one
dental surgeon on a fulltime basis is an employe of that
dentist, even though his sole remuneration consists of
charges listed separately on the dentist’s billings
( WRNS) .
* * *
Hospital Construction, Hill-Burton. — Up to July 31,
1957, the Hill-Burton program embraced 3,535 approved
projects, with a total estimated cost of $2,890,497,651,
the federal share of which was $908,689,102. These have
added or will add more than 153.000 beds to the 898
health units. Two thirds of the projects are completed
and in operation nearly 1,000 others are in various
stages of construction (WRMS).
* * *
Clarence L. Candler Honored. — The Detroit News for
Sunday, July 28, 1957, carried a picture of Dr. Clarence
L. Candler, Detroit, and a story of his retirement from
the practice of medicine in which he has been very
active for many years, including service as a delegate t
to the Michigan State Medical Society and a visitor to I
the AMA meetings. Dr. Candler had practiced for more
than forty years, had served as President of the Detroit
BRIGHTON HOSPITAL
A non-profit Foundation
FOR ALCOHOLISM
A facility designed to rehabilitate or to aid
the addict in arresting his addiction.
Walter E. Green, M.D., Superintendent and Medical Director.
12851 East Grand River
(U.S. 16)
Brighton, Michigan
Academy 7-1211
Brighton Hospital meets the stand-
ards established by the Michigan
State Board of Alcoholism and is
recommended by that Board.
1324
Say you saw it in the Journal of the Michigan State Medical Society
JMSMS
NEWS MEDICAL
oard of Health, and had also been a police surgeon
at least he had a red flasher on top of his car to
icilitate early arrival when calls came for help). The
actor hopes to devote more time to his private movies
id “do-it-yourself.”
* * *
Standing Orders for Nurses in a Mass Disaster. — The
etroit Department of Health, the Medical and Public
ealth Divisions of Civil Defense, and The Wayne
ounty Medical Society have adopted a schedule of
anding orders for use of nurses in mass disaster in the
isence of a doctor, or before he arrives; also a formula
i care for the victim patient. The Co-ordinating Com-
ittee of the Michigan State Medical Society has ap-
-oved the same rules for use anywhere in the state,
hese rules have been revised as of February 1, 1957,
id are published by the Detroit Department of Health,
hese rules are primarily for use when the nurse must
:t in the absence of a physician. Three headings are
entioned: (1) Immediate Treatment because of mas-
/e hemorrhage, asphyxia, chest wounds, abdominal
Dunds, burns, crash injuries, and head and spine in-
ries; (2) identification — an emergency medical tag;
id (3) relief of pain, including a list of doses for nu-
erous drugs. Formulae are given for various solutions
id preparations needed. Detailed instructions for frac-
re splints are given briefly. Respiratory obstruction
im whatever cause requires immediate relief. The list
standing orders occupies six single-spaced pages.
Loan Fund. — Early this year the Michigan Chapter of
the American College of Surgeons established a loan fund
for use of residents in surgical training who find them-
selves in financial difficulties. Applicants for the fund
are given a careful screening, and the money is loaned
free of interest, but with the understanding it will be
repaid to the fund as soon as the recipient is established
in practice. To date, three loans have been made. It is
hoped the fund will be self-perpetuating. This is a very
worthy cause, and the experience within a very few
months of establishment proves the need. We con-
gratulate the College.
* * *
J. M. Rawlings, M.D., of Flint, has been elected a
member of the Royal Society of Health of London, Eng-
land. The election was based on a paper delivered by
Doctor Rawlings, in Rome, on “Bio-Chemical Changes
of the Body Found in Pulmonary Tuberculosis.”
* * *
A Fourth Bahamas Medical Conference will be held
at Fort Mantagu Beach Hotel, Nassau, December 1-15,
1957. For information, write B. L. Frand, M.D., 1290
Pine Avenue West, Montreal, Canada.
* * *
The American Medical Association is concentrating
its activities on the fall campaigns for funds to help our
medical colleges. Committees are being formed, and
when anxiety and tension "erupts” in the G. 1. tract...
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ITOBER, 1957
Say you saw it in the Journal of the Michigan State Medical Society
1325
NEWS MEDICAL
information will be coming from Chicago early in the
fall.
* * *
Steven J. Figiel, M.D., Leo S. Figiel, M.D., and
D. K. Rush, M.D., presented a paper at the annual
meeting of the American Medical Association in New
York dealing with “A New Approach to the Colon
Study — High Kilovoltage Spot Compression Technique.”
* * *
Leo S. Figiel, M.D., and Steven J. Figiel, M.D.,
presented a paper and exhibit at the annual meeting of
the Rocky Mountain Radiologic Society in Denver,
Colorado, dealing with “LTnusual Manifestations of Ileo-
Cecal Pathology Including the Appendix.”
* * *
Medical Conferences. — The American Medical Asso-
ciation through its various Councils and activities is
sponsoring several fall conferences of direct interest to
the Medical Profession : A National Conference of Physi-
cians and Schools, October 30 to November 2, 1957, at
the Moraine-on-the-Lake hotel, Highland Park, Illinois,
will feature “A Decade of Progress in Fitness” at its
sixth session. It is sponsored by the AMA’s Bureau of
Health Education and will emphasize continuing interest
in the health and all-around fitness of children and youth.
More than eighty nationally recognized consultants have
been scheduled from medicine, education and public
health to lead the discussion groups.
Broadcasters and Doctors. — A two-day meeting i
scheduled by the American Medical Association and th<
National Association of Radio and Television Broad
casters for November 7 and 8 at the Hotel Sheraton
Blackstone in Chicago, for a conference on utilization o
local radio and television time by medical and healtl
organizations. Public interest programs involving medi
cal subjects are appearing more and more frequently
Both broadcasters and physicians want to be sure tha
such programs are interesting, informative and factual
The fall conference will be open to radio and televisioi
broadcasters, representatives of medical societies, hospita
organizations, voluntary health organizations, and other
interested in public health programs.
Rural Health. — The AMA’s second study confereno
on October 4-5, 1957, for chairmen and members o
Rural Health committees, sponsored by the Council oi
Rural Health, was held at Purdue University, Lafayette
Indiana. The opening session was devoted to organiza
tional techniques of statewide Rural Health Committees
Another session featured representatives of leading farri
organizations outlining their problems.
SMJAB. — The State Medical Journal Advertising Bu
reau, formerly sponsored by the AMA, now an inde
pendent organization of editors and business manager
(M.D.) of most of the state medical society journal:
will hold its annual session in Chicago, October 28 am
29, 1957. These meetings date from 1910, at Chicagc
come to cJ Tmn
for an Autumn Holiday
Fall is a most delightful time of
the year at country-quiet Dear-
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You’ll like the Inn’s colonial
charm in a 28-acre estate-like set-
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including TV and air condition-
ing throughout — its traditional
hospitality — the newly enlarged
cocktail lounge — the fine food
graciously served in either the
Early American Dining Room
or the English Coffee Shop.
And cool, autumn days are ideal
for a visit to nearby . . .
HENRY FORD MUSEUM and GREENFIELD VILLAGE
where you can see a broad profile
of American history from earliest
times to modern day.
Also only a short drive away is
the Ford Rotunda, famous for its
architecture, fascinating exhibits
and miniature test track over
which you can ride.
For further details, write or call
The Dearborn Inn.
135 guest rooms
in the Inn and
Colonial Guest
Houses from
$8 single; $13
double. Reserva-
tions advisable.
The Dearborn Inn . Oakwood Boulevard • Dearborn, Mich. • LOgan 5-3000 • Richard D. McLain, Manager
1326 JMSM
Say you saw it in the Journal of the Michigan State Medical Society
NEWS MEDICAL
RITTER EXAMINING TABLES enable the physician to treat
more patients, more thoroughly with less effort in less time.
Pediatric-Child
Lateral (Sims)
12 Basic Positions provide amazingly easy accessibility to your
patients. These energy-saving features are made possible by
the Ritter exclusive motor-hydraulic base, an 18-inch eleva-
tion range, effortless handwheel tilt, 180 degree table rota-
tion, and easy adjustment of headrest, footrest, back, seat,
and leg sections.
We will be happy to arrange a demonstration of the Ritter Universal
Table at your convenience.
NOBLE-BLACKMER, Inc.
267 W. Michigan Ave., Jackson, Michigan
“Study Abroad” will be the theme of the third world
rr, postgraduate clinical course, sponsored by the Inter-
tional College of Surgeons. The professional trip,
iving San Francisco, October 20, will circle the globe
forty-eight days. The return to New York will be
:cember 7, with optional return routings to permit
ip-over privileges in many European cities. Luxury
lines will be used to cover a wide territory in a rea-
lably short time. Families and friends will be accom-
)dated.
Fellows of the International College of Surgeons have
anged lectures, clinical demonstrations and entertain-
•nt in Hong Kong, the Philippines, Thailand, India,
irkey and Greece. Dr. Arnold Jackson of Madison,
isconsin, past president of the United States Section,
IS., will be the co-ordinator. Detailed information
ly be obtained from the International Travel Service,
:., Palmer House, Chicago.
* * *
Dr. M. Duane Sommerness, Medical Superintendent at
■ State Hospital at Traverse City, Michigan, announces
i appointment of Dr. F. T. Sorum to the medical
ff of that institution. Dr. Sorum received his medical
jree from Rush Medical School of the University of
icago, and since 1952 has been a member of the staff
Willmar State Hospital, Willmar, Minnesota. Dr.
rum is a member of the South West Medical Society
Minnesota, a member of the State Medical Associa-
n, and the American Medical Association. Doctor and
s. Sorum with their two children, Solveg Ann and
lph Edward, moved to Traverse City on September 1.
1TOBER, 1957
The Institute of Industrial Health at the College of
Medicine of the University of Cincinnati announces a
three-day Symposium on Fluorides to be presented De-
cember 9-11, 1957, inclusive. The purpose of this sym-
posium will be to present the most recent information
that is available concerning the physiological behavior
of the absorption of fluoride.
The symposium will be open to physicians and dentists
in industry and public health and to other professional
persons who are interested in the subject. Attendance
will be limited and early application is suggested. The
registration fee will be $50.
For further information and application blank, write
to Secretary, Institute of Industrial Health, Kettering
Laboratory, Eden and Bethesda Avenues, Cincinnati 19,
Ohio.
* * *
The Michigan Proctological Society officers for the
year are: Joseph W. Becker, M.D., Detroit, President;
Donald J. Pearson, M.D., Battle Creek, President-Elect;
Guy W. DeBoer, M.D., Grand Rapids, Secretary; Martin
C. Sharp, M.D., Saginaw, Treasurer.
* * *
The Sister Elizabeth Kenny Foundation announces a
continuance of its post-doctoral scholarships to promote
work in the field of neuromuscular diseases. These schol-
arships are designed for scientists at or near the end of
their fellowship training in either basic or clinical fields
concerned with the broad problem of neuromuscular
diseases.
Say you saw it in the Journal of the Michigan State Medical Society
1327
NEWS MEDICAL
Kenny Foundation Scholars will be appointed annu-
ally. Each grant provides a stipend of from $5000 to
$7000 a year for a five-year period, depending upon the
Scholar’s qualifications. Candidates from medical schools
in the United States and Canada are eligible.
Inquiries concerning details should be sent without
delay to: Dr. E. J. Huenekens, Medical Director, Sister
Elizabeth Kenny Foundation, 2400 Foshay Tower, Min-
neapolis 2, Minnesota.
* * *
Coccidioidomycosis, which was known up to a decade
ago mainly to physicians and mycologists working in the
endemic area, must now be seriously considered in the
differential diagnosis of chronic pulmonary lesions in
nonendemic areas. Because of the great numbers of
military personnel who were stationed in endemic areas
during and after World War II, a widespread scatter-
ing of the disease occurred, although the area itself
apparently showed no signs of expanding. — Denis J.
O’Leary, M.D., and Francis J. Curry, M.D., Ameri-
can Review of Tuberculosis, April, 1956.
* * *
Harold F. Diehl, M.D., Dean of the College of Medi-
cal Sciences, University of Minnesota, and long active
in committee work of the American Medical Association,
will assume his duties as Senior Vice President for Re-
search and Medical Affairs and Deputy Executive Vice
President of the American Cancer Society, on Novem-
ber 1, 1957.
Doctor Diehl is well known for his work with the
AMA Council on Civil Defense, having been a member
since its creation by the 1947 House of Delegates, and
Chairman since December, 1954.
Congratulations, Doctor Diehl!
* * *
William A. Hyland, M.D., of Grand Rapids, Chair-
man of the AMA House of Delegates Committee to study
the Heller Report, has called a number of meetings in
Chicago beginning with one at the AMA headquarters
on August 8. Doctor Hyland has invited all who have
read the Heller Report and who care to make sugges-
tions, to write to him at 110 Fulton Street East, Grand
Rapids, Michigan.
* * *
Osborne A. Brines, M.D., of Detroit, has been elected,
for a three-year term, as President of the International
Society of Clinical Pathology.
Congratulations, Doctor Brines!
* * *
“Standing Orders for Nurses in a Mass Disaster,” as
approved by the Wayne County Medical Society, and
developed by the Detroit Department of Health (revised
on February 1, 1957) were approved by The Council
of the Michigan State Medical Society on July 12, 1957.
A copy of this informative brochure is available by
writing the Medical and Public Health Division of Civil
Defense, Detroit Department of Health, City-County
Building, Detroit 26, Michigan.
(Continued on Page (1330)
r
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■
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each coated tablet contains: Phenaphert
Phenacetin (3 gr.) 194.0 mg.
Acetylsalicylic Acid (2V£ gr.) . 162.0 mg.
Phenobarbital (% gr.) .... 16.2 mg.
Hyoscyamine Sulfate .... 0.031 mg.
plus
Prophenpyridamine Maleate . . 12.5 mg.
Phenylephrine Hydrochloride . 10.0 mg.
■\
1328
Say you saw it in the Journal of the Michigan State Medical Society
JMSM
ST. JOSEPH’S RETREAT
Member: American Hospital Association
Catholic Hospital Association
National Association of Private
Mental Hospitals
The Central Neuro-Psychiatric
Hospital Association
Under the direction of the
Daughters of Charity of St. Vincent de Paul
Serving Metropolitan Detroit
and Michigan almost a century
Martin H. Hoffmann, M.D.
Medical Director
23200 West Michigan Avenue
Dearborn
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'CTOBER, 1957
Say you saw it in the Journal of the Michigan State Medical Society
1329
NEWS MEDICAL
(Continued from Page 1328)
FIVE WAYS TO MAKE YOUR JOB GROW:
1. Spend plenty of time on preliminary planning.
Planning is deciding what you want to do, when you
want to do it and how you intend to do it. Time spent
on planning will prove the most profitable time you
spend on the job.
2. Run your job , instead of letting your job run you,
by handling details efficiently. Don’t let yourself be
constantly burdened by an accumulation of unfinished
jobs — things you intend to do “just as soon as you have
a minute’s spare time.” Do the disagreeable jobs first —
the others are easy. No job is as hard to do as it looks —
it’s easy once you start it.
3. Be persistent. Persistence is a more potent factor
in getting things done than mental brilliance.
4. Don’t ever stop learning. Try to develop the inqui-
sitive type of mentality. Human beings are capable of
adding to their accumulated knowledge as long as they
live.
5. Don’t waste time thinking up alibis. Some wise
man has said that there are two kinds of people: those
who use alibis and those who get things done. Instead
of alibis, which look to the past, spend your time on
constructive planning for the future. (From — The
Office).- — AST A News Summary, 1957.
* * ■*
The man who rows the boat generally doesn’t have
time to rock it.
— Anonymous
The Third Annual Mercy Hospital Clinic Day will
be held October 17, 1957, at Mercy Hospital Auditor-
ium, Port Huron. A buffet luncheon will be served at
1 : 30 p.m.
The program by members of the Medical Staff, Grace
Hospital, Detroit, Michigan, will include the following:
“The Detection and Management of Cardiac Disease
in Pregnancy” — George S. Fisher. M.D., F.A.C.P.
“The Rehabilitation and Employment of the Patienj
with Cardiac Disease” — John G. Bielawski, M.D.,
F.A.C.P.
“The Patient with Cardiac Disease As A Surgical
Risk” — Daniel W. Myers, M.D., F.A.C.P.
Dinner will be served at St. Clair Inn, St. Clair,
Michigan, at 7 P.M. The speaker will be The Honor-
able Robert J. McIntosh, U. S. Representative 7th
Congressional District.
* * *
The Frank E. Bunts Educational Institute, affiliated
with the Cleveland Clinic Foundation, announces a post-
graduate course in “Hematology” at the Institute Head-
quarters, 2020 East 93rd Street, Cleveland, Ohio, Oc-
tober 23-24, 1957. A symposium on Clinical Chemistry
sponsored by the American Association of Clinical Chem-
ists, Cleveland Section, will also be held at the Institute
Headquarters, November 13-14-15. For information,
write the director at the above address.
* * *
Michigan Blue Cross-Blue Shield were named winners
of the top trophy for their 1956-57 Public Relations
1330
Say you saw it in the Journal of the Michigan State Medical Society
JMSMS
NEWS MEDICAL
Program. The award was made at the annual Blue
Cross-Blue Shield Public Relations Institute, held in
Madison, Wisconsin, August 15. The Michigan BC-BS
entry — one of fifty submitted by the eighty-six clans in
the United States, was selected Grand Winner on the
basis of its “Systematic Realization of Planned Objec-
tives.”
M.D. LOCATIONS
Through September 1, 1957
Placed by Michigan Health Council
Royal Hames, M.D Lansing
Robert Kamp, M.D Beulah
James P. Capo, M.D Sunshine Hosp., Grand Rapids
* * *
The Academy of Psychosomatic Medicine will hold its
fourth annual meeting at the Morrison Hotel, Chicago,
October 17-18-19. For program, write William S.
Kroger, M.D., Chairman, 104 S. Michigan Avenue
(Suite 415), Chicago 3, Illinois.
* * *
The Milwaukee Academy of Medicine announces a
Symposium on Radioisotopes, to be held at Marquette
University (Brooks Memorial Union), Saturday, Decem-
ber 7, 1957. For program and information, write Joseph
F. Kuzma, M.D., 561 North Fifteenth Street, Milwau-
kee, Wisconsin.
* * *
Retirement point credits may be earned by reserve
officers of the Military Medical Services attending ses-
sions of the 64th annual convention of the Association
of Military Surgeons of the United States to be held in
Washington, D. C., October 28 to 30, 1957, the office
of the Surgeon General has announced. This applies
to eligible reserve officers of each component of the
medical services of the army, navy and air force.
Assisted by Michigan Health Council
Morton J. Kripke, M.D Berkley
D. Bonta Hiscoe, M.D Lansing
James E. Kelly, M.D Flint
Robert Huebner, M.D Hastings
James G. Hopkins, M.D Muskegon
Clarence H. Schultz, M.D Dearborn
John O. L. Jui, M.D Grand Rapids
Alfred Touma, M.D Royal Oak
Victor Glikman, M.D Pontiac
David Schane, M.D Detroit
John L. London, M.D Lakeview
Ralph Woodbury, M.D Gross Pointe
MEDICAL TELEVISION SHOWS
Produced by Michigan Health Council
WJBK-TV, DETROIT
August 4 — Alcoholism — (Film — “Alcoholism the Revolv-
ing Door”)
August 11 — M.D. Qualities — (Film — “Even for One”)
August 18 — Mental Health — (Film — “Roots of Happi-
ness”)
August 25 — Rehabilitation — (Film — “Man in the Win-
dow” )
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Say you saw it in the Journal of the Michigan State Medical Society
1331
Communication
SAMMOND PLEASANT LODGE
Offers to the elderly and chronically ill
Peace and quiet. Freedom of a large and richly
furnished home and acres of lawns and wooded
rolling grounds, scientifically prepared tasty
meals, congenial companionship. A real
"Home away from Home"
Approved by the American Medical Association
and Michigan State Department of Social Wel-
fare— Highly recommended by members of the
Medical Profession who have had patients at
the Lodge.
For further information write to:
SAMMOND PLEASANT LODGE
124 West Gates Street
Romeo, Michigan
Dear Dr. Haughey:
Congratulations on the new cover design — “Michi-
gan” is now visible from a distance of well over my pres-
ently receding presbyopic minimum. I like it fine.
I also liked the meaty section on medical care plans,
and I wonder if a dozen copies or so might be obtained
for our use here. Are over-run pages or tear sheets
available?
I'm just home one day from a 9,000-mile cross-coun-
try tour with Mrs. Arnold and our fourteen-year-old
son — it took us eight weeks, ever since the AMA meet-
ing. We settled for a week between Mullet Lake and
Mackinac, and again on a dude ranch in Jackson Hole,
but the rest of the time we were on the move pretty
steadily. Nothing like a road map to warn you that
bifocals are just around the comer!
I hope to see you in Chicago in October, if I can
get away.
Cordially yours,
Harry L. Arnold, Jr.
Honululu 14, Hawaii
(formerly, Owosso, Michigan)
July 30, 1957
Dear Doctor Haughey:
The Journal of the Michigan State Medical j
Society, Vol. 56, No. 7, for July, 1957, contains an
editorial captioned, What Is A Hospital? over the name
of Dr. Clarence I. Owen. This has been drawn to my
attention because of the deep interests of the staff of one
of our research projects in arriving at such a definition.
The first article on this subject has been published in
Hospitals, the journal of the American Hospital Asso-
ciation, under the title “Sense or Jabberwocky?” This
first article appeared in issue No. 12 of Vol. 31, pub-
lished under date of June 16, 1957. We anticipate that
the first set of definitions, including those for hospitals
in certain broad categories, will be published in the near
future.
I should like to make it clear that our definitions are
the product of research activity conducted under the
sponsorship of the American Hospital Association, but
otherwise independent of Association direction or policy.
The Association may later choose to adopt definitions
we have arrived at if they stand the test of scrutiny to
which they are sure to be subjected. The research pro-
gram is carried on under grant from the Bureau of
Medical Services of the U. S. Public Health Service
through its National Advisory Hospital Council. The
definitions work is one phase of a total project devoted
to determination of “The Future Needs for Hospital
Facilities.”
I would like to express sympathetic understanding of
Doctor Owen’s viewpoint as expressed in this editorial.
Teamwork of a high order between those who bear
responsibility for the administrative and professional
activities within hospitals is essential in this as in all
other operations of mutual concern. We look forward
to considerate reflection on our labors by the medical
profession in all its component parts when our defini-
tions are published. Dr. Owen may wish to watch for
this output of our staff.
Sincerely yours,
Alan E. Treloar, Ph.D
Director of Research
Chicago, Illinois
August 22, 1957
0 TMSMS
.Say you saw it in the Journal of the Michigan State Medical Society
COMMUNICATIONS
’o The Editor
tear Sir:
Upon reading my good friend Foster’s contribution to
re symposium on Michigan Medical Service, in the June
sue of the Journal, I am compelled to contribute a
;w items to the historical account. I agree that the
aunger members of the profession should be informed
bout its birth. It is a legitimate one.
My interest is also legitimate, due to the fact that I
m one of the two living members of the original com-
littee that started the whole thing. The other is Dr.
Feg. Christian of Lansing.
The committee in question, as you will remember,
as known as The Marshall Committee. It was ap-
ointed by the then President, Dr. Carl Moll of Flint,
ad consisted of Dr. William Marshall, Flint, Chairman;
'r. Frederick A. Baker, Pontiac; Dr. L. G. Christian,
ansing; Dr. B. U. Estabrook, Detroit; Dr. C. S. Gors-
ne. Battle Creek. Dr. F. C. Warnshuis, then secretary
: the State Society, acted as an ex officio member.
We presented the first insurance plan, mutual health
:rvice, back in 1933, when the phrase, health insur-
ice, was a dirty word. Those were the days of the great
ipression, days of fear. Federal government was up-
tting our old concepts. The social revolution was on.
ompulsory health insurance was being widely urged
i powerful lay groups.
We were ahead of the times with our proposal. The
-ofession, not only in Michigan, was afraid of insurance
edicine. The AMA strenuously opposed it. Our House
Delegates refused to accept even the principle of
surance.
Today, all this sounds funny. I can assure you that it
as not funny then!
I would add this. There is much to be done. I trust
at those in charge continue to have the vision and
courage necessary for making Michigan Medical Service
better. To quote Sir Arthur Salter, “It is our system
in which we have grown up that we must reform — and
in part transform.”
Most sincerely yours,
Frederick A. Baker
Pontiac, Michigan
August 12, 1957
Dear Mr. Burns:
Previously, we have written to you and asked your
co-operation on this same subject. We appreciate your
consideration and thank you sincerely for your past help.
The following paragraph is from our contract, VI 005
M76, with the Veterans Administration:
“USP and NF Products — The Contractor, with-
out cost to the Veterans Administration, will from
time to time, and by appropriate means, advise the
Michigan State Medical and Dental Societies of the
availability of USP and NF Products in an effort
to establish prescribing practice which will permit
the dispensing of the highest quality drugs for
beneficiaries of the Veterans Administration at the
lowest possible cost to the Veterans Administration.”
Following the details of this paragraph, we submit
for your review and counsel, the enclosed items. When
time and space permits, would you pass this informa-
tion on to your members.
Each licensed pharmacy in Michigan has in his exten-
sive library, an up-to-date copy of the United States
Pharmacopeia and National Formulary.
These publications are available to the members of
the Medical and Dental Societies either for use in the
store or for reference work in the office.
Sending my best personal regards and again, our ap-
when anxiety and tension "erupts” in the G. I. tract...
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Dosage: 1 tablet t.i.d. at mealtime. 2 tablets at bedtime. Supplied: Bottles of 100, 1,000.
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TOBER, 1957
Say you saw it in the Journal of the Michigan State Medical Society
1333
COMMUNICATIONS
Protection against loss of income from
accident and sickness as well as hospital
expense benefits for you and all your
eligible dependents.
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Executive Secretary \
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August 21 , 1957
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Category — Central depressant.
Usual Dosage Each of Ammonium Bromide, Potassium Bromide,
and Sodium Bromide — 300 mg. (approximately 5 grains).
Three Bromides Elixir, National Formulary
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Usual Dose — 4 ml. (approximately 1 fluidram).
One usual metric dose contains about 320 mg. each of Ammonium
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Compound Resorcinol Ointment. National Formulary
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Zinc Oxide Paste with Salicylic Acid, National Formulary
Category — Astringent; protective.
Compound White Pine Syrup with Codeine, National Formulary
Category — Antitussive.
Usual Dose — 4 ml. (approximately 1 fluidram).
One usual metric dose contains 8 mg. of Codeine Phosphate.
Thymol Iodide, National Formulary
Category — Antifungal ; anti-infective.
Thimerosal Ointment, National Formulary
Category — Antibacterial.
Ichthammol Ointment, National Formulary
Category — Local antibacterial: irritant.
Ascorbic Acid Tablets, The Pharmacopeia of the United States
(The United States Pharmacopeia) 15th Revision
Category — Antiscorbutic vitamin.
Dose — Daily, oral and subcutaneous.
Usual — Requirement, 75 mg.
Therapeutic, 150 mg.
Range — Requirement, 25 to 75 mg.
Theraoeutic, 100 mg. to 1 Gm.
Cortisone Acetate Tablets. The Pharmacopeia of the United States
(The United States Pharmacopeia) 15th Revision
Category — Adrenocortical hormone.
Dose — Usual — Oral, 25 mg. four times a day.
Intramuscular, 100 mg. daily.
Range — Oral, 2.5 to 75 mg.
Intramuscular, 5 to 300 mg.
Phenobarbital Elixir. The Pharmacopeia of the United States (The
United States Pharmacopeia) 15th Revision
Category — Central depressant.
Dose — Usual — 5 ml. ^20 mg. of phenobarbital) four times a day. '
Range — 5 to 15 ml.
Atropine Sulfate Tablets, The Pharmacopeia of the United States }]
(The United States Pharmacopeia) 15th Revision
Category — Parasympatholytic.
Dose — Usual — 0.5: top>c?dlv as 1 to 2 per cent solut:on.
Range — 0.3 to 1.2 mg.
Belladonna Tincture, The Pharmacopeia of the United States (The
United States Pharmacopeia) 15th Revision
Category — Parasympatholytic.
Dose — Usual — 0.6 ml. three times a day.
Range — 0.3 to 2.4 ml.
Clove Oil. The Pharmacopeia of the LTnited States (The LTnited
States Pharmacopeia) 15th Revision
Category — Dental obtundant: nharmacputic necessity for Diphen-
hydramine Hydrochloride Elixir.
For External Use — Topically as required.
Isoniazid Tablets, The Pharmacopeia of the United States (The
United States Pharmacopeia) 15th Revision
Category — Tuberculostatic antibacterial .
Dose — Usual — 100 mg. twice a day.
Range — 50 to 200 mg.
Achievements after Sixty. — When you look at the
facts, a man’s best days are not over at sixty. There
are figures to show that the greatest achievements of
man were consummated between his sixtieth and sev-
entieth year.
Examining the histories of some 400 career men, the
most notable and outstanding statesmen, painters, war-
riors. poets and writers of their times, indicates the
decade of years between sixty and seventy contained
35 per cent of the world’s greatest achievements; be-
tween seventy and eighty years, 23 per cent ; after eighty I
years, 8 per cent. In other words, 66 per cent of all
great achievements accomplished by man were devel-
oped and given posterity after he had reached or passed
his sixtieth year. — Midland Rotary Table.
1334
Say you saw it in the Journal of the Michigan State Medical Society
TMSMS
THE DOCTOR'S LIBRARY
I cknowledgments of all books received will be made in this column ,
,nd this will be deemed by us as full compensation to those
ending them. A selection will be made for review , as expedient.
CHRONIC ILLNESS IN THE UNITED STATES.
Volume I. Prevention of Chronic Illness. Commission
on Chronic Illness. Published for the Commonwealth
Fund. Cambridge, Massachusetts: Harvard Univer-
sity Press, 1957.
The Commission on Chronic Illness is publishing four
olumes on Chronic Illness. This is the first, and is the
esult of seven years’ study and investigation by the
oluntary commission composed of representatives of
tany national societies — Cancer, Heart, Dental, Hospi-
il, Medical, Psychiatric, Public Health, Public Welfare,
rheumatism, Muscular Dystrophy, Polio, Multiple Scler-
sis. Tuberculosis, Crippled Children, and Health Insur-
nce, or various Foundations.
During the years, many reports have been issued, but
le work is now being summarized in four very present-
ble volumes from the Harvard University Press.
The introductory part is explanatory. The first section
f the book is devoted to the problems of Prevention,
romotion of Health, Primary Studies, Periodic Health
xaminations, Screening, Education and Planning. Chap-
:rs are devoted to the list of chronic diseases, repre-
sented largely by the national societies associated in the
commission — Arthritis and Rheumatism, Blindness, Can-
cer, Cardiovascular Disease, Cerebral Palsy, Diabetes,
Epilepsy, Deafness, Mental Health, Multiple Sclerosis,
Poliomyelitis, Late Syphilis, Tuberculosis, Chronic In-
dustrial Disease, Dental Health, Emotional Factors,
Heredity, Malnutrition and Obesity. These chapters are
very well written, giving valuable information and pro-
cedures found to be applicable.
The final part of the book is devoted to appendices on
History of the Commission, By-Laws, list of publications.
Appendix E lists the largely controllable chronic diseases,
the partially controllable, and the uncontrollable ones.
WILLIAM HARVEY. His Life and Times: His Dis-
coveries: His Methods. By Louis Chauvois. Foreword
by Sir Zachary Cope. New York: Philosophical Li-
brary, 1957. Price, $7.50.
This is a very well-written and well-translated bio-
graphy of one of the giants in the medical world, pre-
pared for the tercentenial of his death, which occurred
June 3, 1657. The treatment is unusual. A day in Dr.
Harvey’s life is given in detail, and the day selected
was when he was forty-nine years of age, just before
publishing his theory of the circulation of the blood. The
concept had been announced and used by him and some
of his friends for ten years, but had not been published
publically. The story is given of his being summoned
to the bedside of King Charles I, who was very ill with
NEW YORK 18, N. Y
IPHERAL
ANTITUSSIVE . DECONGESTANT • A N T I H I ST A M I N I C
(4cc.) cmIdjm ■.
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Say you saw it in the Journal of the Michigan State Medical Society
1335
EXEMPT NARCOTIC
THE DOCTOR'S LIBRARY
ANNUAL CLONDCAL CONFERENCE
CHICAGO MEDICAL SOCIETY
March 4, 5, G and 7, 1958
Palmer House, Chicago
Lectures Teaching Demonstrations
Medical Color Telecasts
The CHICAGO MEDICAL SOCIETY ANNUAL CLINICAL CONFERENCE should be a MUST on the
calendar ol every physician. Plan now to attend and make your reservation at the Palmer House.
pneumonia. Description is made of treatment and use
of leeches by the doctor himself.
Chapters are given to the early days of study and
sendees in hospitals, his war sendee, and his later years
when he had become famous and wealthy — at least he
had constructed a building at the medical school to con-
tain his office and teaching facilities. The doctor's
death scene is given, his will and the disposition of his
effects, including the withholding from one heir of his
coffee pot, which went to his younger brother, his
executor. About a third of the book is devoted to an
appreciation of Dr. Harvey’s life and work, of which the
discovery of the circulation of the blood was the most
outstanding of all medical history. His work as a re-
nowned surgeon, anatomist and medical writer are well
presented. He made many of his own illustrations. We
are happy to add this volume to an increasing list of
biographies of medical greats.
SURGEONS ALL. By Harvey Graham, M.D. Foreward
by Oliver St. John Gogarty. New York: Philosophical
Library. Price $10.00.
This book gives a rather comprehensive study of the
history of surgery. In covering the development of the
art through the ages, the book travels about, relating
interesting and historical deeds. The book is well written
and the narrative style keeps one’s interest at a high
level. This book is proof that the history of medicine
provides extremely interesting reading.
R.L.M.
AN ATLAS OF THE COMMONER SKIN DISEASES
With 153 Plates reproduced by direct color photog-
raphy from the living subject. By Henry C. G. Semon
M.A., D.M. Oxon., F.R.C.P. London; Consulting
Physician for Diseases of the Skin, and former Lee
turer to Postgraduates, Royal Northern Hospital
Consulting Dermatologist, Hampstead arid North-Wes
London General Hospital; Ex-president and Vic<
President, Dermatological Section. Royal Society o
Medicine; Corresponding Member of the Societi
Francaise de Dermatologie at Syphilologie ; Medailli
d'Honneur de F Assistance Publique, Republique Fran
caise; Medical Referee for Industrial Dermatitis
Ministry of National Insurance. Revised with th
collaboration of Harold T. H. Wilson, M.A., M.D.
Cantab., M.R.C.P., D.T.M., Dermatologist and Lee
turer to Postgraduates. Royal Northern and Centra
Middlesex Hospitals ; Dermatologist, Mount Vernoi
Hospital. Northwood, Wimbledon, and Highlands Hos
pitals. Color photography originally directed by th
late Arnold Moritz. B.A., M.B., B.C. Cantab. Fift
edition. Baltimore: The Williams and Wilkins Com
pany, 1957. Price. $20.00.
This book contains a full-page color photograph alon
with a brief discussion of 131 of the commoner ski
diseases and twenty-two more of the less common ski
diseases. For the most part, the photographs represen
well the topic under discussion, and the color repre
duction is excellent. The authors live in Great Britaii
but their text is very close to that of American author
For a general physician who wants a quick referenc
along with good color pictures to aid him in his dermt
tological problems, this is an excellent atlas.
MERCY WOOD SANITARIUM
Conducted by Sisters of Mercy
Treatment for Mild Nervous and Mental Disorders
JACKSON ROAD ANN ARBOR, MICHIGAN
NOrmandy 3-8571
1336
Say you saw it in the Journal of the Michigan State Medical Society
JMSN
THE DOCTOR’S LIBRARY
OOT TROUBLES. By T. T. Etamm, F.R.C.S. New
York: Philosophical Library, Inc., 1957. Price, $4.75.
This book of 122 pages was printed in England on
rhite non-gloss paper with large easily readable type,
hand size and completely acceptable. The text is
ivided into ten chapters dealing with the foot and its
lechanics, its diseases of improper function, deformities
nd their correction, infections, injuries, pain and effects
f chronic diseases. The care of the foot in health, and
i certain diseases as diabetes which possess certain
>ecial liabilities. Care of children’s feet and footwear
re given proper attention, and the problem of selection
F shoes is studied. There are illustrations and diagrams,
he book is very readable and will be of great assistance
i many lines.
CIBA FOUNDATION COLLOQUIA ON AGEING.
Volume 3. Methodology of the Study of Ageing.
Editors for the Ciba Foundation, G. E. W. Wolsten-
holme, O.B.E., M.A., M.B., B.Ch., and Cecilia M.
O’Connor, BSc. 47 illus. Boston: Little, Brown and
Company, 1957. Price, $6.50.
The Ciba Foundation is continuing its plan of confer-
lces on various medical subjects. The Foundation
ivites to London, England, leaders in kindred subjects
ho attend, present their reports of papers, and enter
ito discussions. The material is then edited and pub-
shed in book form. This number is the third volume
l The Colloquia on Ageing: Methodology of the Study,
wenty-eight scientists from the entire world assembled
and took part; five from the United States and three
from Canada, with Charles H. Best, M.D., of Toronto,
acting as chairman. The thirteen papers were presented
with their discussions, a very creditable array of talent.
This book is just as interesting as its predecessors.
DERMATOLOGIC FORMULARY. From the New
York Skin and Cancer Unit, Service of Dermatology
(Dr. Marion B. Sulzberger, Director). Frances Pasch-
er, M.D., Editor. Revised, 1957. New York: A
Hoeber-Harper Book, 1957.
This is a most complete dermatologic formulary list-
ing a multitude of preparations with a brief discussion
of the items together with their uses, indications and
contraindications. It is right up to date with listings of
drugs which have been on the market only a few months.
This is an excellent booklet and highly recommended
for the general physician or beginning dermatologist.
H.A.
THE POWER OF SELF-KNOWLEDGE. Body and
Mind Awareness; A New Technique For Successful
Living. By Milton W. White, M.D. A dynamic, prac-
tical learning-method to help you understand and con-
trol your own emotions, thinking, and behavior in
order to achieve maximum health, happiness, and self-
acceptance. New York: The Julian Press, Inc., 1957.
Price $3.95.
This book, written by one of our members in Detroit,
is primarily designed for use of patients with psychoso-
matic problems. General semantics are called upon to
when anxiety and tension "erupts” in the G. I. tract. . .
in spastic
and irritable colon
PATH I BAM ATE
Meprobamate with PATHILON® Lederle
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habituation . . . with PATHILON {25 mg.) the anticholinergic noted for its extremely low toxicity
and high effectiveness in the treatment of many G.I. disorders.
Dosage: 1 tablet t.i.d. at mealtime. 2 tablets at bedtime. Supplied: Bottles of 100, 1,000.
’Trademark ® Registered Trademark for Tridihexethyl Iodide Lederle
LEDERLE LABORATORIES DIVISION, AMERICAN CYANAMID COMPANY, PEARL RIVER, NEW YORK
1337
Say you saw it in the Journal of the Michigan State Medical Society
1TOBER, 1957
THE DOCTOR’S LIBRARY
outline self-knowledge, case histories being cited as a
help. The second part, ‘ How to protect yourself from
the fear based emotions,” is philosophical and covers
nervousness, hostility, frustration, guilt, shame, and re-
morse. Proper and suggested co-ordination and willing-
ness can wipe out such emotions and their self-stimulated
disease conditions. The third section of the book is
divided into five sections, showing how self-knowledge
can give a life of health, happiness and self-satisfaction.
This is especially a book for the patient whose troubles
may be mostly self-induced.
THE SURGICAL MANAGEMENT OF PULMONARY
TUBERCULOSIS. Edited by John D. Steele, M.D.
Introduction by Frederick A. C.oller, M.D. Biographi-
cal Sketch of John Alexander by Cameron Haight,
M.D. Springfield, Illinois: Charles C Thomas. Price
$9.50.
In this first volume of a planned John Alexander
Monograph Series, fourteen thoracic surgeons trained by
Dr. Alexander have collaborated to produce a fine
resume of the current surgical treatment of all phases of
pulmonary tuberculosis. The final chapter on the chemo-
therapy of tuberculosis, was written by his medical col-
league. John B. Barnwell. John Steele has reviewed the
evolution of the surgery of pulmonary tuberculosis,
summed up the modern thoracoplasty technique, and has
commented on changes in this field since the 1925 and
1937 textbooks published by Dr. Alexander (who was
working on a revised edition of “The Collapse Therapy
of Pulmonary Tuberculosis” at the time of his death in
1954).
Pulmonary resection for tuberculosis with pneumonec-
tomy and segmental resection is discussed with slightly
varying viewpoints by several surgeons. Other authors
(in separate chapters) cover combined collapse and re-
section therapy, thoracoplasty, extraperiosteal plombage,
treatment of pleural tuberculosis, decortication, caverno-
stomy and the surgical management of pulmonary tuber-
culosis in psychotic patients. These discussions are nicely
illustrated with x-rays and anatomical drawings. This
book is very well done and will be an excellent reference
textbook for physicians and surgeons in this field.
S.B.W.
Classified Advertising
$2.50 per insertion of fifty words or less, with an
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A VACANCY FOR MEDICAL RESIDENT will I
open next February to a physician graduated fro
Class A medical school, interested in tuberculos
possessing either temporary or permanent Michigt
state license. Salary ranges between $9,500 and $12,01
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service here. An apartment, furnished with het
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OTOLARYNGOLOGIST WANTED (Board or Boa
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gan city of 45,000. Write P. O. Box 487, Sheboyga
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FOR SALE: Eleven-room house with newly co
structed ten-room office attached. Town of 700
additional doctor badly needed. Central location t
tween Battle Creek, Kalamazoo, Grand Rapids ai
Lansing. Excellent schools and churches. Best of fis
ing and hunting. Excellent opportunity for doct
interested in locating in central Michigan where me
ern 100-bed hospital provides facilities for special
Present doctor owner retired because of ill heal:
Entire office, equipment, office furnishings and hoi
may be bought on reasonable terms. Contact: Char
H. Truesdell, D.D.S., 305 S. Michigan, Hastings, Mic
igan.
WANTED: Active general practitioner, with inter
in obstetrics, to establish own independent practf
All professional facilities provided. Contact: V.
Chabut, M.D., Northville Clinic, Northville, Michig;
OPPORTUNITY to open practice in one of West Mic
igan’s fast-growing communities. On White Lake a i
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modern suite of offices available on ground floor,
minutes from hospitals. Contact: Norman K. Pitk i
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1338
■Say you saw it in the Journal of the Michigan State Medical Society
THE JOURNAL
of the Michigan State Medical Society
UME 56 NOVEMBER, 1957 NUMBER 11
^ntributors to This Issue
Table of Contents
The Physician and City Commissions
L. A. Drolett, M.D 1393
The Doctor and the Service Club
T. E. Schmidt, M.D 1395
The Doctor and the School Board
Warren B. Cooksey, M.D 1396
Use of Doxinate with Danthron as Withdrawal
Therapy in the Treatment of Chronic Func-
tional Constipation
Edmund S. Socha, M.D 1397
Tracheotomy: Indications and Comments
G. S. Fitz-Hugh, M.D., F.A.C.S., and W. C.
McLean, M.D 1400
Official Report of the Opinion Study of Prepaid
Medical Care Coverage in Michigan 1405
Auricular Septal Defects
Anthony C. Nolke, M.D 1437
The Physiatric Contribution to Geriatrics
K. McMorrow, M.D., M.P.H 1440
Wayne State University College of Medicine —
Sixth Annual Symposium on Blood, January 18-
19, 1957 1444
President’s Message
Market Research and Medicine’s Future 1453
High Points of the 92nd Annual Session 1454
Editorial :
The Doctor as a Citizen 1458
Evidences of the Doctor as a Citizen 1458
Liberalization 1459
Medical Education 1459
The Market Opinion Survey 1459
Reference Committee on Medical Services and
Prepayment Insurance 1460
Don’t Camouflage Health Care 1461
Some Important Actions Insert facing 1460
Michigan’s Department of Health 1462
In Memoriam 1468
News Medical 1474
The Doctor’s Library 1494
You and Your Business 1362
Statement of Principles Between Physicians and
Lawyers 1376
Heart Beats 1380
AMA Washington Letter 1382
AM A News Notes 1388
What They Thought About the 1957 MSMS An-
nual Session 1390
© 1957 by Michigan State Medical Society
BER, 1957
1343
THE JOURNAL
of the Michigan State Medical Society
"VOLUME 56 NOVEMBER, 1957 NUMBER 11
PUBLICATION COMMITTEE
B. M. HARRIS, M.D., Chairman .Ypsilanti
» ILL JAM BKUMML, M.D Detroit
O. B. McGILLICUDDY, M.D Lansing
W. S. STINSON, M.D Bay City
T. P. WICKLIFFE, M.D Calumet
Office of Publication
2642 University Avenue
Saint Paul 14, Minnesota
OFFICERS OF THE SOCIETY
1956-1957
President G. W. SLAGLE, M.D Battle l
President-Elect ..G. B. SALTONSTALL, M.D Char]
Secretary ..L. FERNALD FOSTER, M.D D
Treasurer W. A. HYLAND, M.D Grand P
Speaker K. H. JOHNSON, M.D La
Vice Speaker J. J. LIGHTBODY. M.D _...D
Editor WILFRED HAUGHEY, M.D Battle <
Assistant Editor L. J. BAILEY, M.D D
Editor
WILFRID HAUGHEY, M.D.
610 Post Bldg., Battle Creek, Michigan
Assistant Editor
L. J. BAILEY. M.D.
620 Vinewood Avenue, Birmingham, Michigan
Secretary and Business Manager of THE JOURNAL
L. FERNALD FOSTER, M.D.
441 E. Jefferson, Detroit, Michigan
Executive Director
WM. J. BURNS, LL.B.
606 Townsend Street, Lansing 15, Michigan
All communications relative to exchanges, books for review, manu-
icripts, should be addressed to Wilfrid Haughey, M.D., 610 Post
Bldg., Battle Creek, Michigan.
All communications regarding advertising and subscription should
be addressed to Wm. J. Burns, 2642 University Avenue, Saint
Paul 14, Minnesota, or 606 Townsend Street, Lansing 15, Michigan.
Telephone Ivanhoe 57125.
© 1957, by Michigan State Medical Society.
Published monthly by the Michigan State Medical Society as its
official journal at 2642 University Avenue, Saint Paul 14, Minnesota.
Entered at the post office at Saint Paul, Minnesota, as second
class matter. May 7, 1930, under the Act of March 3, 1879.
Acceptance for mailing at special rate of postage provided for
in Section 1103 Act of October 3, 1917, authorized August 7, 1918.
Yearly subscription rate, $6.00; single copies, 60 cents. Additional
postage; Canada, $1.00 per year; Pan-American Union, $2.50 per
T ear; Foreign, $2.50 per year.
PRINTED IN U.S.A.
THE COUNCIL
D. BRUCE WILEY, M.D., Chairman, Utica
W. B. HARM, M.D., Vice Chairman, Detroit
L. FERNALD FOSTER, M.D., Secretary, Bay City
1
District E.
A. E. SCHILLER, M.D 1st Detroit
O. B. McGILLICUDDY, M.D... 2nd Lansing
H. J. MEIER, M.D 3rd Coldwater
RALPH W. SHOOK, M.D 4th Kalamazoo
C. ALLEN PAYNE, M.D 5th Grand Rapids
H. H. HISCOCK, M.D 6th Flint
J. F. BEER, M.D 7th St. Clair
E. S. OLDHAM. M.D 8th Breckenridge
D. G. PIKE. M.D 9th Traverse City
O. J. JOHNSON, M.D 10th Bay City
W. M. LeFEVRE, M.D 11th Muskegon
B. T. MONTGOMERY, M. D 12th Sault Ste. Marie ...
T. P. WICKLIFFE, M.D 13th Calumet
B. M. HARRIS, M.D 14th Ypsilanti
D. BRUCE WILEY, M.D 15th Utica
G. THOMAS McKEAN, M.D 16th Detroit
W. B. HARM, M.D 17th Detroit
WILLIAM BROMME, M.D 18th Detroit
G. W. SLAGLE, M.D President Battle 1
G. B. SALTONSTALL, M.D President-Elect Char
K. H. JOHNSON, M.D Speaker U
J. J. LIGHTBODY, M.D Vice-Speaker D
L. FERNALD FOSTER, M.D Secretary D
W. A. HYLAND, M.D Treasurer Grand F
ARCH WALLS, M.D Past President D
EXECUTIVE COMMITTEE OF THE COUN
D. BRUCE WILEY, M.D Cha
W. B. HARM, M.D Vice Cha
W. M. LeFEVRE, M.D Chairman, County Societies Comi
B. M. HARRIS, M.D Chairman, Publication Conn
RALPH W. SHOOK, M.D Chairman, Finance Comi
K. H. JOHNSON, M.D S|
J. J. LIGHTBODY, M.D Vice S|
G. W. SLAGLE, M.D Prel
G. B. SALTONSTALL, M.D President
L. FERNALD FOSTER, M.D Sec
W. A. HYLAND, M.D Tre
SECTION OFFICERS
Dermatology and Syphilology
Coleman Mopper, M.D Detroit
Chairman
Alice E. Palmer, M.D Detroit
Secretary
Gastroenterology and Proctology
E. J. Tallant. M.D. Detroit
Chairman
J. F. Wenzel, M.D. Detroit
Secretary
General Practice
E. M. Wakeman, M.D Dearborn
Chairman
C. W. Royer. M.D Battle Creek
Secretary
Gynecology and Obstetrics
R. W. McClure, M.D Detroit
Chairman
L. S. Griffith, M.D. Grand Rapids
Secretary
Medicine
J. M. Kaufman. M.D Detroit
Chairman
J. W. Hall, M.D Traverse City
Secretary
Nervous and Mental Diseases
S. C. Mason, M.D. Ann Arbor
Chairman
S. M. Gould, Jr Ann Arbor
Secretary
Occupational Health
P. B. Rastello, M.D Detroit
Chairman
T. I. Boileau, M.D Birmingham
Secretary
Ophthalmology and Otolaryngology
James E. Coyle, M.D Detroit
Chairman (Oto.)
H. A. Dunlap, M.D Detroit
Co-Chairman (Ophth.)
Harold F. Schuknecht, M.D Detroit
Secretary ( Oto.)
F. A. Barbour, M.D Flint
Co-Secretary ( Ophth.)
Pediatrics
A. M. Hill, M.D. Grand Rapids
Chairman
G. E. Hause. M.D Detroit
Secretary
Public Health and Prevents
Medicine
J. K. Altland. M.D. L i
Chairman
H. B. Robins, M.D Battle i
Secretary
Radiology, Pathology, Anesthesi
R. R. Benson, M.D Grand
Chairman (Rad.)
R. B. Sweet, M.D Ann
Vice Chairman (Anes.)
Viola G. Brekke, M.D Highlan
Secretary (Path.)
Surgery
H. M. Bishop, M.D S
Chairman
R. F. Salot, M.D Mt. C «
Secretary
Urology
R. P. Lytle, M.D
Chairman
A. W. Bohne. M.D
Secretary
Delegates DELEGATES
W. A. Hyland, M.D., Grand Rapids, Chairman 1957
J. S. DeTar. M.D., Milan 1957
C. I. Owen, M.D.. Detroit 1957
W. D. Barrett, M.D., Detroit 1958
W. H. Huron, M.D.. Iron Mountain 1958
R. L. Novy. M.D., Detroit 1958
TO A. M. A. Alternates
W. W. Babcock, M.D.. Detroit
E. F. Sladek, M.D.. Traverse City
O. J. Johnson. M.D.. Bay City.
William Bromme. M.D.. Detroit
J. R. Rodger, M.D., Bellaire
G. W. Slagle, M.D.. Battle Creek
Delegate
Detroit
Ji
Section
G. C. Penberthy, M.D. (Surgical Section)
1344
disappointed with half measures in angina?
<- READ THIS
f<| LMBER, 1957
Say you saw it in the Journal of the Michigan State Medical Society
You and Your Business
RECOMMENDATIONS AND BACKGROUND
OF INFLUENZA— 1957
Adopted, by the Michigan Department of Health,
September 9, 1957.
Approved by the MSMS Committee on National
Defense, September 18, 1957.
Approved by the MSMS Council, September 27 , 1957.
Strains of a new family of Type A influenza
viruses have caused extensive outbreaks of a mild
type of influenza throughout the world. There is
a possibility of an outbreak of this disease this
fall or early winter involving ten to twenty per
cent of Michigan people during a period of from
four to six weeks. A vaccine has been developed
for use against the new influenza family.
Recommendations for the Guidance of
Physicians and Health Officers
Use of Vaccine. — The new influenza vaccine
should be used as rapidly as it becomes available.
To be effective, it must be given at least 10-14
days before exposure. There are no immunological
dangers in giving the new influenza vaccine con-
currently with other immunizing agents. But the
vaccine should not be given concurrently in those
instances where the other immunizing agents are
likely to cause reactions.
Priorities. — With an anticipated shortage of
vaccine and the possibility of a high attack rate,
four groups, in the following order, should be given
priority for immunization:
(a) Those whose services are necessary for the
health of the community ;
(b) Those who provide other basic community
services ;
(c) Those who in the opinion of their private
physicians constitute a special medical risk :
(d) Those who are housed together in concen-
trated groups.
Dosage. — Vaccine dosage should be as follows:
3 months — 5 years — Two doses of 1/10 cc.
intradermally given one to two weeks apart
6 years — 12 years — Two doses of J4 cc. sub-
cutaneously given two weeks apart
13 years and over — One dose of one cc sub-
cutaneously
Diagnosis. — With clinical diagnosis based on the
judgment of the individual physician, the following
points and procedures should be observed:
(a) A reasonable number of laboratory speci-
mens from any outbreak should be submitted for
viral studies to establish the specific etiology.
Specimens for viral studies from an outbreak will
be accepted by the state health department only
upon recommendation of the local health officer
and only within the capacity of the laboratory.
1362
Twelve specimens should be sufficient for th
community purpose involved. Laboratory vira
studies are not of practical value in managing in
dividual cases since the overwhelming majority c
patients recover before such studies are completec
(b) Bacteriological studies should be made o
patients when there is suspicion of bacterial coir
plications.
Home Care. — The vast majority of influenzl
patients should be treated at home. Hospital cai
should be considered only for complicated cast
and for others who in the opinion of their phys
cian constitute a special medical risk.
Community Action. — For the present, at leas:
the risk of the new type of influenza is n<
sufficient to justify either delaying the opening <
schools, the closing of schools once opened or inte
fering with public gatherings.
Public Understanding. — Local health depai
ments are designated as sources for informatic
about influenza, and the state health departme:
will request physicians’ organizations to mal
specific recommendations to their membership ar
patients concerning the management of influen
cases.
Surveillance. — The following procedures will
observed in the surveillance of the disease
Michigan:
(a) All clinically-diagnosed cases of influenz
like disease will be reported.
(b) Local health officers will supplement t
regular reporting from physicians carried c
under the law by. ( 1 ) spot-checking by telepho
with local physicians (or representative samplin
as to the number of patients with influenza se
by them during the past week; (2) spot-checki
by telephone with representative schools and,
industries regarding excessive absenteeism.
(c) The State Health Department will requ
no data from local health departments other tf
the number of diagnosed cases.
(d) Each week, the State Health Departm
will spot-check a sample of the hospitals in
state as to the number of cases of and deaths fr i
pneumonia.
Background
About the Vaccine.
Distribution. — In an effort to secure equita
distribution of the vaccine within the state, ma
facturers of the vaccine have been requested
allot Michigan’s share of their production of
new vaccine to their “detail men” in proportioi 1
the population served by them.
(Continued on Page 1364)
JM! j
in bronchial asthma and respiratory allergies
specify the buffered ‘ ‘predni-steroids”
to minimize gastric distress
combined steroid-antacid therapy ,
‘Co-Deltra’ or ‘Co-Hydel-
tra’ provides all the bene-
fits of “predni-steroid”
therapy and minimizes the
likelihood of gastric distress
which might otherwise im-
pede therapy. They provide
easier breathing — and
smoother control— in bron-
chial asthma or stubborn
respiratory allergies.
supplied: Multiple Compressed
Tablets ‘Co-Deltra’ or ‘Co-Hy-
deltra’ in bottles of 30, 100, and
500.
CoHeltra
2.5 mg. or 5.0 mg.
of prednisone or
prednisolone, plus
300 mg. of dried
aluminum
hydroxide
gel and 50 mg.
of magnesium
trisilicate.
(Prednisone buffered)
(Prednisolone buffered)
•CO-DELTRA' and 'CO-HYDELTRA' are
registered trademarks of Merck & Co.. Inc*
MERCK SHARP 6c DOHME
DIVISION OF MERCK & CO.. INC.
PHILADELPHIA 1. PA.
ember, 1957
Say you saw it in the Journal of the Michigan State Medical Society
1363
YOU AND YOUR BUSINESS
RECOMMENDATIONS AND BACKGROUND
OF INFLUENZA— 1957
(Continued from Page 1362)
Potency and Dosage. — The strength of the
monovalent vaccine now being produced is 200
CCA units per 1 cc. dose. Recommendations are
based upon providing the widest possible use of a
vaccine which can be made available commercially
in the shortest period of time. As the vaccine sup-
ply becomes more plentiful, it is expected that
either the potency of the vaccine or the dosage
will be increased, and that the vaccine may be
modified to protect against other influenza viruses.
Reactions. — Use of the new vaccine is expected
to cause some soreness at the site of injection and
about the same percentage of other reactions as
are caused by the polyvalent forms of vaccine
which have been available commercially over a
number of years. Reactions are most frequent in
younger children, while less than one per cent of
adidts immunized are expected to have more than
local tenderness.
About the Disease
Characteristics. — The newer form of influenza
resembles the clinical picture of mild influenza
occurring during the past ten years. It in no way
resembles the influenza experienced in 1918. Even
in countries with considerable poverty and con-
gested, overcrowded populations, deaths from com-
plications of influenza have not exceeded one per
two thousand cases.
The development of influenza in a given in-
dividual is thought to be dependent upon the
relative dose of the virus received and the patient’s
antibody levels and general health.
The virulence of influenza viruses has not been
observed to change during any outbreaks in the
twenty-four years that they have been identified.
There is no reason to believe that the situation will
be any different this year.
Outbreaks. — In Australia, where this type of
influenza has been occurring this spring and
summer (their winter months), the disease has
continued to be relatively mild. There were few
bacterial complications and there was no serious
disruption of community living. The attack rate
in Australia was about 15 per cent of the popula-
tion in those areas where the disease assumed
epidemic proportion. This incidence occurred in
a four to six weeks period.
Observation of influenza outbreaks in other parts
of the world has again proven that the mainte-
nance of good nutrition and good health habits
are effective in preventing complications.
HIGHLIGHTS OF SEPTEMBER
SESSION OF THE COUNCIL
September 22-27, 1957
A total of ninety-three items was presented a
discussed by the twenty-five members of T
Council (eighteen Councilors, The Preside
President-Elect, Immediate Past President, Sec
tary, Treasurer, Speaker and Vice Speaker) at t
two meetings held coincident with the MSb
Annual Session in Grand Rapids.
Three hundred thirty-one cumulative hoi
were contributed on these two days by the me
bers of The Council in their study of and decisic
on the problems facing the medical profession
Michigan, including:
• Reorganization of The Council:
D. Bruce Wiley, M.D., Utica, was re-elected
Chairman.
W. B. Harm, M.D., Detroit, was again cho:
as Vice Chairman.
Wm. M. LeFevre, M.D., Muskegon, was sek
ed as Chairman of the County Society’s Comn
tee to succeed himself.
Ralph W. Shook, M.D., Kalamazoo, was
elected head of the Finance Committee.
B. M. Harris, M.D., Ypsilanti, was elected
the post of Chairman of the Publication Cc
mittee.
• The Monthly financial reports were studied ;
approved, as well as bills payable which w
ordered paid.
• The Market Opinion Survey Report was f
sented, in its entirety, and referred to the He
of Delegates. A vote of thanks was extendec
Survey Director H. W. Brenneman and
MSMS headquarters staff, for services 'beyi
the line of duty to complete this monumei
task in four and one-half months. The Sur
Report, including action taken on same by
1957 House of Delegates, was ordered tr:
mitted to Michigan Medical Service.
• Group Life Insurance for MSMS Meinb
Report on a survey made by a leading insura
consultant indicated a high percentage of MS
members are interested in this coverage; fa’
able consideration was recommended to
House of Delegates.
• The Annual Report of the Healing Arts St
•Committee was approved and referred to
House of Delegates as a part of the Sup
mental Report of The Council.
• An instance of the practice of medicine b
corporation was thoroughly discussed by
Council; the Chairman was authorized to
point a committee for Liaison with hospital
ministration. The Council hoping for benef
results through mutual understanding ra
than from litigation.
(Continued on Page 1366)
1364
TM
why wine
in digestive
disorders?
Although the effects of wine on the
digestive system have been discussed
for centuries, it has been only in recent
years that many of its physiological
attributes have been determined.
WINE AND THE SALIVARY GLANDS— The increase in salivary flow following a
moderate intake of wine is apparent almost immediately,1 such increase being
attributed to direct sensitization of secretory nerve endings.2
WINE AND GASTRIC SECRETION —With a pH averaging 3.2, wine resembles
gastric juice more closely than does any other natural beverage. Its tannins, organic
acids and salts of these acids serve as buffering agents to maintain this pH.
Relatively low in content of alcohol, table wine has been found to stimulate gastric
secretion and induce production of gastric juice high in hydrochloric
acid, sodium chloride, rennin and pepsin.3
WINE AND THE DIGESTIVE TRACT— With its low concentration of alcohol, wine
i in moderate consumption has been found to induce a marked increase in
biliary flow.4 This, together with increased function of pancreatic enzymes, may
thus encourage better digestion of fatty foods.
THEREFORE — IN THE TREATMENT OF DIGESTIVE DISORDERS— Wine is being
widely recommended in the treatment of anorexia, hypochlorhydria without
gastritis, mucous colitis, spastic constipation and diarrhea, and in digestive disorders
stemming from emotional tension and anxiety.
These and other modern uses for wine are discussed in the brochure
“Uses of Wine in Medical Practice.” For your free copy write— Wine
Advisory Board, 717 Market Street, San Francisco 3, California.
1. Winsor, A. L. and Strongin, E. I.: J. Exper. Psychol. 7 6:589 (1933). «"***
2. Beazell, J. M., and Ivy, A. C.: Quart. J. Studies on Ale. 7:45 (1940).
3. Faroy, G., and Weissenbach, R. J.: Hopital 25:306 (1937).
4. Okada, S.: J. Physiol. 49.457 (1915).
;er, 1957
Say you saw it in the Journal of the Michigan State Medical Society
1365
YOU AND YOUR BUSINESS
HIGHLIGHTS OF THE COUNCIL
(Continued from Page 1364)
• The fee-schedule of the Michigan Society of
Internal Medicine was received for reference to
any committee studying fees.
• Appointments. Wilfrid Haughey, M.D., was
authorized to attend meeting of the Committee
Umphrey, M.D., Detroit, and Lester P. Do<
Detroit.
• C. E. Umphrey, M.D., Detroit, Michig;
Chairman for the American Medical Educat:
Foundation presented his final report, and r
ommendations for the future — during which
praised the Woman’s Auxiliary for its tremi
dous job in furthering AMEF in this State.
• The Beaumont Memorial Foundation, as ;
MEMBERS OF THE COUNCIL, 1957-1958
Seated (left to right): L. Fernald Foster, M.D., Detroit; G. W. Slagle, M.D., Battle Creek;
D. Bruce Wiley, M.D., Utica; G. B. Saltonstall, M.D., Charlevoix; and W. A. Hyland, M.D.,
Grand Rapids.
Middle row (left to right): H. H. Hiscock, M.D., Flint; J. J. Lightbody, M.D., Detroit; Ralph
W. Shook, M.D., Kalamazoo; K. H. Johnson, M.D., Lansing; W. M. LeFevre, M.D., Muskegon;
Editor Wilfrid Haughey, M.D., Battle Creek; E. S. Oldham, M.D., Breckenridge; William
Bromme, M.D., Detroit; and B. M. Harris, M.D., Ypsilanti.
Top row (left to right): O. J. Johnson, M.D., Bay City; G. Thomas McKean, M.D.,
Detroit; D. G. Pike, M.D., Traverse City; O. B. McGillicuddy, M.D., Lansing; Arch Walls,
M.D., Detroit; J. F. Beer, M.D., St. Clair; C. Allen Payne, M.D., Grand Rapids; H. J.
Meier, M.D., Coldwater; and T. P. Wickliffe, M.D., Calumet.
Absent on Society business: W. B. Harm, M.D., Detroit; B. T. Montgomery, M.D., Sault Ste.
Marie; and A. E. Schiller, M.D., Detroit.
on Indigent Care of the AMA Council on Medi-
cal Service, Chicago; Legal Counsel Dodd was
authorized to represent MSMS at workman’s
compensation section of the State Bar of Michi-
gan convention, Detroit.
• MSMS co-sponsorship of 1958 Michigan Rural
Health Conference, Ann Arbor, January 22-24,
1958, was authorized.
• Report and statistics on the MSMS Health and
Accident Insurance program, provided by the
carrier (Provident Life and Accident Insurance
Company, of Chattanooga) were presented and
given study — and included in the Supplemental
Report of The Council.
• Committee to Review the Problem of Profes-
sional Liability was appointed by Chairman
D. Bruce Wiley, M.D., as follows: S. W. Don-
aldson, M.D., Ann Arbor, Chairman, C. E.
thorized by the 1956 House of Delegates,
created coincident with the 1957 MSMS ( i
vention — on September 25, 1957, with the ■
lowing acting as incorporators and member !
its Board of Trustees: Otto O. Beck, M
W. S. Jones, M.D.; C. T. Eklund, M.D.; J i
Fyvie, M.D.; L. J. Hirschman, M.D.; W.
LeFevre, M.D.; A. H. Whittaker, M.D.; G
Saltonstall, M.D.; D. Bruce Wiley, M.D. El •
ed officers were: President, Otto O. Beck, M i
Vice President, W. M. LeFevre, M.D.; Se •
tary-Treasurer, Wm. J. Burns, LL.B. Life m •
bership is $100.00, and sustaining members ,
$5.00 per year. Doctor LeFevre became the t
paid sustaining member.
• The Kopprasch Case. Legal Counsel Dodc •
ported that the Michigan State Medical Sot /
(Continued on Page 1368)
JM
1366
for certain disorders of menstruation and pregnancy
TRULY EFFECTIVE PROGESTATIONAL THERAPY
BY MOUTH
oral progestogen
with
unexcelled potency
and
unsurpassed efficacy
Now, with small oral doses of this new and dis-
tinctive progestogen, you can produce the
clinical effects of injected progesterone. In
amenorrheic women for example, “As little as
50 mg. of [NORLUTIN] administered in divided
doses over a five-day period was sufficient to
induce withdrawal bleeding.”1
CASE SUMMARY 2
Amenorrhea of 4 years’ duration in a
24-year-old married woman. A course of 10 mg.
NORLUTIN twice daily for 5 days was followed
after 3 days by menses lasting about 5 days.
Since no spontaneous menstruation occurred
during the following 35 days, she was given
another course of treatment with NORLUTIN,
10 mg. twice daily for 5 days. This was followed
by menses. j
When this patient was given ethisterone, 40 mg.
twice daily for 5 days, no bleeding had ensued
when she was seen 41 days later.
INDICATIONS FOR NORLUTIN! conditions involving
deficiency of progestogen such as primary and second-
ary amenorrhea, menstrual irregularity, functional
uterine bleeding, endocrine infertility, habitual abor-
tion, threatened abortion, premenstrual tension, and
dysmenorrhea.
packaging: 5-mg. scored tablets (C. T. No. 882),
bottles of 30.
REFERENCES: (1) Greenblatt, R. B.: J. Clin. Endocrinol.
16:869, 1956. (2) Hertz, R.; Waite, J. H., & Thomas, L. B.:
Proc. Soc. Expcr. Biol, ir Med. 91:418, 1956.
; |V; PARKE, DAVIS & COMPANY
* lh): DETROIT 3 2, MICHIGAN
I
vember, 1957
Say you saw it in the Journal of the Michigan State Medical Society
1367
YOU AND YOUR BUSINESS
HIGHLIGHTS OF THE COUNCIL
“YESTERDAY’S HOPELESS”
(Continued from Page 1366)
had been stipulated out of the Kopprasch case
from any damage; only the conspiracy charges
against the county medical society and the
hospital remain. Trial is set in Allegan for Oc-
tober 8-9-10.
® “Big Look.” Chairman W. S. Jones reported
that the Big Look Committee had inspected
property in Lansing as site for the future MSMS
headquarters, but desired additional time for
further investigation. The Council instructed
the Big Look Committee to seek the services of
an architect at the earliest possible date.
• Committee Reports. Rheumatic Fever Control
Committee, meeting of September 1 1 ; Perma-
nent Conference Committee, September 1 1 ;
Committee on Michigan Medical Service, Sep-
tember 11 (the report of this committee as
amended was referred to the 1957 House of
Delegates) ; Committee on National Defense,
September 18.
• Supplemental Report of The Council was given
minute study, amended in several paragraphs,
approved and referred to the House of Dele-
gates.
• Newly elected Councilors were introduced at
the Friday morning (September 27) meeting;
7th District, J. F. Beer, M.D., St. Clair; 8th
District, E. S. Oldham, M.D., Breckenridge ; 9th
District, D. G. Pike, M.D., Traverse City; 10th
District, O. J. Johnson, M.D., Bay City.
• Matters of mutual interest were discussed with
A. E. Heustis, M.D., Michigan Health Com-
missioner.
• Official thanks to all who helped with the 1957
Annual Session were placed on The Council’s
minutes; a special vote of thanks was issued to
Past President Jones and to retiring councilors
L. C. Harvie, M.D., Saginaw; W. S. Stinson,
M. D., Bay City; and H„ B. Zemmer, M.D.,
Lapeer.
• Individual reports on the condition of the pro-
fession in each Councilor District were given by
the Councilors.
MSMS MARKET OPINION SURVEY
The Opinion Survey of Prepaid Medical Care Cover-
age in Michigan, prepared by the Michigan State Medi-
cal Society and presented to its House of Delegates
in Grand Rapids on September 23-24, attracted wide
attention throughout the United States — even the New
York Times devoting a column to the report.
The final report of this survey and the action taken
on it by the 1957 House of Delegates are included in
this number of The Journal.
Brock E. Brush, M.D., Di
troit, Chairman of the Prograi
Committee for the 1958 Mich
gan Clinical Institute, announcf
that some thirty-five eminer
clinicians and teachers will b
guest essayists on a prograi
aimed at presenting practical sc
lutions in everyday clinical med
cine.
“The MCI program next yea
will stress modern diagnosis an
treatment of practical value in everyday practice” state
Dr. Brush. “The whole meeting will present new pro
cedures, drugs and instruments which will help doctor
of medicine transform yesterday's hopeless — the criticall
sick and chronically ill — into healthy, productive am
independent individuals.”
Some of the speakers at the MCI, scheduled for th
Sheraton-Cadillac Hotel, Detroit. March 12-13-14, 1958
are :
Henry T. Bahnson, M.D.. Baltimore, Md.
Laurence W. Kinsell, M.D., Oakland, Calif.
Alexander T. Aitken, M.D., Brookline, Mass.
Preston A. Wade, M.D., New York, N. Y.
Edgar V. Allen, M.D., Rochester. Minn.
Charles H. Rammelkamp, M.D., Cleveland, O.
Isidore Snapper, M.D., New York, N. Y.
John Parks, M.D., Washington, D. C.
Clement A. Smith, M.D., Boston, Mass.
William M. Wallace. M.D.. Cleveland, O.
H. D. Fabing, M.D., Cincinnati, O.
Maxwell Finland. M.D., Boston, Mass.
M. B. Sulzberger, M.D., New York, N. Y
Clyde L. Randall, M.D., Buffalo, N. Y.
G. N. Papanicolaou, M.D., New York, N. Y.
The complete program will be published in th
December number of JMSMS. Meanwhile, Gener: ,
Chairman of Arrangements C. E. Umphrey, M.D., Dt ’
troit, urges all who plan to attend this new-type “r< j
fresher course to secure hotel reservations in Detro j
now. Last year, 1,654 doctors of medicine attended
the MCI, taxing the capacity of every hotel in Detroi
SIXTH ANNUAL SYMPOSIUM ON TRAUMA
Sponsored by
Wayne State University College of Medicine and
Michigan Regional Committee on Trauma
Wednesday, December 4, 1957
Registration : 9:00 a.m.
Morning Session ; Ward Rounds and Operating
Procedures at Detroit Receiving Hospital
Noon Luncheon : Wayne State University College
of Medicine
Afternoon Session: “The Many Phases of the
Care of Trauma Patients”
Write: H. M. Smathers, M.D.
14219 W. McNichols Road
Detroit 35, Michigan
to counteract
complications from
EMiC
lusing It?
MCH ''ASIATIC7 FLU
\e New Virus Threat From Orient
st" flu
1 there
d cases
ucture of the vir
[> ently used vaccine;
e
dden change toe j
' rus in 1947, P
i e '•ine tl
STEARATE (Erythromycin Stearate, Abbott)
effective against staph-, strep- and pneumococci
QMrott
(SFilmtab— Film-sealed tablets, Abbott; pat, applied for.
Statement of Principles Between Physicians and Lawyers
After three years’ study, the Joint Committee
with the State Bar of Michigan developed a state-
ment of principles to guide doctors of medicine
and members of the Bar in the conduct of court
cases. This statement has been approved by both
the Michigan State Medical Society in Annual
Session in Grand Rapids, September 23-24, and
by the State Bar of Michigan, at its Detroit Con-
vention of October 2-3-4, 1957.
The Joint Committee which developed these
principles was composed of three MSMS members
and three representatives of the State Bar: W. M.
LeFevre, M.D.. Muskegon. Chairman for the med-
ical group, A. A. Humphrey. M.D., Battle Creek,
and F. D. MacMillan, M.D., Detroit. Leroy G.
Yandeveer. Detroit. Chairman for the legal group.
Frank C. Smith, Flint, and J. Adrian Rosenburg,
Jackson.
The Statement of Principles is as follows:
Preamble
In recognition of the public service obligations com-
mon to the medical and legal professions, and in the
belief that such action will promote a closer co-operation
and assist in maintaining a harmonious and compatable
relationship between the two professions, thus serving
the public interest, the Michigan State Medical Society
and State Bar of Michigan do hereby adopt the follow-
ing Statement of Principles governing physicians and
lawyers.
Medical Reports Requested by Attorneys
1 . \\ here a report is requested by the patient's at-
torney. upon authorization from the patient, the physi-
cian should furnish to the attorney such report with
reasonable promptness.
2. The contents of such report should be such as
to permit the attorney to protect the interests of the
patient fully and properly and compatibly with the at-
torney-client relationship.
3. When requesting such report, the attorney should
clearly specify the information desired, and make known
to the physician whether or not it is to embody opinions
regarding diagnosis, prognosis and disability evaluation.
4. The attorney should recognize that it is not always
possible for the physician to prepare a medical report
on short notice. Where the physician may indicate that
he deems it necessarv or advisable before submitting
such report to have the opportunity of seeing and ex-
amining the patient, the attorney should co-operate with
the physician by arranging for his client to be seen by
the physician.
5. When a medical report is requested by an attorney,
he should not take the time of the physician for a con-
ference unless:
a) It appears to the attorney that a conference is
necessary for a proper report, or
b The physician requests such a conference before
furnishing his report.
6. After the physician has furnished a report, if
either the physician or the attorney feels it necessary or
desirable to hold a conference with reference to the
contents of the report, the attorney should be cognizant
of the demands of time made upon the phvsician. and
1376
should co-operate to arrange such conference at a time
and place indicated by the physician to be most con-
venient and suitable.
Co-operation between Physician and Attorney in
Cases Expected to be Tried and Where Attor-
ney Proposes to Present Physician as
a Witness
1. It is the duty of the attorney to furnish to the
physician reasonable advance notice that the case is
approaching trial, and that the physician is expected
to be called as a witness on the trial of the case.
2. It is the duty of the attorney to make inquiry and
ascertain from the physician as to any hospital records
in appropriate cases, or other records not under the
direct control or possession of the physician, including
x-rays or reports thereof or other medical records and
reports the physician desires to have available at the time
of his being a witness on the trial of the case, and to
make the necessary' arrangements so that such reports are
thus available for the use of the physician at such
time.
3. It is the duty of the attorney to request and re-
mind the physician to bring with him at the time
he appears as a witness his own office records with
reference to his patient.
4. It is the duty of the attorney, after the physician
requests the opportunity of seeing and examining the
patient before trial, to arrange for the patient to be
seen by the physician.
5. It is the duty of the physician at this time to
review his own office records and any other records per-
taining to his patient so as to co-operate with the at-
torney in the preparation of the trial of the case.
6. While the physician may have heretofore fur-
nished a medical report to the attorney, the physician
should recognize that such prior report was likely fur-
nished for the principal purpose of permitting the at-
torney to properly plead his client’s medical claims in
the case. The physician should further recognize that i
at this time, for the attorney to fully protect the interest
of his client, it may be necessary' or advisable for the
attorney to request a supplemental and amplified report
in the preparation for the trial of the case, and it is the
duty of the physician to co-operate with the attorney
where authorized by the patient to furnish such supple-
mental and amplified medical report.
7. In some cases, it should be recognized by both the
attorney and the physician that it is necessary or most
desirable that a conference or conferences be had be-
tween the attorney and the physician in advance o:
the physician appearing as a witness on the trial of thi
case, whereby the physician is afforded an opportunit1
of discussing with the attorney the medical aspects o
the case from the physician's viewpoint, particular!
any technimal medical matters pertaining thereto. Ai
opportunitv is thus afforded to the attorney of discuss
ing with the physician the legal rules and the positio;
occupied by the phvsician as a witness on the trial o I,
the case, resulting in mutual co-operation for the be:
interest of the patient of the physician and the diet
of the attorney in the presentment cf the case in cour i
Where, however, the physician and attorney mutual!
agree that such a conference is unnecessary it shoul
be avoided in the interest of saving the time of bot
the physician and the attorney. Where such conferent
or conferences are deemed necessary or advisable, tl
attorney should recognize a duty to arrange for tl
(Continued on Page 13~8)
when treating
Tablets
Each tablet contains:
Achromycin® Tetracycline 125 mg.
Phenacetin 120 mg.
Caffeine 30 mg.
Salicylamide 150 mg.
Chlorothen Citrate 25 mg.
Syrup
Each teaspoonful (5 cc.) contains:
Achromycin® Tetracycline
equivalent to tetracycline HC1
Phenacetin
Salicylamide
Ascorbic Acid (C)
Pyrilamine Maleate
Methylparaben
Propylparaben
125 mg.
120 mg.
150 mg.
25 mg.
15 mg.
4 mg.
1 mg.
Available on prescription only
The Achrocidin formula is particularly valuable in treating acute re-
spiratory infections during epidemics and other outbreaks.
In addition to rapid symptomatic improvement, Achrocidin offers
prompt control of the bacterial superinfection frequently responsible
for such disabling complications as pneumonia, otitis media, sinusitis,
bronchitis, pneumonitis to which the patient may be vulnerable.
The comprehensive Achrocidin formulation includes both Achro-
mycin Tetracycline — broad-spectrum antibiotic action — and analgesic
components recommended for rapid relief of malaise, headache, mus-
cular pain, pharyngeal and nasal discharge.
Adult dosage for Achrocidin Tablets and new, caffeine-free Achro-
cidin Syrup is two tablets or teaspoonfuls of syrup three or four times
daily. Dosage for children according to weight and age.
ACHROCIDIN*
TETRACYCLIN E-ANTIH ISTAM IN E-AN ALGES 1C COM
LEDERLE LABORATORIES DIVISION, AMERICAN CYANAMID COMPANY, PEARL RIVER. NEW YORK
*Trademark
EMBER, 1957
Say you saw it in the Journal of the Michigan State Medical Society
1377
STATEMENT OF PRINCIPLES
(Continued from Page 1376)
time and place for such conference or conferences as
most convenient and suitable to the physician.
8. It is the duty of the attorney, in accordance with
the ethics of his profession, that under no circumstances
should he seek or attempt, in any manner, to persuade
the physician to distort or color his testimony.
9. The physician should recognize the moral, as well
as the legal, obligation of appearing in court as a wit-
ness on behalf of his patient, and should understand that
medical testimony is frequently indispensable to prove or
disprove medical claims presented in a case.
The Physician as a Witness on the Trial of
the Case
1. It is required that parties, attorneys and witnesses,
including physicians who are called to testify, recognize
that the administration of justice by the courts and the
trial of cases by the judges thereof cannot depend upon
the convenience of such persons.
2. The attorney owes a duty to the physician who is
to be a witness on the trial of the case to notify him
as far in advance as possible as to when he is to be
needed to testify, and to keep him informed and ad-
vised as to any changes with respect to the time of his
appearance in court as the trial develops.
3. The attorney should notify the physician promptly
of any settlement or other development during the trial
of the case, the result of which is to eliminate the
calling of the physician as a witness on the trial, so
that the physician, who likely has set aside the time in
which he is expected to be in court as a witness, may
have the opportunity of making other commitments for
this time.
4. The attorney should have available for the physi-
cian when he appears as a witness all hospital and any
other records which the attorney and physician have
theretofore agreed shall be at the place of trial for
the physician’s use.
5. The physician should attend court at the time ap-
pointed. The attorney should appreciate, however, that
a physician has continuing and often unpredictable re-
sponsibilities to his patients. Insofar as the attorney
is able, he should make arrangements to permit the phy-
sician to testify with a minimum of inconvenience and
delay to him.
6. The physician while testifying should answer ques-
tions as concisely and objectively as possible, with a ter-
minology, when permissible, which will be most under-
standable to a jury of laymen.
7. If the physician is asked a question to which he
does not know the answer, he should so state and make
no attempt to speculate or guess or theorize or give an-
swers not responsive to the question propounded, and
the physician should not volunteer testimony.
8. In the giving of testimony, the physician, under no
circumstances, should permit any bias, prejudice or
favoritism or personal interest to influence or affect his
testimony.
9. When questioning the physician witness, an attor-
ney should at all times refrain from unwarrantedly brow-
beating or badgering the physician. A physician testify-
ing as a witness should know that if and when he feels
that an attorney is improperly or unfairly conducting an
examination of him as a witness, the physician may ad-
dress the court and inquire if he is required to submit to
such treatment.
10. The attorney owes a duty to the physician wit-
ness to prepare and propound all questions to the wit-
ness in such form and manner as will permit a clear
understanding and a forthright answer from the physi-
cian witness.
11. An attorney who calls a physician to testify as
an expert witness should, in advance of the physician’s
appearance in court, advise the physician of his inten-
tion to qualify and question him as an expert witness,
and where it is proposed to use a hypothetical question,
1378
should in advance of the trial converse with the physi-
cian and explain to him the use of such hypothetical
question, so that at the time the physician in his ca-
pacity as an expert witness is propounded such question,
he will have a reasonable understanding of the use of
the hypothetical question and the limitations with ref-
erence to his answer to such form of question.
Compensation for Services of Physicians
1. It is the duty of the attorney where necessary, to
explain to his client the physician’s bill for services and
the itemization thereof. In cases where the physician
aided in preparing the case but did not have the oppor-
tunity to testify or failed to testify because of a set-
tlement prior to his being called as a witness, it is the
responsibility of the attorney to advise his client of the
physician's assistance and services in the case, and thus
to co-operate with the physician for the purpose of seeing
that such physician receives a reasonable fee for such
services.
2. A physician who, at the request of an attorney,
furnishes a medical report authorized by the patient,
should receive a nominal fee for this service, and it is
the duty of the attorney to co-operate with the physician
to see that he receives such fee. If such medical report
requires extraordinary services in its preparation either
as to time and contents, or the case is of such a nature
that the medical aspects thereof require the physician to
have a conference or conferences with the attorney, or
to furnish subsequent supplemental and/or amplified
medical report, the physician is entitled to a reasonable
compensation for such professional services rendered, and
it is the duty of the attorney to co-operate to see that
such physician receives reasonable compensation in ren-
dering such professional services. Where, after an origi-
nal medical report, the physician is requested to per-
form further services in assisting in the preparation of
the case for trial by furnishing supplemental or ampli-
fied reports and conferring with the attorney or render-
ing other services, it is recommended that when feasible,
an agreed fee for such services be determined in advance
after consultation with the attorney.
3. Where it appears that the patient is indigent or
unable to make payment, the right to compensation for
services in assisting the attorney in the preparation of
the case for trial may be waived by the physician, or
where it appears that the financial status of the patient
is such that ordinary reasonable compensation to the
physician for his services will work a hardship, the
physician may take this into consideration in determin-
ing his fee for services in assisting the attorney in the
preparation of the case for trial.
4. Where a physician testifies as a witness, under no
circumstances should the physician’s charge for his time
as a witness, or his fee. if qualified and testifying as an
expert witness, be contingent or determined by the
amount of the recovery of the patient in the litigation,
or the success or lack of success of the patient’s case.
5. Compensation for the services of a physician in
connection with assisting in the preparation of the
case or for his appearance as a witness in court should
be on a reasonable basis and based on the time and
nature of the services performed.
6. It is the duty of the attorney to co-operate fully
with the physician by assisting the physician to obtain
payment for services properly rendered by the physician
to his patient in the physician-patient relationship. It is
the further duty of the attorney to co-operate with the
physician to obtain payment from the patient for serv-
ices rendered by the physician to the attorney in the
preparation and/or trial of the patient’s case.
Inter-Professional Courtesy and Understanding;
1. For the medical and legal professions to perform
the full duties owed to society by each, it is required
that the members of each profession extend toward the
(Continued on Page 1394)
TMSMS
optimal dosages for atarax,
based on thousands of case histories:
mg. ( q.i.d.
for these
adult indications:
TENSION SENILE ANXIETY
PHOBIA HYPOCHONDRIASIS
HYSTERIA PRENATAL ANXIETY •
PEPTIC ULCER HYPERTENSION
MENOPAUSAL SYNDROME
PREMENSTRUAL TENSION
PRE-OPERATIVE ANXIETY
TICS FUNCTIONAL G. I. DISORDERS PRE-OPERATIVE AN)
HNXIETY • AND ADJUNCTIVELY IN CEREBRAL ARTERIOSCLEROSIS
[TENSION COLITIS NEUROSES DYSPNEA INSOMNIA
ALCOHOLISM DERMATITIS PARKINSONISM PSORIASIS
perhaps the safest ataraxic known
P€4C€ OF MIND ATARAX
Supplied : In tiny 10 mg. (orange) and 25 mg. (green)
tablets. Also now available in 100 mg.
tablets. Bottles of 100. ATARAX Syrup, 10 mg.
pertsp., in pint bottles. Prescription only.
(BRANO OF HYDROXYZINE)
Tablets-Syrup
ATARAX® PARENTERAL SOLUTION
when Peace of Mind can’t wait
In daily practice: always have it handy
• to calm the acutely disturbed or hysterical patient
• to rehabilitate the alcoholic
In hospitals: use it routinely
• to make overwrought patients manageable
without loss of alertness
to allay anxiety and control vomiting
before and after surgery and childbirth
Supplied: 10 cc. multiple-dose vials. The adult dosage is
25 mg. to 50 mg. (1-2 cc.) intramuscularly, 3 to 4 times daily,
at 4 hour intervals. The moderated dosage level for children
under 12, when given intramuscularly, has not yet been
established, and the oral dosage should be used.
November, 1957
Say you saw it in the Journal of the Michigan State Medical Society
1379
PHYSICIAN’S MANUAL ON CONGENITAL
CARDIAC DEFECTS PUBLISHED
The American Heart Association has issued a
new booklet entitled “Congenital Cardiac De-
fects— A Physician’s Guide for Evaluation and
Management.” The publication was prepared by
the Committee on Congenital Heart Disease of
the Association’s Council on Rheumatic Fever
and Congenital Heart Disease, Ruth Whittemore,
M.D., Chairman.
Designed primarily for the physician who is
not a cardiologist, the 27-page booklet will help
doctors who encounter patients with congenital
malformations of the heart to decide whether and
when such patients should have special studies
done in a cardiac center or by a cardiologist
familiar with these problems.
The Association has also issued a report setting
standards for services and equipment in centers
responsible for the diagnosis and surgical care of
patients with congenital defects of the heart and
blood vessels. The report, entitled “Standards
for Centers Caring For Patients with Congenital
Cardiac Defects,” appeared originally in the
April. 1956, issue of the Association’s professional
journal, Circulation, and is of particular interest
to directors of centers concerned with diagnosis
and surgery for patients with congenital cardiac
defects. The report was prepared by the American
Heart Association’s Subcommittee on Education
and Standards in the Field of Congenital Heart
Disease.
Single copies of both pamphlets are available
free from the Michigan Heart Association at the
address listed below.
RESEARCH GRANTS FOR THE STUDY OF
THE EFFECT OF ASIAN INFLUENZA UPON
THE CARDIOVASCULAR SYSTEM
Recognizing the possibility that Asian influenza
may appear in sizeable quantity in this country
in the near future, the National Advisory Heart
Council has recommended that the National Heart
Institute encourage research on the effects of
Asian influenza upon the cardiovascular svstern.
National Heart Institute research grants are
available on a competitive basis to investigators
wishing to study the cardiovascular-renal effects
of influenza. Applications will be processed as
rapidly as possible. Research grant apnlications
may be obtained by writing directly to: Dr. Her-
1380
man E. Schmid, Jr., Grants and Training Branch,
National Heart Institute, National Institutes of
Health, Bethesda 14, Maryland.
NEW PROFESSIONAL FILM SHOWS
DISORDERS OF THE HEART BEAT
“Disorders of the Heart Beat” is the title of a
new 22-minute professional film produced in color
for the American Heart Association and its affili-
ates by Churchill-Wexler, Los Angeles. Wyeth
Laboratories, Philadelphia, sponsored the produc-
tion.
Using animation, the motion picture explains
the theory of how abnormal heart beats develop
and shows how these look on the electrocardio-
gram and phonogram. The film presents aspects
of premature beats, paroxysmal tachycardia, fi-
brillation and flutter, and various conduction de-
fects.
The new film is available — on a free-loan basis
— from the Michigan Heart Association.
BOOKLET ON HIGH BLOOD PRESSURE
AVAILABLE TO PHYSICIANS TREATING
HYPERTENSIVE PATIENTS
“High Blood Pressure” is the title of a nevs
American Heart Association booklet written b)
Edgar V. Allen, M.D., Association President, wht ,
is Senior Consultant in Medicine at the May<
Clinic, Rochester, Minnesota.
To be distributed by physicians to high bloot
pressure patients under their care, the 14-pag
booklet explains what is known today about hig
blood pressure and what the patient can do t
help his physician treat him most effectively.
Dr. Allen warns against self-diagnosis and e?
cessive concern of a hypertensive patient wit
the blood pressure readings. The author stress'
that so much has been learned in recent yea
about how to treat hypertension that the outloc
for patients is now more favorable than ev
before.
Single copies are available free from t
Michigan Heart Association.
* * *
For further information or copies of the ma
rials listed above, write to the Michigan He.
Association. Doctors’ Building, 3919 John R, I
troit 1, Michigan.
IMS
The
Upjohn Company
announces
a major
corticosteroid
improvement
minor
chemical
changes
can mean
major
therapeutic
improvements
The most
efficient of all
anti-inflammatory
steroids
Supplied: Tablets of 4 mg., in bottles
of 30 and 100.
♦TRADEMARK FOR METHYLPREDNISOLONE, UPJOHN
Lower dosage
(K lower dosage
than
prednisolone)
Better tolerated
(less sodium
retention, less
gastric irritation)
For
complete information, consult
your Upjohn representative,
or write the Medical Department,
The Upjohn Company,
Kalamazoo, Michigan.
Upjohn
OVEMBER, 1957
Say you saw it in the Journal of the Michigan State Medical Society
1381
AMA Washington Letter
THE MONTH IN WASHINGTON
Several months in advance of the return of the
85th Congress for its election-year second session,
influential figures in the field of health in both the
executive branch and in Congress were being
heard on what 1958 has in store for the medical
profession.
Because of the roles they play in the Capital,
their views are worth more than passing notice.
One is the chairman of the important health ap-
propriations subcommittee of the House, Rep.
[ohn Fogarty (D., R. I.). He used as a forum
for his prophecies the annual convention of the
American Hospital Association.
Other prognostications came from Dr. Aims C.
McGuinness, special assistant for health and medi-
cal affairs to Secretary Folsom of the Department
of Health, Education, and Welfare. Dr. McGuin-
ness spoke out at a dedication ceremony of a new
chronic disease and rehabilitation facility in Maine.
Mr. Fogarty places at the top of his predictions
some action on federal construction aid to medical
schools. The Rhode Island Democrat has his own
bill on the subject, although there are others pend-
ing. Comments Mr. Fogarty: “. . . the shortage
of health education facilities today is probably the
most serious bottleneck in our whole medical sys-
tem. . . . These schools . . . fall far short of ac-
commodating the fully qualified and competent
young men and women in America who are anx-
ious to train and qualify in medical, dental and
public health fields.”
The record of the past several years has shown
that no member of the House is listened to more
carefully when it comes to health than Mr. Fo-
garty. His philosophy in the health field is worth
noting: “It is now generally accepted that the
health of our people is a major resource and that
the government, therefore, has a direct responsibil-
ity for the health of everyone.”
Dr. McGuinness also spoke out strongly for
federal aid to medical schools. Failure to meet
the needs of the schools, he told his audience,
would be “the worst kind of economy.” He feels
that the administration proposal for $225 million
in construction grants would bring classrooms
and research laboratories “much closer to current
and projected needs.”
While neither man had any specific legislative
proposals to make in the field, both foresee a
growing role for hospitals in the practice of medi-
cine. Dr. McGuinness put it this way: “General
hospitals must broaden their services and achieve
greater co-ordination. The term ‘hospital care’
should include not only bed care but diagnostic
service as well as service to ambulatory patients.”
Mr. Fogarty, looking ahead 25 years, said it
was safe to predict that virtually every general
hospital in the Nation will be providing at least as
much preventive service as curative service. “You
are, in fact, moving closer each moment to the
day when hospitals will be the focal point of health
services for all of us, throughout our entire lives.”
The same day that Mr. Fogarty was urging the
hospitals to use the basic Hill-Burton hospital con-
struction program to meet future health needs, the
AHA House of Delegates approved a set of leg-
islative proposals to present to the next session.
They would accomplish the following: (1) ex-
tend the act for five years beyond June, 1959,
(2) authorize matching Hill-Burton funds for ren-
ovation and repairs of hospital plants, (3) set up
loan authority so that hospitals not desiring grant
money could borrow construction and renovation
funds at very low interest rates (from V/2 to 2%).
The house also urged a grants program to hospitals
with nursing schools and to other nurse institutions
for professional education, exclusive of construc-
tion grants.
Notes
One committee of Congress knows months in
advance just exactly what it plans to do the day
Congress reconvenes. The tax-writing House Ways ■
and Means Committee has set hearings starting
January 7 on possible tax reductions next year.
Included on the agenda will be testimony from
various organizations on the Jenkins-Keogh bills
for allowing tax deferments for money paid into
retirement plans. The American Thrift Assembly,
which is backed by the American Medical Associa-
tion and other professional and business groups,
plans to be heard at some time during the 30 days :
of hearings.
* * *
Veterans Administrator Harvey Higley believes
that the public is losing interest in the veteran
and his problems, and that some doctors no longer
hesitate to attack medical care for veterans, partic-
ularly those with non-service-connected disabilities, j
Mr. Higley spoke at the annual American Legion
convention.
# # *
Health directors of twenty-one American repub- |
lies, holding their annual Pan American Sanitary
Organization meeting here this fall, voted a $3
million budget for the Pan American Sanitary Bu- !
reau’s 160-odd health projects for next year.
1382
JMSMS
clinical studies demonstrate that
XutJSau CAPSULES
effectively help to
shift atherogenic
beta-lipoproteins
to the more normal
alpha-lipoproteins
reduce elevated blood
cholesterol levels
normalize chylomicron-
lipomicron ratios
stabilize function of
the liver, site of
normal metabolism of
cholesterol, lipoproteins
and other lipids
by means of well tolerated
vegetable unsaturated fatty acids
with choline, methionine,
pyridoxine (B6) and
other lipotropics
**from specially
refined safflower
seed oil. Provides
approximately 294 mg.
of linoleic acid.
dosage: Therapeutic dose, 6 to 9 capsules, in divided doses with
meals, or more as needed. Maintenance dose, one LUFA capsule
t. i.d. with meals.
Supplied: Bottles of 100, 500 and 1000 capsules.
Samples, literature and diet charts for patients on request.
u. s. vitamin corporation • pharmaceuticals
(Arlington-Funk Laboratories, division)
250 East 43rd Street • New York 17, N. Y.
::Best results are obtained when LUFA is given as an
adjunct to a diet adequate in protein, low in animal fat and
moderate in fats from selected vegetable and marine sources.
AMA News Notes
CIVIL DEFENSE MEETING
The eighth annual County Medical Societies Civil
Defense Conference was held November 9-10 at Chi-
cago's Morrison Hotel. Sponsored by the AMA Council
on National Defense, the Conference helped local medi-
cal and health personnel plan their roles in disaster and
civil defense emergencies. Congresswoman Martha W.
Griffiths of Michigan reported on the status of national
civil defense legislation which received considerable at-
tention during the first session of the 85th congress.
Mrs. Griffiths is a member of the House Committee
on Government Operations and its Subcommittee on
Military Operations.
Another highlight of the Conference was reports on
the experience gained through several test operational
exercises conducted under simulated disaster conditions,
including a critique of the national exercise “Operation
Alert."
Additional reports were given on such subjects as
general preparedness planning, hospital operational pre-
paredness, the role of the county medical society, radio-
logical aspects of radiation fallout, the AMA-FCDA
study project, the AMA program on Asian influenza.
The group broke up into small sections to discuss
specific problems.
AMA COMMITTEE MEETINGS
Two committees of the AMA Council on Medical
Service plan regional meetings Monday, December 2, in
Philadelphia just prior to the AMA’s eleventh Clinical
Session. The Committee on Maternal and Child Care —
first regional meeting on perinatal mortality and mor-
bidity. Invitations are being sent to members of maternal
and child care committees in Connecticut, Delaware,
Maine, Maryland, Massachusetts, New Hampshire, New
Jersey, New York, Ohio, Pennsylvania, Rhode Island,
Vermont, Virginia, West Virginia. The Committee on
Aging — third regional conference for members of state
committees on aging. Subjects to be discussed include
physical examinations and a health maintenance pro-
gram, guides for the organization and operation of
medical society committees on aging, medical education
in caring for the aged, preretirement counseling, and
special research programs of a medical school.
Physicians interested in attending either of these
sessions should contact the Council for further details.
MEDICAL EDUCATION CONGRESS
Problems confronting medical education in the rapidly
changing scene will be the main topic of concern at
the 54th annual Congress on Medical Education and
Licensure February 9-11. Sponsored by the AMA
Council on Medical Education and Hospitals, the
Federation of State Medical Boards of the United States
and the Advisory Board for Medical Specialties, the
Congress will be held at the Palmer House, Chicago.
The conferees will view medical education’s broad
potential in the light of four factors — the changing
characteristics of the nation’s population, sociological
trends, economy and medical knowledge — and the im-
plications of these factors on medical education, medical
research and medical care.
In addition, four workshop committees — composed of
representatives from the AMA, the Council, the AAMC,
higher education, government, business, insurance, labor
and agriculture — will discuss various problem areas,
endeavor to clarify questions that need to be raised and
recommend possible ways that medicine can assume the
leadership in solving these problems. The committees’
reports will be presented before the entire Congress
for discussion from the floor.
On Monday morning, February 10, the Council will
conduct its annual co-sponsored meeting with the Ad-
visory Board. This session will be devoted principally
to discussions of problems in graduate medical education
created by the changing status of the patient and the
role of the community hospital in graduate medical edu-
cation. The Federation will hold its second examination
institute on Saturday, February 8, and its regular meet-
ing on Tuesday, February 11.
CANCER FILM BOOKINGS THROUGH AMA
Hope in the thought that 75,000 lives in America
need not be lost needlessly to cancer each year is the
theme of a dramatic educational film recently added to
the AMA Film Library. Titled “The Other City,” the
film stresses the encouraging fact that doctors currently
are saving one in three patients as compared with a
previous one-in-four ratio. Setting of the film is
Racine, Wisconsin. Four basic thoughts are developed:
(1) Racine empty and lifeless; (2) a symbolic repre-
sentation of what cancer is; (3) how the 75,000
inhabitants of this token city could have helped save
themselves, and (4) Racine alive and bustling.
Produced by the American Cancer Society, the 16mm
color film runs 22 minutes and 30 seconds. It is suit-
able for showings on local television as well as for
church, club and school gatherings. Medical societies
may book the film through the AMA Film Library.
RESEARCH FOUNDATION ESTABLISHED
The American Medical Research Foundation recentl)
was established by the AMA. Principal purposes of tht
Foundation will be: (1) to promote the betterment o
public health through scientific and medical research
(2) to plan and initiate scientific and medical research
and (3) to collect, correlate, evaluate and disseminat
results of scientific and medical research activities t
the general public. Voting members of the Foundatio
will be AMA trustees. Meetings will be held annual)
at the time of the AMA Annual Sessions.
1388
TMSM
h
for “This Wormy World
Pleasant tasting
‘ANTEPARL
PIPERAZINE
SYRUP • TABLETS * WAFERS
Eliminate PINWORMS IN ONE WEEK
ROUNDWORMS IN ONE OR TWO DAYS
PALATABLE • DEPENDABLE • ECONOMICAL
‘ANTEPAR’ SYRUP - Piperazine Citrate, 100 mg. per cc.
‘ANTEPAR’ TABLETS -Piperazine Citrate, 250 or 500 mg., scored
‘ANTEPAR’ WAFERS “ Piperazine Phosphate, 500 mg.
Literature available on request
^5? BURROUGHS WELLCOME & CO. (U.S.A.) INC., Tuckahoe, N. Y.
IBER, 1957
Say you saw it in the Journal of the Michigan State Medical Society
1389
What They Thought About the
1957 MSMS Annual Session
Leon Goldman, M.D., Cincinnati (guest essayist):
“I wish to thank you for the many courtesies and
privileges extended to me at the recent meeting of the
Michigan State Medical Society. I have been to a
number of meetings, both as guest and just as a relaxed
bystander, but I have never seen such efficient organiza-
tional details as I have seen you all do. This was a
real lesson in administration for us who conduct meet-
ings from the time of the initial invitation until the
time when the guest is tucked away on his plane or
train. I feel I have really learned a lot about adminis-
tration, and I am very grateful. Thank you again.’’
Theodore Winship, M.D., Washington, D. C. (guest
essayist) : “My visit to Grand Rapids was most enjoy-
able and I found the audience unusually responsive
and courteous.”
Samuel Bellet, M.D., Philadelphia (guest essayist):
“Thank you very much for inviting me to participate
in this symposium and I certainly appreciate the cour-
tesies you showed me.”
Paul A. Bowers, M.D., Philadelphia (guest essayist):
“I wish to take this opportunity to express my apprecia-
tion to the members of the Michigan State Medical
Society for the very cordial reception which I received
during your recent meeting.”
Keith Hammond, M.D., Paoli, Ind. (Councilor, In-
diana State Medical Association) : “I would like to
take this opportunity to thank you for the gracious
way in which we were attended and entertained during
our recent visit in Grand Rapids at the meeting of
the Michigan State Medical Society. Our stay was
a most pleasant one.”
Wm. S. Reveno, M.D., Detroit (Chairman, MSMS
Preventive Medicine Committee) : “Word comes to me
of the superb show you put on at Grand Rapids. I'm
not surprised — because that’s what I expected.”
J. Raymond Knighton, Executive Secretary, Christian
Medical Society, Chicago: “I would like to express
our appreciation for the privilege of exhibiting at the
recent MSMS meeting in Grand Rapids. Although we
have been exhibiting at many medical meetings over
the past few years, it is the consensus that the response
we received at this meeting was as good, if not better,
than any previous exhibit. We would also like to
commend you on the very efficient handling of the
exposition by your Executive Director, William J. Burns.
Mr. Burns and staff co-operated most effectively to
make our exhibit efficient and profitable.”
William N. Smith, S. E. Massengill Company, Bristol,
Tenn.: “Just a note to say how much I enjoyed at-
tending the MSMS convention last week. This meet-
ing was one of the best organized conventions I have
attended. You certainly deserved the standing ovation
for a job much more than ‘well done.’ ”
L. G. Dickson, Secretary, Class of 1959, Wayne Stat
University College of Medicine: “On behalf of myse'
and my classmates, who joined me as guests at the recer
MSMS convention in Grand Rapids, may I thank yo
for the opportunity you offered us. We certainly ap
predated this chance to attend the meeting and exh:
bition. Medical students certainly welcome such a
educational experience offered in so generous a spiri
My attendance at this convention, in all respects, ha
been a valuable addition to my medical education.”
Leo H. Bartemeier, M.D., Baltimore (guest essayist)
“It was pleasant to see all you folks again, even for
brief moment.”
Peter C. Kronfeld, M.D., Chicago (guest essayist)
“I enjoyed the Michigan State Medical Society Meetin
very much.”
Adelaide M. Johnson, M.D., Rochester, Minnesot
(guest essayist): “I found the meetings stimulating an
very much enjoyed participating. The audience wa
the responsive kind that is very gratifying to th
speaker.”
James W. Burks, Jr., M.D., New Orleans (gues
essayist): “I should like to express my appreciatio
for the honor bestowed upon me in having me participat
in your recent meeting in Grand Rapids, and to than
you for making my effort a pleasant one. Your hosp
tality was very much appreciated.”
Edward Press, M.D., New York (guest essayist): ‘
am glad to be of help at your meeting and would 111
to commend you on how smoothly and efficiently ru
the session was. I appreciate the hospitality extended I
me at your meeting.”
Hans H. Hecht, M.D., Salt Lake City (guest essayist
“I certainly appreciated the courtesy of your invitatic
and the wonderful reception that I received in Micl
igan.”
Charles Morrill, Secretary, Class of ’59, University'
Michigan Medical School: “I want to take this oppo
tunity to thank the Michigan State Medical Society f
the privilege of attending the meetings of the House
Delegates. It was certainly enlightening to be able
see the policy-making body of the medical profession
Michigan in action.
“One can now appreciate that there will be mai
problems concerning us as future physicians aside fro
knowing and putting into practice medical knowledj
We should now be able to expand our Student Americ
Medical Society to make certain that our educatior
program trains the ‘whole’ doctor and not just t
‘technical’ doctor, important as this is.
“I sincerely appreciate the accommodations that w( j
provided and hope that other students may be al
to attend future MSMS conventions. Thank you.”
.IMS!
1390
Albert V. Whitehall, Vice Chairman, Health Insur-
ance Council, New York: “This is belated appreciation
of your hospitality at your recent meeting and to com-
pliment you on its success. Two things stood out to me.
The effectiveness of Hugh Brenneman for the tremen-
dous public relations impact of your program. He is a
real pro. Second was the efficiency of your staff in han-
dling registration. It reminded me of a warm-hearted,
:ordial IBM machine and seemed to have just the
:riendly touch that could be traced right back to one
Bill Burns.”
Kieffer Davis, M.D., Bartlesville, Oklahoma (guest
ipeaker): “Thank you and many of your fellow workers
n the Michigan State Medical Society for making my
visit in Grand Rapids quite a delightful one. I don’t
enow when I have ever been treated quite so royally.”
E. W. Schoenheit, M.D., President of the Medical
society of the State of North Carolina (guest) : “I
vish to express my grateful appreciation to you and to
he Michigan State Medical Society Members for their
tospitality, and for the kind administration to me dur-
ng my Michigan stay. I take this opportunity to tell
rou what a pleasure it was to see you and how much I
rnjoyed being at the MSMS meeting.”
John D. Porterfield, M.D., Washington, D. C. (guest
essayist) : “I appreciated very much the opportunity to
speak both at the General Assembly and before the
Preventive Medicine Section, and thoroughly enjoyed
the opportunity to talk with Michigan Physicians during
the informal hours. I must say to you truly that I have
never been more graciously hosted at any other medical
meeting.”
Paul K. Danielson, Kansas City, Missouri (exhibi-
tor) : “I would like to compliment you on the very effi-
cient and effective way in which the Michigan State
Medical Society 1957 Annual Session and Exhibit at the
Civic Auditorium in Grand Rapids was conducted. I
have made medical meetings in almost every state and
without a doubt, yours is tops.”
Thomas H. Alphin, M.D., Washington, D. C. (Wash-
ington Office of American Medical Association) : “It
was a great pleasure to be present on such a momentous
and auspicious occasion and of course it is always a
privilege to see a well organized state medical society
in operation. Democracy may be taking a beating in
many areas but it certainly stands foursquare in Michi-
gan medical circles. Considering the strong winds and
storms of your area that is a notable achievement.”
T
' ASIATIC^.
I
s„FL<^.
V
\\ ' I 1 1 I 9 • / '
I
PHENAPHEW PLUS
Phenaphen Plus is the physician-requested
combination of Phenaphen, plus an anti-
histaminic and a nasal decongestant.
fOm MS
Available on prescription only.
each coated tablet contains: Phenaphen
Phenacetin (3 gr.) 194.0 mg.
Acetylsalicylic Acid (2Vz gr.) . 162.0 mg.
Phenobarbital gr.) .... 16.2 mg.
Hyoscyamine Sulfate .... 0.031 mg.
plus
Prophenpyridamlne Maleate . . 12.5 mg.
Phenylephrine Hydrochloride . 10.0 mg.
'VEMBER, 1957
1391
Say you saw it in the Journal of the Michigan State Medical Society
when infection
strikes the respiratory tract . . .
I LOT YC IN
(Erythromycin, Lilly)
provides singularly effective antibiotic
Dosage: The usual adult
dose is 250 mg. every six
hours.
Available in specially
coated tablets, pediatric
suspensions, drops, otic
solution, ointments, and
I.V. ampoules.
therapy because
o Virtually all gram-positive organisms are sensitive
• Allergic reactions following systemic therapy are rare
• Bactericidal action kills susceptible organisms
• Normal intestinal flora is not appreciably disturbed
ELI LILLY AND COMPANY • INDIANAPOLIS 6, INDIANA, U.S.A.
732150
1392
Say you saw it in the Journal of the Michigan State Medical Society
JMSMS
TU JOURNAL
of the Michigan State Medical Society
Issued Monthly Under the Direction of the Council
VOLUME 56 NOVEMBER, 1957 NUMBER 11
The Physician and City Commissions
By L. A. Drolett, M.D.
Lansing, Michigan
A/TY INTEREST in the fire department stems
from my youth. It has always seemed to
me the most interesting business in the world. By
appointment of the mayor, I have been a member
of the Board of Police and Fire Commissioners of
Lansing for the past sixteen years. The eight to
ten hours a month given to this project are a
donation which I feel that I owe to my com-
munity.
The commission is made up of nonsalaried citi-
[ zens who donate their time and services to the gov-
erning of these two departments. A physician on
this board has a splendid opportunity to exchange
ideas with laymen and to glean an insight into
men’s reactions under extreme pressure and ten-
sion. The emotional status, physical stature, sin-
cerity of purpose, and intelligence of candidates
must be evaluated by committee members of the
board. As a doctor, I find my medical training of
great assistance in choosing men for these depart-
ments.
Several years ago it came to my attention, as a
result of complaints by the fracture committee of
the American College of Surgeons, that people in-
volved in accidents on the street were being badly
nanhandled by ambulance crews. Fractures were
reing compounded by injudicious handling. After
;ome study of the problem in various cities
hroughout the country I came to the conclusion
hat perhaps the fire department should handle
imbulance equipment rather than the police.
Dr. Drolett is Commissioner of the Police and Fire
departments of Lansing, Michigan.
They had more time to take the necessary training.
So, in spite of considerable protest, this transfer
was made. More modern equipment was added
to the ambulance, splints and an inhalator were
supplied, sterile dressings, cots, and even a physi-
cian’s bag were installed.
Forty firemen were trained by me to operate this
ambulance. They were trained in the use of the
inhalator, in proper splinting, and other first aid
measures. Later, a second ambulance was added
to the department and, today, all street accidents
within the city limits are responded to by city am-
bulances. The patients from street accidents are
splinted on the scene and any wounds are sterilely
dressed, bleeding is controlled by intelligently ap-
plied tourniquets, and patients are transported to
the hospitals in good condition, compared to the
rough and ready old days. In addition, these
keenly trained men make many inhalator call runs
in the community taking orders from the doctor
who is called simultaneously.
The public has come to recognize this service
and appreciate the dollar value of this training and
equipment, and many other cities have adopted a
similar fire department ambulance service.
Our commission has insisted on both the fire and
police departments using the facilities of Michigan
State LTniversity and various federal schools in
Washington and Memphis, Tennessee. Numerous
police and firemen have been sent to these schools
at city expense to return and pay rich dividends
with the knowledged gained. Recently, at the re-
quest of the Federal Bureau of Narcotics, two
November, 1957
1393
THE PHYSICIAN AND CITY COMMISSIONS— DROLETT
detectives were given twenty-one days of intensive
training in Washington. D. C., in narcotic investi-
gations. It has been amazing to watch these two
men quietly at work in the city investigating com-
plaints of local pharmacists. They have learned so
much in such a short period of training. It is
developing that the physician is quite frequentlv
the greater violator in careless prescribing of nar-
cotics and too often may be an addict himself.
Other officers are graduates of a ninety-day
training period at the FBI school in Washington,
and are used as instructors in addition to their
regular duties of investigation of crime.
As a senior member of our commission, I am
proud of the fact that our departments are becom-
ing more highly skilled and efficient and are rap-
idly becoming professionalized with highly trained
technicians, able to render the best possible sendee
for the tax dollar.
The police and fire departments are obviously
our first line of defense in case of local disaster,
such as tornado, catastrophic fire, or enemy attack.
W ith this in mind, a process of emergence training
has been set up to coordinate with the doctors of
the community. These departments must be ready
immediately to undertake first aid that might take
hours for the civ il defense authorities to take over.
The Ingham County Medical Societv has equipped
three emergency field trunks ; one is kept in each of
the hospitals and one in the central fire station.
These trunks are kept in excellent condition under
the supervision of command officers of the depart-
ment. They are stocked with plasma, sterile dress-
ings, tourniquets, surgical instruments, and an)
equipment that we feel can be used to set up a
portable field hospital at the scene of disaster
The firemen constantly check this equipment and
maintain it for immediate use.
In the activities of the fire department today,
perhaps more than at any other time, the per-
sonnel are being called upon to deal with noxious
gases and fire hazards that were nonexistent ten to
fifteen years ago. The men must be educated and
trained to cope with these situations in order to
survive. In accepting this training, it is interesting
to note that the men are eager and willing to learn
more about their jobs. Undoubtedly, this attitude
stems from the commission’s insistence on ad-
vanced training for the men in the department.
The men in the police department have likewise
steeled themselves to cope with the extreme vio-
lence of crime as it exists today. Many '‘fight calls”
result in the apprehension of individuals who will
kill on very little provocation.
My sixteen years of sendee to the community
on the Police and Fire Commission have beet
gratifying to me. I feel very keenly that it is ever
physician’s duty not only to render service to hi
profession but in some way to try and add hi
bit to community effort. If he does, he will gai
the confidence of the public and express to th
people that we are interested not only in the;
physical well-being but also in their communit
welfare.
STATEMENT OF PRINCIPLES BETWEEN PHYSICIANS AND LAWTERS
Continued from Page 1378 )
other full courtesies and amenities and engage in a
mutual understanding of the problems of each other.
2. It is required that the attorney understand the
vast demands made upon the time of the members of
the medical profession, and at all times to avoid un-
necessarily claiming the time of anv physician either in
the attorney's preparation of the case for trial, or while
engaged in the trial of the case.
3. It likewise is required that the physician under-
stand that in many instances, the legal rights of the
patients, in litigation having medical aspects, may be
properly protected only by the attorney seeking and ob-
taining the time and services of the phvsician in the
preparation and trial of the case.
4. Courtesy requires, where necessary, that the at-
torney assist and enlighten the physician with respect
to his position as a witness on the trial of the case, his
role as a witness, and the rules to be observed in con-
nection with the matter of giving testimony in court.
5. Courtesy requires of the physician that he aid
the attorney so that the attorney may be enlightened on
the highly specialized medical aspects of the case, and
1394
may be assisted in properly presenting on the trial of t
case the medical phases involved through sufficient r j
derstanding with the physician to conduct an intellige
examination of the physician witness.
6. Courtesy requires that the attorney co-oper;
with the physician to minimize as far as practicable t
time required for the physician to remain in court.
7. If an attorney plans to have a subpoena sen
upon a physician, wherever practicable, the physic
should be notified in advance and service made un
arrangements convenient and acceptable to the physici
8. Courtesy requires that wherever practicable,
attorney and physician should consult in advance v
reference to the fee of the physician to be charged
his time spent in attendance in court as a witness.
9. Courtesy requires that where, by requirement
statute, the amount of an expert's fee may be set (
by the court, the physician be notified thereof in
vance. with the further assurance of the attorney I ,
he will petition the court, at the proper time, for
order setting a proper and reasonable fee for
physician's services as an expert witness.
im:
he Doctor and the Service Club
By T. E. Schmidt, M.D.
Jackson, Michigan
OU’RE no “joiner.” You’re too busy, but
you accept the invitation to attend a service
ub luncheon meeting just to please the guy. Said
e’d have you back by 1:45.
There’s a lot of jovial milling around and
iendly banter. Everybody wears an absurdly
age luncheon badge. Calls each other by his
rst name. Seems nice. Nobody has a board up
is back.
The membership startles you. Almost everyone
head of some important business. You’re intro-
Liced around and, as you sit down, you look the
)om over and find most of the leaders in the
)mmunity present. Table conversation is refresh-
igly free from professional matters. You’re sur-
rised to find you are having a good time in very
mgenial company.
After the meal, a couple of lively songs. Some
ng a bit off-key, but no matter. You join in.
hey really go all-out on “Smiles”- — a favorite.
You’re amazed at the guests. They’re from all
'er. Most of them from nearby clubs, but there’s
le from Melbourne, Australia, and one from
psala, Sweden, on a business trip to this country,
it they keep up their attendance standing by
:ending meetings here. You’re told this service
lb has over 9,500 clubs in 104 countries. More
untries than belong to the U.N. Over 400,000
siness and professional men belong to this inter-
tional organization. Over 10,000 usually attend
1 international conventions held annually. Must
quite an experience. Meeting men from all
ti “r the world. You wonder what attacts so many
I ;y men into the service club movement.
; ifou begin to suspect that this is more than a
1 cheon club on hearing a few brief committee
r orts — members transporting sixty crippled chil-
c n to a summer camp supported by the club, a
F gress report on city planning and slum clear-
a, e initiated by the club, commitments obtained
f n local concerns to furnish leadership and
s] tisor fifteen Junior Achievement groups, an
e erience in private enterprise for youngsters.
C Sams, whom you well know to be a
b ad to all young doctors (he helped you when
Nl EMBER, 1957
you first began practice), reports that his com-
mittee is going to enlarge the playground and
youth center which the club sponsors. Dr. Sams
carries a heavy professional schedule, is active in
medical affairs and has done much to encourage
high ethical standards in your profession. You
learn that he is a past president of the club and
is very active in community affairs. An all-around
citizen.
You’re told that seven of the club’s twenty-odd
committees are hard at work on various com-
munity projects. The genuine enthusiasm shown
in community work by these men impresses you.
It’s something they call “community service.” Has
nothing to do with their occupations.
It’s time for the speaker. He’s a lad in his
twenties. Most of the members are old enough
to be his father. But they listen attentively. He
is just back from a year’s graduate study in Italy.
A clean-cut fellow. You’re intrigued by his first
hand knowledge and keen interpretation of the
social, political and economic problems and
customs of the Italian people. He bespeaks his
gratitude to the members of the service club in
Padova who opened their homes to him, the
friendly courtesies, the numerous opportunities to
speak to clubs about our own country and our
way of life. You are experiencing not a mere
vicarious adventure in foreign travel but an ad-
venture in international friendship and under-
standing— a true ambassador of goodwill.
From the president’s remarks you gather that
this fine young man is one of some 130 carefully
chosen young men and women from thirty-odd
countries who have spent this year in a foreign
land, sponsored by their home clubs through a
three million dollar foundation financed by mem-
ber clubs of this organization. Over six hundred
such fellows have been sponsored by the founda-
tion. Many are now filling important posts in
their homelands and are still ambassadors of
friendship between nations. It is one of many
club projects in what is called “international
service.”
(Continued, on Page 1396)
1395
The Doctor and the School Board
By Warren B. Cooksey, M.D.
Detroit, Michigan
TT WAS thirty years ago this past July that I
began my active medical practice. Early in
those first years of practice, I made a strong resolve
that I would try and spare some energy and time
in an effort to be a good citizen as well as a
good physician. I have not regretted this resolve
for it has led me into some fields of usefulness
and enjoyable friendly relationships that I cherish
a great deal. It was apparent to me very early in
some of my community responsibilities that there
were too few doctors willing to devote some time
to such things as the Community Chest, Social
Services, and the Red Cross, and in such gather-
ings it was, and still is, a stirring experience to me
to see how extremely welcome the presence of a
physician in such committee meetings and endeav-
ors can be. I can honestly say that many times in
the past years, I have witnessed an absolute yearn-
ing on the part of citizen groups for the opinion
and judgment of a physician member, and I do,
indeed, feel that we physicians have a very great
responsibility and obligation to help support, as
much as our energy and talents permit, the various
enterprises and philanthropies that make a com-
munity truly great.
I am sure that in all the activities in which I
have articipated, no experience has been quite the
same challenging situation as that which I found
when I was appointed to the Detroit Board of
Education to replace the late Douglas A. Jamie-
son. I have found that at many points the physi-
cian, by background and training, can be useful
in the conduct of the affairs of public education.
There are indeed all sorts of human relationships
that a school board must deal with very carefully,
such as those related to emotional adjustments,
racial problems, traumatic accidents, and personnel
situations. We, as physicians, are constantly anal-
yzing factual data in order to come to a proper
conclusion, and such problems as teacher retire-
ment, salary adjustment, building costs, vocational
training and guidance, curriculum, teacher and
classroom shortages, to mention only a few, require
the kind of mind that a physician must cultivate in
order to practice medicine successfully.
I think it is inherent in the well-trained physi-
cian to adopt a careful conservative attitude to-
ward life’s situations and nowhere could such a
background serve one in good stead better than
serving on an active Board of Education, especially
in a large school system such as Detroit. We physi-
cians have had considerable opportunity by train-
ing and experience to acquire ability in public
speaking and working under the glare of public
opinion. The necessity of performing one’s duties
in open meetings with the ever present public
press, and of carefully scrutinizing one’s every
word, is a situation it seems to me in which wide
medical training and experience is a great asset
indeed. It is my further observation that no finer
group of people can be found in any community
than those concerned with the training of our
youth. I must say that I have enjoyed immensely
my service on the Detroit Board of Education and
I hope and believe I have at times been useful in
solving some of the problems which we have faced.
It seems undeniable to me that the finer the
education provided our youth, the more certain it
becomes that we will have happy and prosperous
communities for the future. Whenever oppor-
tunity offers, therefore, I would urge physicians to
participate actively in matters of public education.
THE DOCTOR AND THE SERVICE CLUB
(Continued, from Page 1395)
Acquaintance, fellowship, friendship, com-
munity service, business and professional ethics,
friend and example to youth, international under-
standing and goodwill — these are some of the
aims and objects of service club membership.
You’re back at your desk at 1:45. You’re no
“joiner,” but maybe this service club business is
more than appears on the surface. You’re at least
convinced that this town is a better town because
it has a service club.
1396
JMSMS
Use of Doxinate with Danthron as Withdrawal
Therapy in the Treatment of Chronic
Functional Constipation
T N 1955, Wilson and Dickinson12 published an
original report describing the usefulness of
dioctyl sodium sulfosuccinate in the treatment of
constipation. Since that time the results of a
number of other studies with this drug have ap-
peared in the literature. 1’3’4’8'9’10’11 Investigators
have consistently found this substance to be an
effective fecal softening agent. Animal experi-
ments and extensive clinical observations failed
to reveal any evidence of toxicity, probably be-
cause the agent is not appreciably absorbed.2’12
In the treatment of constipation, dioctyl sodium
sulfosuccinate produces a soft stool, and in those
cases where chronic functional constipation is due
to hardening of the feces, the drug should result
in correction of the condition.
Where fecal hardening is complicated by the
presence of an atonic bowel musculature, it is
obvious that fecal softening action alone may not
be fully effective without adjunctive therapy. In
fact, the lack of effectiveness of dioctyl sodium
sulfosuccinate in this type of constipation has been
pointed out.7
In cases of this latter type, the simultaneous
; administration of a mild peristaltic stimulant may
be desirable to aid elimination of the softened
stool. Since the sole purpose of this adjunct to
fecal softening is to aid evacuation, the ideal agent
would be one which acted solely on the lower
: bowel with the least possible irritating action.
Danthron ( 1,8 dihydroxyanthraquinone) is a
suitable agent for this purpose and its effectiveness
and safety have been fully demonstrated.6
A preparation combining diocytl sodium sulfo-
succinate and Danthron is commercially avail-
able*
Dioctyl sodium sulfosuccinate exerts its effect by
aurely physical means. It reduces the interfacial
H
Dr. Socha is Institutional Medical Director of the
Vlichigan Reformatory.
*The combination used in this study was supplied as
Doxinate with Danthron through the courtesy of Lloyd
Brothers, Inc., Cincinnati, Ohio.
November, 1957
Edmund S. Socha, M.D.
Ionia, Michigan
tension between the oil and aqueous phases of
the heterogeneous material. It produces a softened
and more homogeneous stool which is easier to
evacuate. Unlike irritant laxatives, it obviates “re-
bound constipation.” It eliminates the interfer-
ence with absorption and the leakage often seen
with mineral oil. It cannot cause “bloating” or
impaction as can bulk laxatives.
It is apparent, therefore, that a combination
of these two drugs would offer the advantages of
easier movement and elimination of the fecal mass
in chronic atonic constipation.
The problem of proper bowel management is
an annoying one among the inmates of this re-
lormatory. It may be due, at least in part, to the
starchy food which constitutes a major portion
of their diet; and to the fact that many of them
have been taking cathartics more or less regularly
even before entering the institution. The object
of this study was to determine whether constipa-
tion could be corrected by the judicious use of
dioctyl sodium sulfosuccinate and Danthron on a
gradual withdrawal basis.
Material and Method
Our study included seventy-four male patients
(forty-four colored and thirty white) who ranged
in age from seventeen to thirty years. All of these
patients were institutionalized and were receiving
a similar diet. Each patient was asked a series of
questions concerning his use of cathartics before
entering the institution. The frequency of use
of cathartics, frequency of the daily bowel move-
ment, and liking for particular types of food were
ascertained. This latter factor we believe to be in
large part responsible for the frequency of the
constipation problem in patients who otherwise
had not been dependent on laxation before enter-
ing the institution. A classification of these pa-
tients based on this information is shown in
Table I.
The group included fifty-four patients who had
1397
CHRONIC FUNCTIONAL CONSTIPATION— SOCHA
TABLE I. CLASSIFICATION OF PATIENTS ACCORDING
TO DIETARY HABIT, USE OF CATHARTICS
AND FREQUENCY OF THE BOWEL
MOVEMENT
Particulars Number of Patients
Dietary Habit
Mostly Starchy Food 44
Balanced Diet .,...30
Use of Cathartics
Daily 6
2-3 times a week 34
Once a week 12
1-2 times a month 10
Occasionally 12
Frequency of Bowel Movement
Daily 20
Every other day 40
Twice a week or less 14
been habitually taking some form of cathartic to
induce a bowel movement. The remaining twenty
patients had been using cathartics more or less
regularly after their arrival at the institution. Con-
sidering the dietary preference of the individual
patients, forty-four patients indicated a strong lik-
ing for starchy food such as bread, spaghetti or
potatoes. Before starting the therapy, fifty-four
patients were not having a bowel movement more
often than every second or third day and had
complained of frequent difficulty in the elimina-
tion of a hard stool.
All the patients included in this study, except
seven who left the institution earlier, were treated
for a period of eight weeks. Each patient was given
one or two capsules of Doxinate with Danthron
on the first day together with 3 Doxinate 60 mg.
capsules. The same medication was given on the
second and the third day, except that Doxinate
■with Danthron was not given if the patient re-
ported a satisfactory bowel movement following
the therapy of the day before. On the fourth day,
the patient was given only one capsule of Dox-
inate with Danthron together with 3 Doxinate
60 mg. capsules. In several cases, the use of Dox-
inate with Danthron was not needed after the
second or third day. On the following days, the
number of Doxinate 60 mg. capsules was gradually
reduced from three to two to one each day,
depending on the improvement in the regularity
of the bowel movement of the patient. Where the
bowel movement failed for two consecutive days,
one capsule of Doxinate with Danthron was given
the next evening together with the Doxinate cap-
sules. All patients were given the medication by
the attending nurse in person in their cells each
day, and the response of the patient for the pre-
vious day was recorded at that time. Each patient
TABLE II. DURATION OF TREATMENT OF PATIENTS
WITH DOXINATE AND DOXINATE
WITH DANTHRON
Medication
Duration of Therapy
Number of Patient
Doxinate
8 weeks
7
7 weeks
3
6 weeks
5
5 weeks
16
4 weeks
36
Less than 4 weeks
7
Doxinate with
During first 10 days
56
Danthron
Occasionally after 10 days:
1-5 days
8
6-10 days
8
Enema or
20-25 days
2
Cathartics
During 8 weeks
0
TABLE III. TEMPORARY SIDE EFFECTS OBSERVED
DURING THE TREATMENT OF CHRONIC
CONSTIPATION WITH DOXINATE
AND DOXINATE WITH DANTHRON
Patient Complaint
Number of Patients
Gas
19
Fullness
7
Cramps
7
Nausea
4
Headache
1
was given at least one Doxinate 60 mg. capsule
per day through a period of six weeks, though a
majority of the patients were having a satisfac-
tory daily bowel movement after being treated
for four or five weeks. Few patients needed any
further medication after the sixth week of therapy.
The use of neither enema nor harsh cathartic;
was required during this treatment. These date
are summarized in Table II.
Results
During the first week of the therapy, we foun
that a certain amount of confusion existed in th
minds of several patients with regard to their rf
sponse to therapy. It was necessary to teach th
patient that the object of treatment was a sof
“normal” stool rather than a violent purgatio:
During this first week of therapy, we also n
ticed some complaints of loose stool, gas or fu:
ness. One patient complained of headache ar
a few others of cramps or nausea. The data <
such side effects are presented in Table III.
Soon after the first week of treatment, t
patients’ response became satisfactory and, as t
treatment proceeded, their appreciation of t
efficacy of the therapy increased. A majority
the patients were able to discontinue the use
the preparation containing Doxinate with D;
thron after the first week. Beyond this period, o
a few patients were given one capsule of D
IMS 1
1398
CHRONIC FUNCTIONAL CONSTIPATION— SOCHA
late with Danthron once every one or two weeks
r even less frequently.
After four weeks of the treatment, a majority
f the patients were found to be regular in their
owel habit and needed no further medication,
towever, Doxinate therapy was continued
irough a minimum period of six weeks in all
le patients by giving each patient at least one
'oxinate 60 mg. capsule per day. This was ex-
ected to provide a more lasting effect in the
jrrection of the future bowel habit of the patient.
Inly ten patients continued to receive one Dox-
late 60 mg. capsule per day during the seventh
eek of the treatment, and this number was
irther reduced to seven patients who were using
•oxinate during the eighth week.
The overall satisfaction of the patients was
Kxellent. There were no complaints of hard
ools at the end of the treatment. All of the
atients, except two, were very enthusiastic about
re results which they had obtained from this
terapy. They co-operated well in taking the
rescribed therapeutic regimen. The two patients
To insisted on the more frequent use of Dox-
late with Danthron in order to get a more satis-
ictory bowel movement had previously been us-
lg cathartics or enemas through most of their
dult life. They simply failed to get psychological
atisfaction without a purgative effect.
As a result of the correction in bowel habit,
aost of the patients reported that they were
teling better, several said that they were sleeping
etter, and some even gained weight. One patient
ho had been using cathartics each day for the
ast nine months and was not eating well, gained
D pounds in weight during the period of treat-
lent.
Discussion of Cases
Several case summaries from the group are of
terest.
1 One ambulatory patient aged twenty-three, under
| satment for chronic asthma, had a long-standing
mplaint of severe constipation. A variety of laxatives
d been used, but catharsis commonly resulted in two
| more prompt watery bowel movements followed by
1 /ere “rebound constipation.” This patient received
rctyl sodium sulfosuccinate therapy without change
anti-asthmatic medication. The two medicaments
re given at different times. He received 3 Doxinate
mg. capsules per day for 12 days, reducing to two
asules per day during the following 1 2 days and to
, ly one capsule per day for an additional one week.
)
►VEMBER, 1957
As a result the patient had one or more bowel move-
ments daily with soft consistency of the stool. No diarrhea
or side effects were present. The patient was fully
satisfied with the therapy and was effectively relieved
of his constipation problem.
Another patient, aged twenty-six, was receiving 50
mg. of Chlorpromazine twice daily as a tranquilizer.
He had a long-standing history of constipation and had
taken different types of cathartics for most of his adult
life. Constipation was effectively relieved by three
Doxinate 60 mg. capsules together with one Doxinate
with Danthron for the first day and two Doxinate 60
mg. capsules per day for about one month.
A third patient, aged twenty-one, had a history of
duodenal ulcer. He was receiving antispasmodic medica-
tion and a restricted diet. This patient complained of
frequent constipation and could not tolerate cathartics.
Treatment was carried out with 120 mg. of dioctyl
sodium sulfosuccinate per day for a period of five weeks,
administered separately from other medicaments. No side:
effects were present and the constipation was eliminated.
Summary and Conclusions
The therapeutic value of dioctyl sodium sulfo-
succinate and its combination with 1,8-dihydroxy-
anthraquinone has been studied in a series of
patients with chronic functional constipation. All
of the patients were started on the combination
therapy. In the mild and the moderate forms of
chronic constipation, Danthron could be quickly
withdrawn. In these cases, the subsequent use
of dioctyl sodium sulfosuccinate alone was found
to be quite effective in regulating the bowel habit
of most of the patients. In the severe cases of
chronic constipation, the occasional use of the
preparation containing Danthron was continued
through two to six weeks to obtain the most
effective results. The need for enemas was.
eliminated. The fecal softening action was con-
sistent and pronounced. No severe side effects or
evidence of toxicity were seen. The patient co-
operation in the acceptance of the therapeutic
regimen was excellent.
This therapy did not interfere with the ad-
ministration of other medicaments given at dif-
ferent times. The results of this study clearly
indicate that the use of Danthron in combination
with dioctyl sodium sulfosuccinate may be very
effective when used as a withdrawal therapy in
the management of the bowel habit of patients
with chronic functional constipation.
(Continued, on Page 1443)
1399
Tracheotomy: Indications and Comments
/^\NE of us (G.S.F.) 4’5’6 has been interested in
the various aspects of tracheotomy during
the past twenty years. It has been observed that
initially the procedure was performed in the vast
majority of instances for the relief of obstruction
in the upper respiratory tract at the laryngeal
level, and that a good many (40 per cent) were
performed in children two years old and younger.
However, in recent years, there has been a tremen-
dous increase in the scope and indications for
tracheotomy, with more adults being the recipient
of the procedure and fewer operations being per-
formed for laryngeal obstructions. Much of the
impetus to this development has been the result of
the investigations and experience of Galloway,7
Priest,11 Bower,1 Cummings,2 3 and others.
We have devised a classification for the indica-
tions for tracheotomy, finding it useful in the
presentation of the subject to those physicians not
specifically interested in otolaryngology. Before
discussing the subject further, the basic reason for
tracheotomy, as far as we are concerned in this
presentation, is to permit a normal exchange of
air in the alveoli of the lung for the absorption
of oxygen and the elimination of carbon dioxide,
as so aptly stated by Harris.9 Any serious inter-
ference with this mechanism will result in rapid
death from asphyxia; or, if corrected just prior to
this catastrophy, very possibly will result in irrever-
sible nerve or other tissue damage with death sec-
ondary to complications therefrom. If survival
ensues, one may anticipate embarrassment or some
compromise in the efficient function of the human
mechanism. Again, repeated episodes of subclini-
cal hypoxia may result in tissue damage which may
not be recognized in its early stages.
Returning to the question of classifications, four
groups or categories are to be considered (Table
I).
1. First are the patients who exhibit the mani-
festations of an impaired airway with hypoxia due
From the Department of Otolaryngology, University
of Virginia Hospital, Charlottesville, Virginia.
Presented at the 91st Annual Session of the Michigan
State Medical Society, Detroit, September 27, 1956.
G. S. Fitz-Hugh, M.D., F.A.C.S.
and W. C. McLean, M.D.
Charlottesville, Virginia
to a more or less fixed mechanical obstructive
process, such as that encountered in a neoplasm,
edema of the laryngeal mucosa, or abductor para-
lysis of the vocal cords. The degree of obstruc-
tion to the airway is usually so severe that tracheo-
tomy is mandatory. Little question is raised re-
garding the necessity of the procedure. The devel-
opment of hypoxia in this group is rapid and
obvious, with dramatic relief resulting from the
improved airway provided by the tracheotomy.
This category will not be considered further in
this presentation.
TABLE I. CLASSIFICATION OF THE INDICATIONS
FOR TRACHEOTOMY
1. Fixed Obstruction to Upper Airway (Rapid ob-
vious hypoxia)
2. Fluid Obstruction to Lower Airway (Slow obscure
hypoxia and hypercapnia)
3. Prophylactic (To prevent 1 and/or 2)
4. Laryngeal Spasm?
2. In the second classification are the patients
in whom the airway is compromised by fluid
obstructions, resulting from the accumulation of
excessive material in the tracheobronchial tree,
secondary to aspiration of oral secretions, inflam-
matory exudation, congestive transudation, or
hyperfunction of the secretory elements from any
other causes. It is in this group that the develop-
ment of dangerous hypoxia and asphyxia may be
very slow, insidious and deceiving. Also, it is in
this group that the presence of a normally func-
tioning cough reflex and medullary respiratory
center are essential. Further comments in regard
to this will be forthcoming, as we are most inter-
ested in this class of patients in this presentation.
The indications are not as clearly defined here as
in the other categories, and more judgment must
be demonstrated in deciding upon the need for
tracheotomy.
j ®
3. The third group comprises those cases in
which it is believed that the airway will be com-
promised by the conditions cited in indications one
and two. Anticipating much difficulty, tracheo-
I'l
1400
JMSMS
TRACHEOTOMY— FITZ-HUGH AND McLEAN
tomy is performed as a preventative measure. An
example would be a case of extensive surgery upon
the head and neck for neoplasm. As in category
one, no further comment will be made in this
presentation in regard to this prophylactic group.
intercostal, and abdominal muscles responsible for
the positive action of the reflex (Table II). The
circuit may be interrupted at any one or more
points along its pathways. For example, the medul-
lary respiratory center may be so depressed by
TABLE II. COUGH MECHANISM
I
Respiratory Center
— Brain Stem —
I
Afferent Impulses
Laryngotracheobronchial
Tree
Efferent Impulses
Muscles of Respiration
Abolish Cough Reflex < > Accumulation of Secretions
Obstruction and Hypoventilation
4. A fourth group and one which the existence
thereof is questionable, will just be mentioned.
Conceivably, tracheotomy may be necessary in the
case of laryngeal spasm per se. We believe we
have seen this in only one instance: a twelve-year-
old girl with tetanus. We do know that in spasm
superimposed upon an abnormal larynx as the
result of inflammatory edema, neoplasm or such,
tracheotomy has been necessary and usually with
some degree of urgency.
So much for classification. As has been men-
tioned, in this presentation, we are interested in
tracheotomy’s being utilized for the second cate-
gory of patients. It is in this group that there has
been a noticeable increase in the incidence of
tracheotomy, due to the realization of the benefits
derived from this approach to cleansing the
tracheobronchial tree of obstructing materials.
The need for tracheotomy in preventing local
pulmonary and generalized systemic complications
is predicated upon the failure of the cough re-
flex.14 Any interruption in the proper function
of this reflex is followed by an accumulation of
secretions or other types of fluid material in the
lower respiratory tract which, in turn, will lead
to certain well-recognized local pulmonary and
many less well-recognized complex systemic changes
in the human mechanism. The cough reflex is
mainly responsible for the elimination of fluids
accumulated in excess in the laryngotracheobron-
chial tree, although movement of secretions by
ciliary action plays a significant part. Sensory
impulses of the reflex from the larynx, trachea,
and lung, are transmitted by the vagus nerves to
the co-ordinating medullary respiratory center,
from whence the motor impulses are relayed to
he relevant laryngeal, diaphragmatic, pulmonary,
November, 1957
TABLE III.
Hypoventilation
i
Asphyxia
Hypercapnia < > Hypoxia
> Acidosis 4-1
disease or even by excess C02 that it can no longer
respond to the nerve impulses or to C02 stimula-
tion. The muscles and nerves of the reflex may be
rendered non-functional by trauma or disease.
Once the patient is unable to cough efficiently,
then one may expect an accumulation of nasal,
oral, and pulmonary secretions with resulting dele-
terious pulmonary and systemic changes.
Obstruction of the tracheobronchial tree by
secretory or foreign material, such as regurgitated
food, predisposes to edema of the mucous mem-
branes, further obstruction, atelectasis, infection
secondary to stasis, and finally, to frank suppura-
tion such as pulmonary abscesses. These are the
readily recognized local conditions which may
develop. There is another systemic condition which
is related to the physiology of respiration.2,8 With
tracheobronchial obstruction, normal ventilation
is impaired. Impairment in ventilation is initially
mechanical in type. Inspired air does not ade-
quately reach the alveoli; thus, sufficient oxygen
does not reach the alveoli to pass into the blood
by diffusion and, in turn, carbon dioxide present
in blood is not adequately expired. This inade-
quacy leads to oxygen want or hypoxia, carbon
dioxide retention or hypercapnia, then respiratory
acidosis, and later, metabolic acidosis or acidemia.
The combination of hypoxia, hypercapnia, and
acidosis will lead to asphyxia (Table III).
The symptoms and signs of hypoxia and hvper-
1401
TRACHEOTOMY— FITZ-HUGH AND McLEAN
capnia will be emphasized, for they may well be
ascribed to, and confused with, the primary dis-
ease which has created the problem. Those of
hypoxia are mental disturbances, which may be
exhilaration, confusion, disorientation, irration-
an oral or nasopharyngeal tube, and direct aspira-
tion through an endotracheal tube or broncho-
scope are methods which have been successfully
utilized at times. However, when it is apparent
that these measures will not suffice or be appli-
TABLE IV. SYMPTOMS AND SIGNS
Hypoventilation
Weak or absent cough
Gurgling with respiration
Pallor — Cyanosis — Dyspnea
4 Changes in Percussion and Auscultation 4
Cardiovascular changes
Hypoxia (Anoxemia)
Exhilaration and disorientation
Confusion and irrationality
Unresponsiveness and lethargy
Restlessness and combativeness
Dyspnea
Pallor
Cyanosis
Cardiac Irregularities
Hypercapnia and Acidosis
Flushing of face
Headache
Restlessness
Apprehension
U ncooperativeness
Drowsiness
Loss of consciousness
Cardiac Irregularities
Asphyxia
Respiratory Collapse
Cardiac Failure
ality, unresponsiveness, lethargy, and coma. Signs
are restlessness, combativeness, dyspnea, pallor,
cyanosis, and cardiovascular irregularities.
The symptoms and signs of hypercapnia and
acidosis are much the same as those of hypoxia.
Flushing of the face, headache, restlessness, unco-
operativeness, apprehension, drowsiness, loss of
conciousness and abnormal cardiac action are indi-
cative of this carbon dioxide retention. Asphyxia
with cardio-respiratory collapse is all too obvious,
and is irreversible.
The need for the relief of obstruction of the
type in the second category is determined better
by clinical observations than by any laboratory
means, though carbon dioxide combining power
determinations may be helpful. The clinical symp-
toms and signs are decreased to absent cough
reflex, audible gurgling sounds with respiration,
changes on ascultation and percussion, and radio-
logic evidence of atelectasis (Table IV).
Once it becomes reasonably certain that a pa-
tient has an excessive accumulation of fluid in the
tracheobronchial tree, what may be done to cor-
rect the situation? It is certain that in many
patients, the fluid obstruction may be satisfac-
torily removed by means other than aspiration
through a tracheotomy. Encouraging the patient
to cough, elevation of the foot of the bed 15
degrees, constant or intermittent aspiration through
cable for reasons such as lack of skilled nursing
attention, various muscle paralyses, and interfer-
ence with patient rest, then tracheotomy should
be performed without undue delay and should be,
technically, an orderly elective procedure in this
group of patients.
The advantages of tracheotomy are that ( 1 )
fluid aspirated or collected in the tracheobronchial
tree may be readily and efficiently removed by
aspiration through the tube; (2) the pharynx and
its secretions are by-passed and thus eliminated
as a cause of obstruction; (3) the upper respira-
tory areas of obstruction are removed; (4) the
tube itself acts as a partial mechanical barrier to
the aspiration of material from above its site; (5)
less skilled nursing care is required, and (6) the
improved airway allays apprehension.
Disadvantages of tracheotomy are : ( 1 ) ai
already ill patient is subjected to added straii
resulting from the operative procedure; (2) th'
risk of complications such as wound infection
hemorrhage, pneumothorax, pneumomediastinum
tracheal stenosis; (3) obstruction to the flow c
air offered mechanically by the tube; (4) resp:
rator care, if one is being used or will be needec
is made more difficult (Table V) .
The advantages and disadvantages of trachec
tomy which are mentioned are presented in pa
in a brochure published by The National Found;
tion of Infantile Paralysis.10
1402
TMSIv
TRACHEOTOMY— FITZ-HUGH AND McLEAN
TABLE V. TRACHEOTOMY
Advantages
l. Provides efficient route for the aspiration of obstruct-
ing secretions.
!. Allays apprehension
5. Pharynx and pharyngeal secretions by-passed and
eliminated as a cause of obstruction.
1. Eliminates areas of obstruction of upper air passages.
j. The tube itself mechanically acts as a partial barrier
to the aspiration of material from above.
i. Less skilled attention necessary.
Disadvantages
1. Subjects an ill patient to an operative procedure.
2. Risks of complications, e.g., infections, hemorrhage,
tracheal stenosis, pneumothorax.
3. Tube obstructs flow of air.
4. Respirator care more difficult.
TABLE VI. INDICATIONS FOR TRACHEOTOMY IN VARIOUS CATEGORIES
Series in Years
1930-1940
1943-1953
1954-1956
( 10-year period)
( 10-year period)
(2-year period)
No. Patients
102
150
no
Category 1
Laryngeal Obstruction
65%
53%
29%
Category 2
Tracheobronchial Obstruction
30% *
(Approx.)
20%
54%
Category 3
Prophylactic
5%*
(Approx.)
27%
16%
Category 4
Laryngeal Spasm
0%
0%
1%
*In the first series, the present classification was not utilized; however, the figures are essentially accurate.
It is our opinion that, when needed, the ad-
vantages of tracheotomy over the disadvantages
ire so great that one need give the latter little
:onsideration. Complications and risks of tracheo-
tomy even when performed by physicians with
little surgical experience, are so rare and of so
ittle consequence that they should be given small
:hought in making the decision to perform the
irocedure. Complications are greater, but still
isually of little consequence, in the cases in which
iperation is performed for obstruction at the
aryngeal level, some of these being disorderly
mergency operations.
In our study of more than 300 tracheotomies
lerformed under all types of conditions and upon
11 kinds of patients, we have found three ex-
I mples in which a complication of the procedure
er se could be considered contributory to the
. eath of the patient. All were in the earlier group,
lere being none in the last 250 patients. Two
i 'ere the result of secondary tracheal erosion and
emorrhage, due to an ill-fitting cannula; and the
lird, to a bilateral tension pneumothorax. These
ere in young children. Occasionally, a case of
acheal stenosis was seen resulting from high
acheotomy performed elsewhere as an emergency
rocedure in an infant. The stenoses were subse-
rently successfully treated. We have often seen
ight wound infection, mediastinal emphysema,
I j
DVEMBER, 1957
and pneumothorax, none causing any real con-
cern.
Tracheotomy in the second category has been
employed in a large and variable number of ill-
nesses. Our list includes poliomyelitis, cardiac
arrest, brain tumors, amyotrophic lateral sclerosis,
Gullian-Barre syndrome, meningitis, tetanus,
uremia, pneumonia, neoplasms, cerebrovascular
accidents, various types of trauma, to facilitate the
administration of anesthesia, and others. Tracheo-
tomy as an aid in the treatment of leprosy,
eclampsia, and other conditions has been recorded
in the literature.13 We agree with Putney12 that
while the question of its necessity in such numer-
ous and varied incidents may be open to more
critical considerations, it has undoubtedly proved
to be the difference between life and death in
many cases.
The only contraindication to tracheotomy in
the second category group, that has occurred to
us, is in the case of pulmonary edema secondary
to cardiac failure. Tracheotomy as a route for
the successful removal of secretion may well be of
no avail and, in fact, may be harmful. The proper
treatment is the belief of the decompensation and
pulmonary fluid by digitalization and other non-
surgical means.
Some comment should be made in regard to
the use of oxygen in the treatment of the group
1403
TRACHEOTOMY — FITZ-HUGH AND McLEAN
of patients in which ventilation is inadequate for
various reasons.2’8 Administered oxygen which
reaches the alveoli level will certainly aid in the
relief of arterial hypoxia. The replacement of
oxygen deficiency in the tissues will alleviate
metabolic acidosis and strengthen the respiratory
center. However, oxygen per se will do nothing
to relieve carbon dioxide retention and respiratory
acidosis, nor will it prevent pulmonary disease
secondary to stasis and infection. The arterial
blood can be well oxygenated despite severe hypo-
ventilation if high concentrations of oxygen are
inspired; however, carbon dioxide cannot be eli-
minated properly without an adequate volume of
alveolar ventilation.
Table VI contains data in regard to the indica-
tions for tracheotomy in the various categories.
From the figures in Table VI, one can observe
a relative decrease in the number of tracheotomies
for laryngeal obstruction — the category for which
the procedure was originally devised many cen-
turies ago — and an increase in the use of the
procedure for other reasons. This has resulted
from a better knowledge of the physiology of
respiration and the methods of correcting diseased
conditions responsible for any deviation from nor-
mal pulmonary ventilation.
The increase in the numbers in the second and
third categories is due in part to the performance
of more radical and extensive surgery about the
head and neck in an effort to control carcinoma,
and also to increased trauma sustained by the
head, neck, and chest as the result of highway
automobile accidents.
Another observation of interest to us was that
in the 1940 series, it was necessary to examine
records over a period of approximately ten years
to obtain 102 cases of tracheotomy; in the 1953
series, also approximately ten years were neces-
sary for the 150 cases; but in the 1956 series, a
total of 110 patients had tracheotomies in a period
of two years. It is true that in the last twenty-odd
years there has been a gradual increase in the
number of admissions to the University of Vir-
ginia Hospital, but not nearly enough to be a
major influence in the statistics cited. It is obvious
that many more tracheotomies have been per-
formed in recent years upon essentially the same
type and number of patients. Also, it should be
mentioned that our poliomyelitis service has been
a very small one, and this disease has been respon-
sible for a very few tracheotomies in comparison
to the number in other institutions having large
respiratory centers treating this disease.
The recent increase in the number of tracheo-
tomies performed, particularly in our hospital, has
raised the question in our minds (as, apparently,
also in Putney’s12) of its real necessity in such a
numerous and varied list of patients. At the pres-
ent time, the indications for tracheotomy for the
individual patient are being scrutinized carefully
and possibly will result in a decrease in the num-
ber of procedures. However, it must be kept in
mind that the discomfort, complications from, and
disadvantages of tracheotomy are so negligible that
in case of doubt, the procedure should be favored.
Another matter of interest to us, and one on
which we have no definite figures at the present,
is the apparent lack of utilization of tracheotomy,
except in the first category, in the smaller hos-
pitals in our state which have less well-developed
intern and resident staffs. Perhaps in the smaller
community hospitals, encouragement in use of the
procedure may result in the salvage of some lives.
Summary
Observations are made in regard to the changes
in the indications and increase in the incidence of
tracheotomy. Emphasis is placed upon the value
of tracheotomy as a route by which the lower
tracheobronchial airway may be kept free ol
obstructing fluids in patients whose cough refle>
is impaired for various reasons. The symptoms
signs, and deleterious effects of hypoxia and hyper l
capnia are stressed. Advantages, disadvantages
and the insignificance of complications of th
precedure are briefly considered. Its employmen
may be abused, but when indicated, it may be
method of saving lives even in the nonemergenc
group of patients suffering with low grade, diff
cult-to-recognize, tracheobronchial obstructioi
preventing satisfactory pulmonary ventilation.
Bibliography
1. Bower, A. G., Bennet, V. R., Dillion, J. B., ai
Axelrod, B. : Investigation on care and treatme
of poliomyelitis patients. Ann. West. Med & Sur
4:561-582 (Oct.) 1950.
2. Comroe, J. H., Jr., et al: The Lung, Clink
Physiology and Pulmonary Function Tests. Chit
go: Year Book Publishers, 1955.
3. Cummings, G. D., Jr.: Tracheotomy in bulbar j
liomyelitis. Laryngoscope, 61 : 668-686 (July) 19!
4. Fitz-Hugh, G. S.: Tracheotomy: A study of 1
consecutive cases. South. M. J., 34:1116-11
(Nov.) 1941.
(Continued on Page 1443)
IMS!
1404
Study Discloses Public and Doctor Opinion-
MSMS House of Delegates Recommends
Changes in Blue Shield
ACTION-Part One
(See page 1406)
T
" he 1957 House of Delegates of the Michigan State Medical Society, meeting in
Grand Rapids, September 23, 24, and in special session September 25, unanimously
approved Reference Committee recommendations for sweeping changes in Michigan
Medical Service (Blue Shield).
The House of Delegates Reference Committee on Medical Service and Prepay-
ment Insurance, chaired by Max L. Lichter, M.D., gave long hours of consideration
to reports of the Committee on Michigan Medical Service, George W. Slagle, M.D.,
chairman, the Committee to Study Comprehensive Prepaid Insurance Plans, C. 1.
Owen, M.D., chairman, and the Survey Committee, D. Bruce Wiley, M.D., chairman.
The amended Slagle Report, as approved by the Delegates, is herein reported, as
the culmination of the House action on this important question.
SUPPORT-Part Two
(See pages 1408 and 1411-1436)
Pointing the way for Blue Shield changes were the results of the statewide Opinion
Study of Prepaid Medical Care Coverage in Michigan, sponsored by the Michigan
State Medical Society. The study was directed by the Delegates meeting in special
session April 27 in Detroit.
Five months later, the four separate surveys of public and doctor opinion were
presented to the House of Delegates in Grand Rapids by J. J. lightbody, M.D.,
vice-speaker; George W. Slagle, M.D., president-elect, and Hugh W. Brenneman,
survey director.
The study results commanded nationwide attention, and nearly 100 representa-
tives of state medical societies, insurance companies and the press attended the
Annual Session of the House of Delegates.
A copy of the 240-page study was distributed to delegates in Grand Rapids to
aid them in their deliberations. In reproducing the study for this issue of The
Journal, statistical tables have been omitted. A very limited number of copies
of the full-published study report are available from the MSMS office,
November, 1957
1405
OPINION STUDY OF PREPAID MEDICAL CARE COVERAGE IN MICHIGAN
ACTION
Report of the Reference Committee on
the Report of the Survey Committee
The report of the Survey Committee was re-
ceived by your Reference Committee. In consider-
ing this report the committee was aware of the
great national interest evoked by the survey.
Present were representatives from many state
medical societies throughout the country, the in-
surance industry, associations concerned with health
services, editors from state medical journals and
national medical journals, and members of the
press. In addition, numerous requests are being
received from a variety of interested organizations.
The Committee was impressed with the extent
of the study and the thoroughness with which it
was conducted. The Committee strongly urges the
utilization of the data of this admirable survey
by all those concerned with the subject of prepaid
medical care insurance.
Your reference committee highly commends the
Survey Committee for an assignment well done.
Particular commendation is due the survey direc-
tor, Mr. Hugh W. Brenneman, our esteemed public
relations counsel, for his unflagging zeal in or-
ganizing this monumental effort, his leadership
which earned the untiring cooperation of his staff,
and his meticulous attention to myriad of detail
— and still completing the task on time.
The Committee wishes also to express its high-
est commendation to those who worked with Mr.
Brenneman in this study:
To L. Fernald Foster, M.D., MSMS Secretary,
and Mr. William J. Burns, MSMS Executive Di-
rector, who with Consultant David J. Luck, Di-
rector of the Bureau of Business Research of Michi-
gan State University and Richard B. Oudersluys,
Director of the Market-Opinion Research Com-
pany, supported and wisely counseled.
To Warren F. Tryloff, Associate Director of the
Study and Dick Philleo, Supervisor of Production,
who at great personal sacrifice devoted their rec-
ognized talents unceasingly to the successful exe-
cution of the study.
To John B. Kantner of the Michigan Health
Council who so ably wrote, and advised upon the
preparation of the report, as well as the attendant
publicity, in cooperation with Miss Kay Asby, a
devoted and competent special survey assistant.
To Jack Pardee, Miss Jean MacDonald, Miss
Vada Studt, Miss Helen Schulte and to the
MSMS stenographic staff who sincerely contrib-
uted with their interest and time to the produc-
tion of the materials upon which the survey de-
pended.
And to Artist Dirk Gringhuis whose advice and
assistance aided the publicity and was responsi-
ble for the fine appearance of the report.
Report of the Reference Committee on the Report
of the Committee on Michigan Medical Service
A. GENERAL CONSIDERATIONS
The Michigan State Medical Society has made
an intensive study of the development and the
operation of the many means currently employed
both in Michigan and elsewhere to insure against,
or to prepay, the cost of medical care. The con-
clusions resulting from that study are set forth be-
low and are based upon the following fundamental
considerations:
1. The people of Michigan are entitled to and
should have health care which meets the highest
standards attainable.
2. Means generally should be available in
Michigan which will permit the financing of the
costs of necessary medical services and supplies
to the greatest extent possible and practicable
through prepayment.
1406
3. To whatever extent the cost of a particular
medical service is not covered by prepayment,
such uncovered amount shall be predictable, be
known to the patient in advance, and be within
his ability to budget out of income.
The foregoing can be accomplished only if
those responsible for rendering the necessary med-
ical services, namely the physicians of Michigan,
assume the further responsibility of establishing
within the profession a structure around which
sound insurance or prepayment plans can be built
and also a system by which the profession can as-
sure itself, the prepayment-plan subscribers, and
the underwriters that the structure is functioning
in accordance with its commitments.
II C
.TMSMS
REFERENCE COMMITTEE REPORT
B. COMMITMENTS BY THE MICHIGAN
STATE MEDICAL SOCIETY
In light of the foregoing, the Michigan State
Medical Society undertakes the following com-
mitments.
1. Any contract offered by an insurance car-
rier or prepayment plan organization which em-
bodies the principles set forth in Section C herein
shall receive the endorsement of the Society, pro-
vided the carrier issuing this contract shall stip-
ulate it will not offer any prepaid medical care
contract which is preferential or discriminatory in
its rating. This endorsement shall remain in ef-
fect as long as the carrier continues to make
such contracts available and keeps the stipulation
in effect.
2. It being the objective of the medical profes-
sion to make certain that voluntary health protec-
tion be available to all self-sustaining people at
reasonable cost, the endorsement of the Michigan
State Medical Society will be given only if rates
charged by the insurance or prepayment carrier
are fair and equitable and non-discriminatory.
3. The Society will use its best efforts to se-
cure the participation of its members in all con-
tracts endorsed by the Society.
4. A subscriber rendered care by a participat-
ing physician will receive "service benefits" as
provided in his contract, the basis set forth in
Section D, below.
5. The Council of the Michigan State Medical
Society will appoint a Medical Care Insurance
Committee having the following functions:
(a) To examine all contracts submitted for en-
dorsement. A report will be sent to The
Council which will have the authority to issue
a certificate of endorsement on behalf of the
Society.
(b) To cooperate with the Permanent Advisory
Committee on Fees of the House of Deleqates
concerning the Relative Value Scale and ap-
plicable unit values.
(c) To develop review procedures for any mat-
ters concerning the subscriber, the physician,
the insurance carrier, and others.
(d ) To develop review committees in each of the
Councilor Districts of the Society, nominated
locally, which shall be appointed by The
Council of the Michigan State Medical So-
ciety. These shall function under the direc-
tion of the Medical Care Insurance Commit-
tee, which will also serve as a unit to which
appeal can be made from decisions of the
review committee (s) .
(e) To make such interpretations of the language
herein as may be required in connection with
the endorsement of contracts.
6. Amendments to, or interpretations of, the
principles set forth herein may be made by The
Council of the Michigan State Medical Society
| November, 1957
during the interim, between meetings of the House
of Delegates of the Michigan State Medical So-
ciety.
7. The Michigan State Medical Society, spon-
sor of Michigan Medical Service, will urge Mich-
igan Medical Service to make available, to any
qualified group or individual, protection in ac-
cordance with the principles herein set forth, at
fair and equitable rates, and pledges its support
in such an endeavor.
C. PRINCIPLES TO BE EMBODIED
IN INSURANCE CONTRACTS
1. Th ere must be complete freedom of choice
of physician by the patient. Nothing in any con-
tract will imply any restriction of this principle.
2. All benefits will be on a service basis con-
sistent with the principles set forth in Section D,
except when a subscriber voluntarily occupies a
private room in a hospital.
3. The following services must be included in
any basic program:
(a) Surgical procedures wherever performed.
(b) Medical services when the patient is confined
to a hospital.
(c) Consultation service in the hospital; surgical
assistants where required.
(d) Obstetrical services for the actual procedure
in normal delivery, Cesarean section, or abor-
tion and complications of pregnancy, but not
to include routine prenatal and postnatal
care. Optional supplemental insurance by
the carrier to cover all obstetrical costs may
be offered as provided in Item 4, immediately
below.
(e) Anesthesia by a physician, not an employee
of a hospital.
(f) Diagnostic laboratory procedures shall be
provided in the out-patient department of a
hospital, a private laboratory, in the physi-
cian's office (screening procedures are ex-
cluded).
(g) Di agnostic and therapeutic radiologic pro-
cedures shall be provided in the hospital, the
out-patient department, or in the physician's
office.
4. At the option of the carrier, additional cov-
erage may be provided for other medical serv-
ices and supplies such as:
(a) Home and office calls.
(b) Benefits for prescriptions filled by a registered
pharmacist.
(c) The furnishing of prosthetic devices.
(d) Physiotherapy in the out-patient department
or the physician's office.
(e) Other services which may be required in the
treatment of the patient.
5. (a) For any necessary service other than
in-hospital medical care, surgical care, ob-
stetrical c are and anesthesia, the subscriber
shall have, at the time of utilization, a degree
1407
OPINION STUDY OF PREPAID MEDICAL CARE COVERAGE IN MICHIGAN
of financial participation in, and responsi-
bility for, medical fees in addition to his
premium. This shall be determined by the
carrier but the responsibility of the patient
shall be not less than 10 per cent or $5.00,
whichever is more, but not in excess of the
scheduled fee allowance. In accordance with
the terms of the contract, this amount shall
become the obligation of the patient to the
physician at the time of service and will be
subtracted by the carrier from the payment
for service it shall make to the physician. For
any calendar year, however, patient partici-
pation shall not exceed the following:
Contract
for which
Eligible
Limit of Patient
Participation
Per Year
A
B
C
$25
50
75
(b) While the provisions of (a) above are strong-
ly urged by the Michigan State Medical So-
ciety, any carrier may have the option to
waive the provision of (a) by a rider to pro-
vide for coverage without subscriber contri-
bution.
6. There shall be three contracts to be known
as Plans A, B, C. Each of these contracts shall
apply to a specific income level and will provide
service benefits. The income level shall be de-
termined by a projection of the current rate of
earnings of the basic wage-earner in the family
and not by family income.
Where the basic income is not readily determ-
ined and established (such as self-employed, farm-
ers, salesmen on commission) the Committee on
Medical Care Insurance of the Michigan State
Medical Society shall develop appropriate criteria
for determining eligibility for service benefits.
(a) Plan A will provide full service benefits for
those subscribers whose basic income is less
than $2,500.
(b) Plan B will provide full service benefits for
those subscribers whose basic income is at
least $2,500 but less than $5,000.
(c) Plan C will provide full service benefits for
those subscribers whose basic income is at
least $5,000 but less than $7,500.
Those subscribers whose income is in excess of
$7,500 may purchase only Plan C. In this event,
the total fee shall be the result of agreement be-
tween the patient and his physician. The plan
will pay the applicable "dollar allowance" to
the physician.
7. The insurance carrier shall be responsible for
classification of subscribers and appropriate des-
ignation of the plan in which they must be enrolled.
Income designation shall reflect the subscriber's
current rate of pay, projected on an annual basis.
This designation shall be reviewed annually and
changed as indicated by the review.
D. BASIS OF SERVICE BENEFITS
1. The Michigan State Medical Society will
develop a "relative Value Scale" which will as-
sign to the individual surgical, obstetrical, and
other medical services a value in units propor-
tional to the relative value of that service. The
Society will determine the applicable value of one
unit for each class of benefit. By multiplying the
number of units assigned to a procedure by the
value of one unit, the "dollar allowance" for that
procedure is obtained.
2. (a) The Michigan State Medical Society
will establish unit values for medical, surg-
ical and obstetrical procedures and anesthesia
for each of the plans.
(b) For diagnostic laboratory procedures and for
all radiologic procedures, the unit value will
be the same for all plans.
(c) For any optional benefits offered by a car-
rier, the Society will establish appropriate
unit values.
3. Until the Michigan State Medical Society
establishes a Relative Value Scale, the scale de-
veloped by the California Medical Association
shall be used.
4. No participating physician may charge more
for a particular service rendered a subscriber than
the "dollar allowance" payable for that service
under the subscriber's contract. A subscriber
covered by Plan C, whose income is designated as
in excess of $7,500, however, shall be responsible
for any part of fees to which he agrees with his
physician, in excess of the applicable "dollar al-
lowance."
Respectfully submitted,
Max L. Lichter, M.D., Chairman
Laurence S. Fa Mis, M.D.
H.C. Hill, M.D.
R. L. Novy, M.D.
D. G. Pike, M.D.
Sydney Scher, M.D.
W. F. Strong, M.D.
The Opinion Study of Prepaid Medical Care Coverage in Michigan was published
and distributed to the Delegates in Grand Rapids. The 240-page volume contained
detailed tables of statistics. In reprinting sections of the Study for JMSMS, only
the statistical tables have been omitted.
1408
JMSMS
Official Report of the
Opinion Study of Prepaid Medical Care
Coverage in Michigan
MICHIGAN STATE MEDICAL SOCIETY
606 Townsend Street, Lansing, Michigan
Kenneth H. Johnson, M.D., Speaker
House of Delegates
Michigan State Medical Society
Sunday, September 22, 1957
Dear Doctor Johnson:
On April 27, 1957, the House of Delegates instructed that the attitude of the public
and its various components be obtained on the general subject of prepaid medical
care and problems related thereto. The Council of the Michigan State Medical
Society embarked on May 15 upon this assignment by initiating the "Opinion Study
of Prepaid Medical Care Coverage in Michigan."
The responsibility for the conduct of this opinion study was vested in the Executive
Committee of the Council, which became the Survey Committee.
The Study sought opinions and information regarding medical care coverage from
four sources: (I) The consumers of medical service — a selected sample of the
public queried through personal interview; (2) a broader selected public reached
by the mailed questionnaire; (3) the doctors of medicine as the purveyors of medical
care; and (4) available research material on the overall question.
By action of The Council this day, September 22, 1957, the report of the Michigan
State Medical Society Opinion Study of Prepaid Medical Care Coverage in Mich-
igan was approved in its entirety and is submitted to you with the intent and hope
that the information will be of value in consideration, by the MSMS House of Dele-
gates, of the weighty problems that face our Society's policy-making body.
We have confidence in your wisdom and judgment.
Respectfully submitted,
D. Bruce Wiley, M.D.
Chairman of The Council
•vember, 1957
1409
Contents
Official Report of the Opinion Study
of Prepaid Medical Care Coverage
in Michigan
Letter from Chairman of The Council 1409
Introduction to Study 1412
Methodology 1413
Conclusions 1414
Highlights
Public opinion survey of prepaid coverage and related costs 1417
The doctor opinion survey on prepaid medical care plans 1419
Summary
Summary of opinion survey of prepaid medical care coverage and related
costs 1423
Summary of survey of consumer opinion on medical care protection 1428
Summary of survey of doctor opinion on prepaid medical care plans 1430
Summary of survey of related studies on prepayment of medical costs 1435
1410
TMSM
Acknowledgments
AN OPINION STUDY OF PREPAID MEDICAL CARE COVERAGE IN MICHIGAN
MICHIGAN STATE MEDICAL SOCIETY
Sponsor
MICHIGAN HEALTH COUNCIL
Co-Sponsor
Survey of Consumer Opinic
OFFICERS OF MSMS
President
Arch Walls,
M.D.
President-Elect
George W. Slagle,
M.D.
Secretary
L. Fernald Foster,
M.D.
Treasurer
W. A. Hyland,
M.D.
Speaker
Kenneth H. Johnson,
M.D.
Vice Speaker
J. J. Lightbody, M.D.
Editor
Wilfrid Haughey,
M.D.
Executive Director
and Administrator .
William J. Burns,
LL.B.
* * *
President, Michigan Health
Council
J. K. Altland,
M.D.
SUPERVISION
Editorial
John B. Kantr.er, Lansing
Production
Dick Philleo, Lansing
Publicity
Kay Asby, Lansing
Graphic Arts
W. L. Veenendaal, M.S., Michigan
State University, East Lansing
DEVELOPMENT
Jean MacDonald
Jack Pard ee
Helen Schulte
Vada Studt and five MSMS Stenographers
SURVEY COMMITTEE
D, Bruce Wiley, M.D., Utica, Chairman
W. B. Harm, M.D., Detroit, Vice Chairman
L. Fernald Foster, M.D., Detroit
Wm. J. Burns, LL.B., Lansing
W. A. Hyland, M.D., Grand Rapids
K. H. Johnson, M.D., Lansing
W. M. LeFevre, M.D., Muskegon
J. J. Lightbody, M.D., Detroit
B. B. Saltonstall, M.D., Charlevoix
Ralph W. Shook, M.D., Kalamazoo
G. W. Slagle, M.D., Battle Creek
Arch Walls, M.D., Detroit
STAFF
Director of Study
Hugh W. Brenneman, Lansing
Associate Director of Study
Warren F. Tryloff, Lansing
Consultants
David J. Luck, Ph.D., Lansing
Richard B. Oudersluys, Detroit
Lester P. Dodd, Detroit
November, 1957
SERVICING AGENCIES
Market-Opinion Research Company, Detroit — Richard B.
Oudersluys, Managing Director, Service Bureau Corporation
Division of International Business Machines Corporation
Beurmann-Marshall Service Corporation, Lansing.
Lansing Secretarial Service Center, Lansing — Mrs. W. A.
Pomeroy
*
* *
It is difficult to acknowledge formally all of
those who contributed to this study. But to the
many persons, in addition to those above, who
helped by giving their time, advice and encour-
agement, we express our grateful appreciation.
Special thanks are expressed to the Detroit Sun-
day Times and Lansing State Journal newspapers
for the sincere interest in this study and their help
in getting reader participation in the survey by
printing it in full, so it could be filled out and re-
turned for tabulation.
The Market Opinion Research Company of De-
troit accepted and carried out the responsibility
for conducting the Opinion Survey of Prepaid
Medical Care Coverage and Related Costs.
1411
OPINION STUDY OF PREPAID MEDICAL CARE COVERAGE IN MICHIGAN
Introduction to Study
Prosperity was general in the year 1957. People
were working and making money and jobs were
plentiful. Yet, because of inflation, people were
sometimes hard put to make ends meet.
Although the costs of all products and services
were increasing, one of the most galling bills to
pay was the doctor's bill.
While, realistically, people accepted the fact
that their doctor was a highly trained, skilled
scientist, they did not fully appreciate the rapid
advances in his science. Many scientific changes,
such as the administration of anesthesia, for ex-
ample, offered greater protection to the patient,
but, sadly enough, they cost him more money
when he went to a hospital for an operation. The
new drugs lessened the patient's stay in bed and
got him back to work sooner, but it was more pain-
ful to pay for the prescription.
There were other changes taking place, too —
socio-economic changes in which people in 1957
sought and expected greater security in the finan-
cial returns from their jobs. Fringe benefits be-
came the accepted and demanded right of the
individual.
So they came to expect it.
But nothing is free. The economic facts of
life still continued to operate. Costs continued
to rise, and the medical insurance plan which
fitted the financial structure of the forties was
an economic lag in the fifties. The doctors realized
it and began to make a careful appraisal of these
plans to see where changes could be made.
It was about that time that the labor unions
saw an opportunity for a new approach in fertile
fringe benefit territory. Whenever they demand-
ed higher wages, the higher wages merely in-
creased the cost of the products and added to the
spiralling inflationary process. That left the work-
er with little net gain in the value of his take-
home pay. So labor turned its attention to the
sociological programs in which health insurance
plans were one of the most important to union
members. Labor talked of increases in benefits
which would lead to full medical coverage in such
programs as the Blue Shield plan operated by the
doctors of medicine, and they threatened to start
their own medical plan if the doctors did not
accede.
It was in this climate of social and economic
change that the Michigan State Medical Society's
Opi nion Study of Prepaid Medical Care Cover-
age in Michigan was born.
Changes had to be made in medical care plans
and surgical insurance protection. Since the medi-
cal profession and the public are partners in
these plans, it was felt that both should have an
opportunity to express their views about what
1412
medical-surgical services should be offered.
The Michigan State Medical Society House of
Delegates met in Special Session in Detroit on
April 27, 1957 to consider the necessity of changes
in the Blue Shield Plan. After careful delibera-
tions, they passed the following motion:
That to complement better the work of present com-
mittees, the Michigan State Medical Society Council or
its Executive Committee be instructed to immediately
conduct a survey to determine the attitude of the con-
sumer public generally regarding services which should
be offered, as well as the economic potential to pay for
such services, and that it utilize any survey material
and information already available together with such
other facts as can be secured to effect that end, this
survey information to be made available to this House of
Delegates at the September, 1957, meeting through the
Annual Report of the Council of the Michigan State
Medical Society.
In other words, members of the House of Dele-
gates authorized a Study which would find out
four things —
1. What medical services do people want cov-
ered by medical prepayment plans, and what do
they feel is the order of priority for these services?
2. How much will people be willing to budget
for these services, and which of the services are
they most willing to pay for?
3. What do doctors want from any prepaid
medical or health insurance plan?
4. What data is available from other surveys
conducted througout the United States recently on
the same questions?
The project was given the title, "An Opinion
Study of Prepaid Medical Care Coverage in Mich-
igan." The Survey Committee of the Michigan
State Medical Society accepted responsibility for
the Study. Members of the Committee were ac-
tually members of the Executive Committee of the
Council of MSMS. The Michigan Health Council,
a non-profit educational organization, cooperated
with the Michigan State Medical Society in con-
ducting a portion of the total Study.
The entire study was unique in many ways. For
one thing, it was operated on a fast-moving time
schedule. Usually a comprehensive study of this
nature would take several years to complete. From
the decision to report of the results, this one was
finished in only five months. The speed was an
essential part of the study's accuracy.
The study was unusual in another way, in that
an extensive publicity campaign was carried out
all the time the project was in the works, includ-
ing radio, television, and press coverage. As a
rule, there is little publicity on a survey until the
results are announced. In this case, however, much
attention was given the Study so that there would
be a maximum return of the questionnaires.
JMSMS
METHODOLOGY
Many hours of work have gone into the prepara-
tion of this comprehensive report. The members
of the Michigan State Medical Society undertook
this project as a public service to the people of
Michigan and the nation. It is hoped that the
vital information contained in the pages that fol-
low will be of use to insurance companies, health
insurance advisory groups, other state medical so-
cieties and Blue Shield plans.
The people have spoken. Inevitably their
thoughts and opinions will have a significant effect
on the course and direction of future medical in-
surance programs.
Methodology
The Opinion Study on Prepaid Medical Care
Coverage in Michigan consisted of four separate
but integrated surveys —
• Opinion Survey on Prepaid Medical Care
Coverage and Related Cost
• The Survey of Consumer Opinion on Med-
ical Care Protection
• The Survey of Doctor Opinion on Prepaid
Medical Care Plans
• The Survey of Related Studies on Pre-
payment of Medical Costs.
Information from the first three surveys listed
above was recorded on IBM cards and tabulated
by the Service Bureau Corporation on IBM ma-
chines.
OPINION SURVEY ON PREPAID MEDICAL CARE
COVERAGE AND RELATED COST
The Medical Care Coverage and Related Cost
Survey consisted of 1,000 personal interviews con-
ducted by the Market-Opinion Research Company
of Detroit. Forty per cent of the sample was se-
lected from eighty-five census tracts in Wayne
County. The balance of the sample was taken
from twelve out-state counties — Allegan, Berrien,
Calhoun, Chippewa, Grand Traverse, Ingham, Kala-
mazoo, Kent, Lenawee, Saginaw, St. Clair, and
Oakland.
This is how the census tract selection was made
for the interviews. Census tracts are numbered.
The first tract was selected at random, then every
sixth tract was chosen as an interview location. A
block was chosen at random in each tract and four
interviews were conducted per block. In larger
census tracts, two blocks were chosen. A total of
100 blocks were used in the Survey.
When no census tract was available for the sam-
ple selection, the "quota control method" was
used. In this method, the interviewers have quotas
of respondents which represent population char-
acteristics such as rural, urban, occupational, age
and racial classifications. Quotas are in propor-
tion to the population and number of population
characteristics in each county.
November, 1957
SURVEY OF CONSUMER OPINION ON
MEDICAL CARE PROTECTION
The Survey of Consumer Opinion on Medical
Care Protection was a mail survey conducted by
the Michigan Health Council. The names of per-
sons to receive the questionnaires were selected
from the 1957 Michigan automobile registrations.
This is a more recent and complete listing than that
provided by the 1950 U. S. Census Bureau. In
addition, approximately 80 per cent of the names
on the list are men. Since this survey was directed
toward men who actually purchase about 80 per
cent of the medical insurance contracts through
their places of employment, the proportion of
men on the automotive listing made it an ideal
source of names.
Questionnaires were allotted each county ac-
cording to its percentage of population to the
entire state as indicated in U. S. Census figures.
Lansing, with its diversified representation of in-
come, occupation, and age groups was designated
as the test city. Returns from Lansing compared
favorably with early returns from throughout the
state.
To give the survey the widest distribution pos-
sible, questionnaires were published in full by the
Defrolf Times and the Lansing Sfafe Journal. A
total of 308 persons responded.
In a special effort to get the questionnaire di-
rectly into the hands of people who work in Mich-
igan industries, municipal governments, merchan-
dising and sales organizations or trade associations,
personal letters were written to employers, with a
copy of the questionnaire enclosed. The employers
were asked to spread the word in their publica-
tions and request additional copies of the ques-
tionnaire for wide distribution among their work-
ers. Approximately 12,800 were sent in answer
to requests and 859 or 6.7 per cent were returned.
The Michigan Health Council mailed 40,162
questionnaires and 39,380 were delivered. The
return was 4,702 or I 1.9 per cent.
The Michigan State Medical Society mailed
6,340 questionnaires to its members, and 6,328
were delivered. The return was 1,878 or 29.7 per
cent. The Michigan Health Council also mailed
10,000 to the Lansing area with a delivery of 9,461.
The return was 1,066 or I 1.3 per cent.
1413
OPINION STUDY OF PREPAID MEDICAL CARE COVERAGE IN MICHIGAN
Total returns on the Survey of Consumer Opinion
on Medical Care Protection, including request and
newspaper distribution, amounted to 8,813.
The 1,878 questionnaires returned by the med-
ical profession were not tabulated with those re-
turned by the general public because answers from
this special occupational group would bias the sur-
vey. However, these questionnaires will be tab-
ulated and used in subsequent studies. Thus, by
subtracting the 1,878 responses from the total re-
turns, the adjusted total returns would be 6,934.
SURVEY OF DOCTOR OPINION ON
PREPAID MEDICAL CARE PLANS
The Survey of Doctor Opinion on Prepaid Med-
ical Care Plans was a mail questionnnaire sent to
Michigan State Medical Society members along
with the Survey of Consumer Opinion on Medical
Care Protection. The number sent was 6,340 and
6,328 were delivered. The return was 2,435 or 38.5
per cent.
The total number of returns for all three surveys
was 12,248. The mailings and personal inter-
views took place in July, 1957. The cut-off date
for returns on all public-opinion questionnaires was
July 31. The cut-off date for returns on the Doc-
tor Opinion questionnaire was August 17.
Recording and tabulation began with the return
of the first questionnaire. The "write-in" answers
were coded so that these answers could be incor-
porated with the other pre-coded answers on the
balance of the questionnaire. These, in turn, were
punched, tabulated, and sorted by the Service Bu-
reau Corporation, a subsidiary of the International
Busi ness Machine Corporation. IBM heavy produc-
tion equipment was used in handling the millions
of factors involved.
SURVEY OF RELATED STUDIES ON PROTEC-
TION AGAINST MEDICAL SERVICE NEEDS
The Survey of Related Studies on Protection
Against Medical Service Needs was developed
by reviewing and compiling twelve surveys made in
other parts of the United States on the same basic
question. These were the only surveys previously
made.
The six surveys selected for report include —
• Summary of Survey of Physician's Atfiiudes
Toward Voluntary Health Insurance, American
Medical Association, Council on Medical
Service, January, 1954
• Attitudes Toward Health Insurance, Social
Research, Inc., 1956
• Reactions of People in Two Harbors to Differ-
ent Plans of Paying for Medical Care, Depart-
ment of Rural Sociology, University of Min-
nesota, 1956
• Report of Committee to Study Comprehensive
Prepaid Insurance Plans, Michigan State Med-
ical Society, 1957
• Family Medical Costs and Voluntary Health
Insurance: A Nationwide Survey, Health In-
formation Foundation, 1956
• Voluntary Health Insurance in Two Cities, A
survey of Subscriber Households, Health In-
formation Foundation, 1957
• Charts and Graphs: A Supplement to Volun-
tary Prepayment Medical Benefit Plans. Coun-
cil on Medical Service, American Medical As-
sociation, S957.
Conclusions
THE OPINION STUDY OF PREPAID MEDICAL
CARE COVERAGE IN MICHIGAN AS
REPORTED IN THIS DOCUMENT
IS A VALID ONE
It has been checked against statistical facts
available from other recognized sources and found
to be within the tolerances of accuracy.
The separate surveys of the study, although ac-
complished independently and using different sam-
ples, agree in every basic category of study. Even
in details where minor differences are noted, the
trends and their implications are alike.
The desires of the sponsors of this survey, as
reviewed elsewhere in this report, have to a major
degree been met. The sponsors at no time ex-
pressed a desire for anything except the most un-
biased information. In every instance where bias
might have been possible, extra precaution was
taken to avoid it insofar as it is humanly possible
under the accepted standards of survey proced-
ures.
The timetable of the survey was unusually rapid.
This increased the expense, at the same time im-
proving the accuracy and eliminating possibility of
an organized campaign by any person or group
to bias the answers received.
The public took a great interest in the survey,
as is evidenced by the unusually high ratio of re-
turn of mailed questionnaires. The interviewers
received an unexpectedly sincere welcome from
those interviewed and were given thoughtful re-
plies. Interest in the survey reflects interest in the
question. Cooperation of the public was also re-
flected by the generous help and attention given
the survey by the various media of communication.
Few previous surveys on any subject have received
comparable publicity prior to the release of their
findings.
1414
JMSMS
CONCLUSIONS
The present value of this study is that it supplies
a true reflection of the desires and attitudes of
both the surveyors and consumers of medical care
in Michigan which cannot be fairly questioned or
distorted and upon which decisions affecting the
lives of millions of persons can be reliably based.
The attitudes delineated herein may change,
but this survey will continue to have value in the
future as a bench mark. For, as of this date, the
people have spoken and their voice is accurately
reported. Literally millions of facts are available
from such an extensive survey as this.
The Survey Committee does not pretend to be
omnipotent in foreseeing that answers to all ques-
tions asked by any person, which can be obtained
from the satistics, are herein reported. However,
the conclusions and highlights arrived at are, in
the opinion of the Committee, the answers to the
major questions posed by the sponsors of the sur-
vey.
Among the voluntary, non-profit, health insur-
ance* plans on a national basis, the most widely
accepted plan is the combination service-cash in-
demnity. Blue Shield in Michigan falls in that
category. There is not known to be any great
difference between the types of commercial insur-
ance policies sold in Michigan and those generally
sold throughout the country. In this state, there is
but one Blue Shield plan administered by a single
corporation — Michigan Medical Service.
This corporation is guided in its policy by the
recognized policy-making body of the medical pro-
fession in this state. There are no Blue Shield
plans offered in Michigan other than that by Mich-
igan Medical Service. This contrasts with many
other states which have one or more Blue Shield
plans, with one or more corporations administering
them.
Blue Shield in Michigan has a larger percentage
of the total population of the state enrolled than
does any other plan in any other state. A total
percentage representing eight out of ten persons
in Michigan [81 per cent) are covered by some
form of health insurance. The responsibility and
influence of Michigan Medical Service in the
health insurance field in Michigan cannot be gain-
sayed when the fact is faced that six out of ten
persons covered by health insurance (64.6 per
cent) are protected by Blue Shield.
It is further significant that today, in contrast
to yesteryear and in fantastic contrast to the situa-
tion in 1940, this state has reached a point of semi-
saturation in the health insurance field. This has
caused major competition for business between in-
suring agencies to be directed toward persons al-
ready insured, or becoming nev/ly eligible. The
remaining number of uninsured are, in their ag-
gregate, relatively poor prospects.
Although often confused in terminology with
*The words "health insurance" or "insurance" used
throughout these conclusions means some type of prepaid
medical and/or surgical coverage.
November, 1957
the term Blue Cross, the existence of the Blue
Shield plan is widely known and the terms Blue
Cross or Blue Shield are rapidly becoming in the
public mind generic, — meaning a non-profit vol-
untary health insurance plan. Those persons not
covered by Blue Shield remain unprotected in the
main, according to their replies, because they
"can't afford it." No attempt was made to go
behind this answer.
Coverage exists in all counties of the State with
concentration paralleling density of population.
Blue Shield is popular in Michigan. Eighty-one
per cent of the people who have it, like it. This is
a higher percentage of favorable reaction than is
held by the insured of any other company in which
they are insured. A greater percentage of people
have a favorable attitude toward Blue Shield than
toward any other insurance plan offering medical-
surgical coverage, and that percentage is a sizable
majority of the total population of the state. Of
interest is the fact that, on the whole, members of
unions have a slightly more favorable opinion of
Blue Shield than does the general populace, and
an even greater percentage of favorable attitude
when compared with non-members of unions. Peo-
ple in the most densely populated area of the
state (Wayne County) expressed an unfavorable
opinion more often than did the residents of other
areas of the State. High rates was the reason
most often given for an unfavorable attitude, when
such was expressed. People like it, but some peo-
ple don't like to pay for it.
The doctors like Blue Shield too, even though
they feel that its service can and should be im-
proved. They are more skeptical of the favorable
attitude held by the people than the facts war-
rant.
The doctors have thousands of ideas for improv-
ing their corporation's service. They are not hesi-
tant about expressing these ideas to their society
or their corporation and seem perfectly willing to
be identified with the thought they express, be it
critical or complimentary. The doctors are not
adverse in their attitude, generally, toward health
insurance being sold by insurance companies. In
fact, many, although a small minority of the total
number, believe that the medical profession should
"get out of the health insurance business alto-
gether." They don't like plans which propose
closed panel service at all.
The doctors' chief gripe at Blue Shield is "in-
equities" in the schedule of payments they receive
for services. They say the fee schedule hasn't
kept pace with the changing science of medicine,
nor the rising cost of living. They think most of
the people who have an unfavorable attitude to-
ward Blue Shield have it because they don't un-
derstand what benefits they are entitled to and
have an exaggerated concept of the amount of
money they oav for protection. This judgment
of the people's lack of knowledge and undersfand-
inas is born out by the facts.
There is evidence of sufficient dissatisfactions
1415
OPINION STUDY OF PREPAID MEDICAL CARE COVERAGE IN MICHIGAN
with various and sundry aspects of Blue Shield to
warrant investigation of changes which might im-
rove it, both from the standpoint of rates and
enefits as well as from payments to doctors. This
is not to say that, on the evidence, such a change
should be drastic. The changes most often re-
quested by respectable numbers of returns from
doctors point to inequities which, although they
may have existed before Blue Shield, are nonethe-
less accentuated, in the minds of the doctors, by
Blue Shield. Specialties, hardly in existence when
Blue Shield was born, now have standards and skills
demanding consideration of increased payments on
the basis of every criterion save tradition.
The public seems to understand and recognize
the value of the more widely publicized medical-
surgical procedures such as surgery and x-ray and
want to be protected against their cost so they
can have these services wherever and whenever
needed. Illustration of this fact is the almost unani-
mous demand (96 per cent) for protection against
surgical expense. Of the services not presently
covered by Blue Shield, the highest number of
eople wanted x-ray in the doctor's office or the
ospital out-patient department.
Great numbers of people are almost shockingly
unfamiliar with the provisions of their Blue Shield
contract or their insurance policy. Insofar as rates
are concerned they almost always think they are
paying more than they are. They think they are
paying an average of 100 per cent more than they
actually do! Reasons advanced for this common
misconception is that the Blue Cross (Hospital)
premium is often confused with the Blue Shield
(Medical) premium since they are sold in the same
package and only one total payment per month is
made. Nonetheless, the wide divergence from
reality of the cost or rates of Blue Shield is a fact
and (see above) a major cause for unfavorable
opinion. Since the overwhelming proportion of
Blue Shield protection is purchased through the
place of employment, it is quite possible that
the subscriber merely accepts what is offered and
doesn't find out what's in the policy. This may
account for misconceptions about coverage which
plague the doctors and makes them believe that
the subscriber does not understand his contract.
Almost 50 per cent of the doctors think that doc-
tors, generally, don't understand the coverage of-
fered, either.
Broadly speaking, the people want most of the
benefits which they now have in the Blue Shield
contract, but think they have more benefits in their
contracts than are actually there. They want
benefits they don't now have in about the same
proportion and preferential sequence as the ones
they mistakenly thought they had.
Most of the doctors believe that some benefits
not presently included in the Blue Shield contract
should be. Certain generalists and internists are
in accord that some benefits which they would
service should be included. Comparing the pay-
1416
ments for their services now included in the con-
tracts with those received by the surgeon and cer-
tain other specialties, they feel they are underpaid.
Most doctors agreed that if outpatient diagnos-
tic benefits were to be added to the Blue Shield
contract, such benefits should not be limited only
to treatment in a hospital outpatient department,
but should be qualified if the treatment were in the
doctor's office or certified laboratories as well.
While doctors were almost equally divided on
the question of what benefits should be added,
they were in agreement that the medical service
principle should not be limited to low-income
groups. They also agreed that the service prin-
ciple should apply to those subscribers in the
$7,500-and-be!ow income bracket, providing the
payment to doctors for services rendered to this
group were increased.
The people are willing to pay more than they
are now paying for prepaid medical care cover-
age. That statement is generally true but it is
qualified with two provisions. The first qualifica-
tion is that they will pay more than they are now
paying if they get all the benefits they ask for,
and it is quite obvious that they are willing to pay
more than these services now would cost (at the
prevailing $5, 000-income limit fee schedule). The
other provision is that the income limit be raised
to include a far larger majority of the people
than is included under the $5, 000-income limit.
The evidence is that the people are willing to
pay much more than they are now paying for
the addition of relatively few and not too costly
additional services. This may be an index of pros-
perity or it may be conditioned by the fact that
they now think they are paying more than they
actually are.
A deductible feature is popular with a large
number of people — almost a majority when it is
predicated upon a lowering of monthly premium
costs. The survey also showed that twice as many
people wanted major and minor costs covered as
wanted major costs only. The value of this lat-
ter conclusion (taken from the Consumer Opinion
Survey) in determining public opinion is dimmed
by the demonstrated lack of unanimity on the
meaning of the terms, as well as a lack of knowl-
edge of the various benefits.
Findings of the Doctor Opinion Survey definitely
give the conclusion that by far the majority of
doctors in private practice want and need Blue
Shield, believe in its policies, abide by its prin-
ciples, and are satisfied with its administration.
They would like to see as much of the control
vested on the local level as can reasonably be
done without sacrificing the present generally sat-
isfactory performance of the corporation. Should
additional control be placed on the local level,
the doctors want the guiding hand to be the county
medical society in every instance.
Widely agreed upon was the necessity of some
supervision, more than is presently arranged, of the
TMSM!
HIGHLIGHTS
utilization of Blue Shield. Even more definite was
the opinion that greater supervision must be ac-
corded utilization of Blue Cross. This necessity
was sensed from the Consumer Opinion Survey,
even though no question regarding utilization was
asked (as it was not germane to the two basic aims
of that survey). It seems fairly apparent that
with the obvious advantages of a plan which has a
service feature goes the responsibility of providing
a maximum efficiency and a minimum of needless
waste.
Throughout the Doctor Opinion Survey, the
results showed the doctors generally agreed on
basic principles and basic philosophies and sup-
ported present policies, no matter when and with
which questions they were tested. Areas of lack
of agreement were recognizable only on ques-
tions when matters of methods or fees were at
stake.
And in instances which involved the need for
knowledge of the more difficult and unfamiliar
aspects of insurance or business practice marked
agreement was usually not apparent. It was noted
that upon questions which involved intimate re-
lationships with agencies, the doctors uniformly
tended to prefer to "stay away" from contact with
these agencies as a means of avoiding difficulty or
external controls, which they obviously abhor.
However, the doctors are willing to subject them-
selves to disciplining from their own profession as
a practical necessity, even though it means some
loss of independence in their practice. These
findings are consistent with the profession's opin-
ion that policy matters in respect to administra-
tion of Blue Shield should remain, in general, the
prerogative of the doctor but that lay experts
were needed to solve administrative problems with
the help of advisors from the profession.
These are a few of our conclusions. You are
welcome to draw additional conclusions from the
tables published in this study.
* * *
The preceding Conclusion Section was prepared especially
for the September 23-24, 1957, meeting of the Michigan
State Medical Society House of Delegates. In subsequent
publications of this study, this section may be augmented.
Highlights
PUBLIC OPINION SURVEY OF PREPAID COVERAGE AND RELATED COSTS
1. An overwhelming majority (81 per cent) of
people in Michigan have some type of health in-
surance to protect themselves against unpredict-
able medical expenses.
2. Just over a third of the relatively small num-
ber of those who did not have health insurance
claimed they hadn't bought it because it was too
expensive for them. The rest gave varying reasons
and included the persons who said they never got
around to taking out a policy, as well as the rug-
ged individuals who didn't feel they needed insur-
ance because they could take care of themselves.
3. More than twice as many insured* people
(64.6 per cent) are covered by Blue Shield in
Michigan than by all other health insurance plans
and policies combined.
4. All or part of medical insurance premiums
are paid by employers for half of the Michigan
policy-holders, and employers pay the entire prem-
ium for about one-third of this group. Two-thirds
of these people said they would be willing to pay
an additional premium themselves to get any add-
*Tbe word "insured" used throughout these Highlights
means a person who is protected by some type of prepaid
medical and/or surgical coverage.
NOTE: People who were interviewed were allowed to
make up a hypothetical policy for themselves by selecting
benefits from a complete list of possible services in hos-
pitals, doctors' offices and the patient's home. The list
included everything that people might possibly want in a
policy. Numbers II to 18 tell what they wanted in medical
insurance protection, according to the three types of plans
offered — family plan, self and spouse or single persons.)
November, 1957
ed benefits they would like in their group con-
tract. One-third were not willing to pay an added
premium to get added benefits over and above
that paid by their employer.
5. The ratio of the insured in the surveys gen-
erally agreed with the number of family groups,
homes with only a husband and wife, and single
people in the state. The ratio is approximately
5-3-2 — five for family, three for husband and wife,
and two for single.
6. Nearly three out of four people have called
upon their insurance company for policy benefits.
7. Of those using their insurance, 61 per cent
had to pay an additional amount over and above
that paid for them by the insurance company.
Slightly more than half of the extra charges were
from doctors' fees, and less than half were for
services not covered in their policy.
8. X-ray was the major service, other than doc-
tor fees, causing the extra charge 17-19 per cent
of the time.
9. Twenty-two per cent of the people said they
paid less than $50 for medical expense over and
above that amount paid by the insurance company
the last time they used their policy.
10. People want x-ray services, either in the
doctors' offices or out-patient departments of hos-
pitals, covered in their policies. Farm, labor, and
business and professional groups had four bene-
fits they were most interested in — emergency house
calls, diagnostic services in doctors' offices, x-ray
in hospital out-patient department, and diagnostic
x-ray in doctors' offices. Farmers were least inter-
1417
OPINION STUDY OF PREPAID MEDICAL CARE COVERAGE IN MICHIGAN
ested in the adding of any of those benefits.
11. Everybody in all three plans wanted three
in-hospital benefits in particular. Surgical led the
list, diagnostic x-rays were second, and medical
in-hospital visits were third.
12. When they were asked to choose what
services members of all three plans wanted in a
doctor's office, again they were unanimous in the
leading choice — each desired emergency first aid.
The second selection was minor surgical treatment.
13. Relatively fewer people were interested in
having medical services in their homes. Less than
half of them wanted home calls covered. About
the same number wanted ambulance service, too.
!4. The benefits selected by those interested in
a hypothetical "family" plan would cost $! 1.24 a
month. The price for the "self and spouse" plan
after selections were made was $8.75, and the cost
of the "single" plan was $3.26. Remember, these
price tags on each plan differ because, naturally,
they vary in proportion to the number of people
covered in each of their respective and individual
contracts.
15. Union members developed hypothetical pol-
icies which cost slightly more than nonunion mem-
bers. Union members in the "family" plan chose
one which would cost 62 cents more. Those on
the "self and spouse" plan selected one costing
75 cents more. However, union members in the
"single" plan, chose a policy costing exactly the
same as nonunion members. So the maximum va-
riation in the price of a policy selected by union
and non-union members was only 75 cents.
16. In a comparison between income groups,
those making over $5,000 a year wanted a "family"
policy that cost only 60 cents more than the one
selected by the people making less than $5,000
a year. Those in the "self and spouse" plan mak-
ing more than $5,000 a year picked a plan that
costs 23 cents more than the people who were
earning less than $5,000 a year. And those in the
"single" plan making over $5,000 a year chose a
policy that costs 3 cents less than the one desired
by the people who earned less than $5,000 an-
nually, so the greatest spread in this case was
only 60 cents.
17. Rather than eliminate services in the pol-
icy they had selected to reduce the monthly prem-
ium, three-fourths of the people preferred to pay
for the benefits in their original selection, rather
than eliminating any item of service. The per-
centage of the vote on the items they would elim-
inate was very small. In fact, the highest percent-
age v/as only I I per cent, and this was voted by
those in the "self and spouse" plan who chose
diagnostic x-rays in the out-patient departments of
hospitals as the thing they would eliminate. Those
in the "family" plan also chose this service, but
only 9 per cent were in favor of eliminating it.
18. After eliminating certain coverages to bring
the costs down, the prices of the three hypotheti-
cal plans stacked up like this. The "family" plan
1418
was reduced from $1 1.24 to $10.09, or a reduction
of 95 cents. The "self and spouse" plan original-
ly selected would cost $8.75 a month. This was
reduced by $1.10 to $7.65 a month. The final
price desired in the "single" plan was only 14 cents
cheaper. Originally the "single" plan people
had selected a policy worth $3.26 a month, and in
their final selection it was $3.12 a month. In every
case, union members were willing to pay an aver-
age of 33 cents more than nonunion members for
the services they wanted.
19. Forty-seven per cent of the people were
in favor of the idea of a deductible type of med-
ical-surgical insurance plan; 53 per cent were not
in favor of if.
20. A little less than half of the people who
favored a deductible plan were willing to pay the
first $25 of medical expense. About a third of
those who favored it, were willing to pay up to
$50, and slightly more than 10 per cent were will-
ing to pay the first $100 of medical expense.
21. A two-thirds majority of both farm and
labor organization members wanted a $25 plan.
The same percentage of people making less than
$5,000 a year wanted the $25 deductible.
22. Two-thirds of the people wanted their pre-
paid medical plan to cover both major and minor
items of expense.
23. A majority of the people (78 per cent)
would rather have the insurance company pay the
doctor directly.
24. When people were asked what they thought
their insurance contracts covered, 95.8 per cent
knew they had surgical benefits, 93.9 per cent knew
they were covered for obstetrics, 83.6 per cent
correctly figured they had diagnostic X-ray, 65
per cent thought medical visits in the hospital were
included, but only 44.4 per cent — less than half —
knew for sure that they had the benefit of emer-
gency first aid in the doctor's office. And more
seriously, only 27.8 per cent knew that nineteen
surgical procedures, which could be done in the
doctor's office, were covered. Yet the maximum
contract covered all these things.
25. Then they were asked what they thought
they had, and here's how they answered. Nearly
half — 45 per cent — assumed they had diagnostic
benefits other than x-ray, 42 per cent assumed the
surgical assistant was paid by the insurance com-
pany, 36 per cent figured they were covered when
their doctor had a medical consultation with an-
other doctor about their case, 34 per cent banked
on the insurance to cover pre- and post-natal care
in the doctor's office, and finally, 32 per cent
figured that out-patient diagnostic x-rays were
covered. But none of these benefits are covered by
existing Blue Shield contracts.
26. A majority of the public (64 per cent) has
a favorable opinion of Blue Shield. Only 10 per
cent of the people felt unfavorable toward the
plan, while one-fourth of the people interviewed
had no opinion, one way or the other. The ma-
TMSMS
HIGHLIGHTS
jority of union members felf favorably towards
Blue Shield. In fact, union members felf more
favorably toward Blue Shield than the general
public, by 2 per cent.
27. Of the small percentage of people who felt
unfavorably toward Blue Shield, two-thirds felt the
rates were too high, and only one-third complained
about the coverage.
28. The policy holders of Company A were asked
to express the opinion they had about their com-
pany. More than three-fourths of them looked upon
the company favorably. When policy holders in
Company A and nonpolicy holders in Company A
were asked what they thought of the firm, one-
fourth of all the people interviewed had a favor-
able opinion of the company, but two-thirds ex-
pressed no opinion. Of the 12 per cent who had
an unfavorable attitude toward Company A, half
THE DOCTOR OPINION SURVEY ON
1. Of Michigan's M.D.s, 28 per cent believe that
administration of the major medical and surgical
prepayment plans in Michigan should remain in
the hands of the medical profession and the com-
mercial insurance companies on a competitive
basis, as it exists today. One-third felt that the
plan should be administered by qualified laymen
retained by the medical profession. Another third
felt that the medical profession itself should ad-
minister the programs.
2. Nearly two-thirds of the doctors believe that
their profession is not given sufficient voice at the
local level in determining Blue Shield policies.
Half of them don't think they have enough to say
about Blue Shield policies on the state level. They
fee! that county medical societies and specialty
groups should have more to say about policy mat-
ters.
3. Almost three-quarters of the doctors agreed
that the House of Delegates should elect the Blue
Shield Board of Directors.
4. The majority (60 per cent) thought that the
Board of Directors at Blue Shield should include
representation from groups other than the medical
profession. Slightly more than three-fourths of
them felt that management should be represented
on the Board, and just under three-fourths thought
that labor should be represented.
5. Doctors feel that some supervisory control
should be placed over the medical care provided
NOTE: These are the opinions of the members of the
Michigan State Medical Society on prepaid medical care
plans. One-third of those answering the questionnaire were
general practitioners, 13 per cent were internists, and 12
per cent, surgeons. The remaining doctors who answered
the questionnaire were identified with seventeen other spe-
cialties. One-third of the doctors lived in cities with a
population of more than half a million. Six per cent lived in
cities of less than 2,500 people. Eighty per cent of the doc-
tors who returned the questionnaires participate in at least
one of the two Blue Shield contracts, and 68 per cent par-
ticipate in both Blue Shield income-limit contracts.
November, 1957
of them felt the company misrepresented the policy
and had a poor claim-paying record. Less than
10 per cent complained about poor coverage and
high rates.
29. One-half of the policy holders in Company
B had a favorable opinion of the organization, but
slightly more than 40 per cent had no opinion
about the company. All of the persons interviewed,
whether they were policy holders or not in Com-
pany B, were asked how they felt about the com-
pany. Three-fourths of the people had no opinion,
14 per cent had a favorable opinion, and 10 per
cent had an unfavorable opinion. Half of the peo-
ple who had an unfavorable attitude toward the
company thought they had a poor claim-paying
record, about one-third felt the policy was mis-
represented and gave poor coverage; while 14 per
cent complained about the rates.
PREPAID MEDICAL CARE PLANS
under medical insurance plans. More than half of
them said that the medical profession should exer-
cise these controls. Forty-five per cent said that
a combined board of doctors and lay persons
should handle these controls.
6. Committees to oversee the utilization of Blue
Shield are favored by 75 per cent. There is little
difference of opinion among those who favored
utilization committees when answers from doctors
were compared by the size of the communities in
which they lived. In addition, the doctors felt
that a utilization committee should be a standing
function of county medical societies, and a little
over one-third thought that hospital staffs should
have that responsibility.
7. The majority of the doctors (83 per cent)
did not believe that Blue Shield's medical service
principal should be available only to people with
incomes under $5,000.
8. More than half of both the generalists and
specialists agreed that Blue Shield should not offer
a contract which would include all professional
services.
9. If out-patient diagnostic benefits were added
to Blue Shield contracts, almost half of the doc-
tors felt that this benefit should be paid when
treatment was given in a doctor's office. About 10
per cent fewer doctors felf that payment should
be made only when the service was provided in
hospital out-patient departments and certified la-
boratories.
10. Just about three-fourths of the doctors be-
lieve that insurance benefits should provide for
consultation. Ten per cent more specialists be-
lieved this than did general practitioners.
I I. Doctors were divided about half and half
on whether the present 24-hour limitation on first
aid treatment should be increased. Two-thirds of
those who favored it thought it should be in-
creased to 48 hours.
1419
OPINION STUDY OF PREPAID MEDICAL CARE COVERAGE IN MICHIGAN
12. A majority of the doctors do not believe
that Blue Shield should offer hospital coverage on
an indemnity basis, nor do they believe that Blue
Shield should offer such things as life insurance,
disability protection, etc., as well as medical serv-
ice coverage in the policies.
13. Because of present economic conditions, 60
per cent of the doctors recommended that the
present $5,000 income limit be raised along with a
higher-fee schedule for the contract.
14. One-third of the doctors recommended that
a $7,500 income-limit contract be added to the
$5,000 and $2,500 contracts which are already
offered.
15. Sixty-eight per cent favored a new $7,500
income limit contract providing the present $5,000
fee schedule was raised by 32 per cent and then
used as the $7,500 fee schedule.
16. A majority (70 per cent) feel that the
present $2,500 contract should not be eliminated,
nor do they believe that the $2,500 contract should
be continued as an indemnity to serve as basic
coverage for larger income groups.
17. A resounding majority (83 per cent) said
they did not object to reporting their total charges
for each case on the service report form submitted
to Blue Shield.
18. Sixty-three per cent feel that the most im-
portant factor in determining their fees is to fol-
low the "usual" fee in the community as represent-
ing the value of the services rendered, whether it
is a non-insured patient or one who has Blue Shield
but has an income greater than the income limits
of his contract.
19. A majority of the doctors (65 per cent) feel
that the Blue Shield should be raised on a selec-
tive basis, and 69 per cent feel that Blue Shield
should adjust its premiums and fee schedules as
living costs vary.
20. Of the general practitioners, 90 per cent
do not advocate a difference in the fees paid by
Blue Shield to generalists and specialists for the
same category of treatment. Sixty per cent of the
specialists feel there should be a difference in fees.
21. If the patient knows of the payment, 82 per
cent of the doctors believe that assisting surgeons
should be paid by Blue Shield. Ninety-two per
cent of the generalists and 75 per cent of the spe-
cialists agreed to this. Of those agreeing, 47 per
cent thought it should be paid in all hospitals, 42
per cent favored separate allowances for the assist-
ing surgeon based on a percentage of the surgical
fee paid to the surgeon in charge, 37 per cent
favored separate allowances for the assisting sur-
geon on a flat rate based on major and minor sur-
gery, and 35 per cent thought it should be paid
only in hospitals without interns and residents.
22. More than half of the doctors said that their
income has been increased by Blue Shield because
of better collections.
23. Eighty-one per cent believe that their col-
leagues are dissatisfied with Blue Shield fees. More
doctors in cities of 100,000-500,000 felt this way.
24. Slightly over half of the doctors felt that
Blue Shield subscribers should receive a roster of
participating doctors providing it can be done
ethically.
25. Eighty-two per cent of the doctors stated
that separate contracts should be offered by Blue
Shield in addition to full pay policies, to permit
the subscriber to buy a deductible or coinsurance
policy.
26. Eighty-one per cent personally believe that
Michigan Medical Service is providing a satisfac-
tory service to the public at present, but a ma-
jority of these think its service can be improved.
However, 57 per cent believe that the public is
not entirely satisfied with Blue Shield. Yet, on the
other hand, the doctors believe that the subscrib-
ers are satisfied.
27. Eighty-eight per cent of the doctors believe
that Bl ue Shield subscribers do not sufficiently un-
derstand their contract.
* * *
The preceding Highlights Section was prepared especially
■for the September 23-24, 1957 meeting of the Michigan
State Medical Society House of Delegates. In subsequent
publications of the Study this section may be augmented.
TYPE OF COVERAGE DESIRED
MINOR COSTS
ONLY (20)
0.3 °/o
1420
TMSMS
COVERAGE IN MICHIGAN
PERCENTAGE OF PERSONS IN MICHIGAN
COVERED BY A PREPAYMENT DEVICE
PERCENT
0 10 20 30 40 50 60 70 80 90 100
PERCENTAGE OF THOSE COVERED
-PERCENTAGE TOTALS OVER 100 DUE TO
MULTIPLE MENTIONS.
BLUE SHIELD
MISCE
2 6.6
DON’T KNOW
4.8 'Vo
64.6 °/o
NO COVERAGE BECAUSE!
CAN'T AFFORD IT
HAVEN'T GOT AROUND TO TAKING IT OUT
DON’T THINK WE NEED IT
DOESN'T BELIEVE IN INSURANCE
I CAN'T GET IT
HAD UNFAIR EXPERIENCE
DON'T GET ENOUGH OUT OF IT
I THINK RATES ARE TOO HIGH
GET FREE TREATMENT
COVERED BY VETERAN'S BENEFITS
MISCELLANEOUS
NO REASON -NEVER INVESTIGATED IT- NEVER
[GAVE IT A THOUGHT.
DON'T KNOW
PERCENT
-PERCENTAGE TOTALS OVER 100 DUE TO MULTIPLE MENTIONS.
November, 1957
1421
OPINION STUDY OF PREPAID MEDICAL CARE COVERAGE IN MICHIGAN
(monthly)
BLUE SHIELD SUBSCRIBERS BELIEVE THEY PAY $5.93
BLUE SHIELD SUBSCRIBERS ARE PAYING
ALL PERSONS INTERVIEWED ARE WILLING
> PAY
IS A
DEDUCTIBLE PLAN
FAVORED
?
YES
NO
'5.93
TOTAL
RESPONSES
4 7 . 0%
53 . 0%
UNION
MEMBERS
43 . 6%
56 . 4%
2.83
NON - MEMBERS
4 8. 8%
5 1.2%
OVER $5000 INCOME GROUP
5 i . 4%
48 . 6%
UNDER
$5000 INCOME GROUP
4 1 . 9%
5 8. 1 %
6.9 S
DOCTORS
82 . 2%
1 7 . 8%
/ALL FIGURES AVERAGE FOR SINGLE, SELF AND
V SPOUSE, AND FAMILY PLANS
HOW MUCH SHOULD 3E DEDUCTIBLE?
FIRST $25.00
FIRST $50. 00
FIRSTS 00- 00
4 7.7% OF RESPONSES
33.0% OF RESPONSES
( 1.5% OF RESPONSES
ATTITUDE
PUBLIC
DOCTORS’
SLUE SHIELD SUBSCRIBERS’
ATTITUDE
OPINION
ATTITUDE TOWARD COST
BLUE! 1 OTHER 1 BLUE
SHIELD ICOMPANIESI SHIELD
TOTAL
INTERVIEW'S D
BLUE SHIELD
SUBSCRIBERS
PUBLIC
GENERALLY
FAVORABLE E&iS
UNFAVORABLE ES
NO OPINION □
SATISFIED Hi
NOT ENTIRELY H
NOT SATISFIED □
BLUE SHIELD
3LUE SHIELD
UNION
NON-
OVER
SUBSCRIBERS
SUBSCRIBER
MEMBER
UNION
$5,000
INCOME
ABOUT RIGHT 111
TOO HIGH [H
TOO LOW I I
•■90
-80
•70
UNDER
^ 5,000
INCOME
DOCTORS ATTITUDE
BLUE SHIELD IS PROVIDING A SATISFACTORY SERVICE
YES 30.1%
YES BUT COULD BE IMPROVED 50 7%
NO 5.1%
NO UNLESS GREATLY IMPROVED 14.1%
SUPERVISORY CONTROLS ARE NECESSARY *
FOR BLUE SHIELD YES 7 8.8%
NO 2 1 2 %
FOR BLUE CROSS YES 8 5.4%
NO 14.6%
■* (ESTABLISH POLICING COMMITTEES
ON COMUNITY LEVEL UNDER
COUNTY MEDICAL SOCIETIES)
SUBSCRIBER AWARENESS OF CONTRACT BENEFITS
BENEFITS INCLUDED SUBSCRIBERS BELIEVING
BENEFITS INCLUDE
SURGICAL BENEFITS - -- -- -- -- -- -- 95-3%
OBSTETRICS - - 93.9
X-RAY DIAGNOSTIC - -- -- -- -- -- -- 83.6
MEDICAL VISITS IN HOSPITAL - -- -- -- -- 65.0
SURGICAL TREATMENTS IN DOCTORS
OFFICE 19 (PROCEDURES) _________ 27.8
EMERGENCY FIRST AID IN DOCTOR'S OFFICE - - 44 .4
BENEFITS NOT INCLUDED
DIAGNOSTIC OTHER THAN X-RAY _______ 45.1%
SURGICAL ASSISTANTS - -- -- -- -- -- - 41.7
MEDICAL CONSULTATION - -- -- -- -- -- 35 6
PRE AND POST NATAL OBSTETRICAL
CARE IN DOCTOR'S OFFICE - -- -- -- - 34.3
X-RAY OUTPATIENT DIAGNOSTIC- - -- -- -- 31.8
1422
JMSMS
SUMMARY
DESIRED BENEFITS
SINGLE PLAN - SELF AND SPOUSE PLAN-FAMILY PLAN
SURGICAL BENEFITS IN HOSPITAL
X-RAY DIAGNOSTIC IN HOSPITAL
MEDICAL VISITS IN HOSPITAL
EMERGENCY FIRST AID -DOCTOR'S OFFICE
DIAGNOSTIC OTHER THAN X-RAY IN HOSPITAL
MEDICAL CONSULTATION IN HOSPITAL
CALLS FOR MEDICAL CASES IN DOCTOR'S OFFICE
SURGICAL ASSISTANTS
AMBULANCE SERVICE
SURGICAL TREATMENT AT DOCTOR'S OFFICE
HOME CALLS
DIAGNOSTIC SERVICES INCLUDING LAB. FEES
THERAPEUTIC X-RAY IN HOSPITAL
SHOTS AND VACCINATIONS
X-RAY OUTPATIENT DIAGNOSTIC
X-RAY THERAPY IN DOCTOR'S OFFICE
ALLERGY TESTING AND TREATMENT
PRIVATE NURSE IN HOSPITAL
OBSTETRICS
PRE AND POST NATAL OBSTETRICAL CARE
0 10 20 30 40 5 0 6 0 70 80 90 100
PERCENT
Summary
Summary of Opinion Survey of Prepaid Medical Care
Coverage and Related Costs
PERCENT
Who has medical-surgical protection?
!. Eight out of ten persons (31 per cent) in
Michigan have some kind of prepayment device
protecting them against medical-surgical expense.
(a) Of the occupational groups, skilled trades-
workers have the highest coverage — nine out
of ten (91 per cent). Next highest are cler-
ical and salespeople, eight out of ten (85 per
cent), unskilled laborers eight out of ten (83
per cent) and professional and semiprofes-
sional eight out of ten (83 per cent). Lowest
coverage is found among retired, widows and
unemployed with five out of ten (49 per
cent).
(b) Coverage in rural and urban areas is nearly
equal (urban 81 per cent, rural 80 per cent).
November, 1957
(c) Union members have higher coverage than
nonmembers of unions, the former having
nine out of ten (96 per cent), the latter
seven out of fen (76 per cent) .
(d) in the "over-$5,0QQ" family income group
eight out of ten are covered (86 per cent)
compared to seven out of ten (75 per cenfj
for the ‘'under-$5,000" family income group.
What company or plan provides the coverage?
1. Six out of ten persons (64 per cent) having
medical coverage were subscribers to Blue Shield.
2. About two out of ten ( 18 per cent) of those
covered by any plan were protected by more than
one policy or contract.
1423
OPINION STUDY OF PREPAID MEDICAL CARE COVERAGE IN MICHIGAN
Extent of awareness of benefits in contracts
I. Blue Shield subscribers were asked their
opinion on what benefits they thought were pro-
vided in their contracts. They were given a pre-
pared list of benefits some of which were offered
by Blue Shield and some of which were not. They
were asked to select from this list the benefits
they thought were included in the maximum Blue
Shield contract. Following is the percentage of
inclusions given for each benefit which is actually
covered by the maximum Blue Shield contract:
Surgical benefits 95%
Obstetrics 93%
X-ray diagnostic 83%
Medical visits in hospital 65%
Surgical treatments in doctor's office
(19 procedure) 27%
Emergency first aid in doctor's office 44%
Note: Anesthesia was included as part of the surgical benefit.
2. From the total listed benefits to be selected
from, those which are not covered by present Blue
Shield contracts, but which were mistakenly be-
lieved to be covered are as follows: (Only those
benefits receiving more than a 30 per cent men-
tion are listed.)
Diagnostic other than X-ray 45%
Surgical assistants 41%
Medical consultation 35%
Prenatal and postnatal obstetrical care in
doctor's office 34%
X-ray out-patient diagnostic 31%
Opinions regarding monthly premiums
for medical coverage
1. The average cost for all monthly premiums
for medical-surgical coverage was thought by the
respondents to be $6.25.
2. Nearly four out of ten persons (37 per cent)
did not know how much their monthly or annual
premiums amounted to.
3. Of the Blue Shield subscribers nearly three
out of ten persons (27 per cent) did not know their
monthly or quarterly premium cost. Of those who
did answer, their average estimate was $5.96 per
month (all plans, single, couple and family, were
included).
Estimates of amount of cost paid by employer
1. Five out of ten persons (54 per cent) said
they paid the entire cost of the medical-surgical
coverage premiums. The employer was thought
to have paid all the premium by two out of ten
persons (16 per cent) and part of the cost of
premium by three out of ten persons (30 per cent).
2. About 80 per cent of the employers paying
part of the premiums paid half the cost with the
employee paying the other half.
Are the cost of plans believed to be "about
right," "too high," or "too low,"
considering the benefits provided?
I. Of the single and widowed persons seven out
of ten thought the cost of Blue Shield protection
was "about right." Slightly fewer married per-
sons, six out of ten (57 per cent) thought that the
1424
costs were "about right." Three out of ten per-
sons (28 per cent) in the divorced category
thought that the cost of Blue Shield premiums were
"about right."
2. Six out of ten union members (56 per cent)
thought that Blue Shield premium costs were
"about right." A slightly higher percentage of
non-members of unions were satisfied with the
costs, six out of ten (60 per cent) indicating they
thought the costs were "about right."
3. Of the "over-$5,000" income group, six out
of ten persons (60 per cent) thought costs of
Blue Shield premiums were "about right" and
57 per cent in the "under-$5,000" income group
held the same opinion.
4. Reactions of a small sample to the rates
charged by various insurance companies vary be-
tween 55 per cent and 93 per cent thinking the
costs were "about right."
Persons claiming benefits under
medical-surgical coverage plans
1. Seven out of ten persons (69 per cent) have
called upon their prepayment device for benefit
payments.
2. Just over eight out of ten (83 per cent)
carrying the family contract have used their bene-
fits. Seven out of ten (66 per cent) with the self
and spouse contract have claimed benefits, and
four out of ten persons (38 per cent) with the
single contract have claimed benefits.
3. Five out of ten (48 per cent) of the persons
under age 30 have claimed benefits. Eight out
of fen persons (81 per cent) between the ages of
30 and 40 have claimed benefits and between six
and eight out of ten (60 per cent to 75 per cent)
of the older-age groups have called for benefits
under their policies or contracts.
4. Thirteen per cent more union members have
claimed benefits than nonmembers of unions.
The illnesses or injuries which resulted
in benefit claims
1. Of the persons claiming benefits (52 per
cent of the total coverage) nearly two out of ten
(18 per cent) did so for an illness or injury clas-
sified, by the respondent, as an emergency.
2. The next most frequently-mentioned reason
for benefit claims was obstetrics (16 per cent) fol-
lowed by observation (12 per cent). With the
exception of tumor removal and broken bones, no
other single illness category accounted for more
than 5 per cent of the mentions.
Amount of medical-surgical expense
covered by benefits
1. Four out of ten persons (44 per cent) had
had their entire medical-surgical expense covered
during their latest compensable illness.
2. Nearly six out of ten persons (59 per cent)
who made claims for compensable illness, had part
of the medical-surgical expense paid by the Blue
Sh ield or insurance company. Three per cent re-
ceived no benefits and 3 per cent "didn't know."
jmsm; s
SUMMARY
3. Blue Shield paid all expenses 38 per cent of
the time, part of the cost in 58 per cent of the
cases and none of the cost in I per cent of the
reported instances.
Amount of the cost of medical-surgical
care paid by individual
I. Of the persons whose medical coverage plan
paid "part," "none" and "don't know" (37 per
cent of the total number having compensable ill-
nesses), the following amounts were paid by these
individuals over and above the amounts paid for
them by the insuring plan:
$1.00— $50.00 142
$50.00— $100.00 44
$100.00— $200.00 25
$200.00— $1,000.00 8
2. One out of ten of the respondents (12 per
cent) to the question "How much of the cost of the
medical-surgical expense did you pay?" did not
know how much they had paid and one out of ten
had one or more additional policies which covered
remaining cost or more.
Medical-surgical items not covered
by plan or insurance
I. Although four out of ten persons (40 per
cent) could not recall the medical-surgical items
for which they had paid in excess of benefits re-
ceived, three out of ten (31 per cent) had to pay
for X-ray, 14 per cent for medication, 7 per cent
for pre- and post-natal care, 6 per cent for anes-
thetic, and 6 per cent for laboratory fees. The
remaining items had fewer than 4 per cent of the
total mention.
Reasons for extra expense, above that
paid by plan or insurance
1. Three out of ten (34 per cent) paid the
costs in addition to the amount paid by the plan
or insurance, because the services were not cov-
ered in the policy or contract.
2. Four out of fen (44 per cent) paid the addi-
tional costs because the doctor's fee was more
than the amount provided. Two out of ten (16
per cent) said that both noncoverage and higher
doctor's fees was the cause, and one out of ten
(12 per cent) didn't know.
Payment to doctor directly, or to patient
I. In three out of four instances (76 per cent),
the plan or insurance paid the doctor directly.
One out of four (25 per cent), paid the doctor
and was then reimbursed by the plan or insurance.
Extent of coverage in the past for
medical-surgical care of those who
are not now covered
I. Of the persons not now covered, five out
of ten (50 per cent) had been covered at one
time and the same number believed they had
never been protected.
Reasons for not now being covered
I. "Can't afford it" headed the list of reasons
| November, 1957
for not now being covered, with three out of ten
(34 per cent) of the total mentions. One out of
five (20 per cent) in the "over-$5,000" income
group cited this reason, and two out of five (42
per cent) in the "under-$5,000" income group
mentioned it.
2. "Haven't gotten around to taking it out"
was cited by two out of ten (17 per cent).
3. "Don't think we need it" was mentioned by
one out of ten ( 1 5 per cent) .
Benefits desired by "family plan" respondents
1. Of the benefits desired in the "Medical-
Surgical Services in Hospital" category those cited
most often were: surgical benefits 96 per cent,
x-ray diagnostic 83 per cent, and medical visits
in hospital 74 per cent. Of the remaining bene-
fits listed each received less than 66 per cent
mention.
2. Of the benefits desired in the "services in
the doctor's office" category, that cited most often
was "emergency and first aid," 75 per cent. Of
the remaining benefits listed each received less
than 57 per cent mention.
3. Forty-five per cent wished to have ambu-
lance service added to the list of benefits and
42 per cent wanted home calls.
4. When the benefits desired were separated
on the basis of whether the respondent's employer
presently pays "all," "part," or "none" of the
premium, relatively minor percentage differences
were indicated for inclusion of selected benefits.
Monthly costs of premiums for benefits
selected under full family coverage
contracts or plans
1. The average monthly premium cost for the
benefits selected by those respondents wishing cov-
erage for themselves and family was $1 1.24. This
figure varied by no more than $1.00 per month,
regardless of whether the average was taken from
the replies of union members or nonunion mem-
bers, the over- or under-$5,000 income groups, or
whether the employer of the respondent presently
paid "all," "part," or "none" of the premium.
2. When asked to eliminate benefits that were
least important in order to reduce the total month-
ly premium cost, eight out of ten persons (78 per
cent) were willing to pay the costs for the benefits
rather than to eliminate items.
3. The benefit receiving the highest percentage
of mention for elimination was X-ray out-patient
diagnostic. This was cited by one out of ten per-
sons (8 per cent) of the total number of persons
choosing the family plan. Five per cent would
eliminate private nurse ten-day limit, with other
benefits receiving even smaller percentage.
4. Monthly premium cost of the final selected
plan (after eliminating certain coverages to bring
the cost down) was an average of $10.09 per
month. Variations of this cost between union
members and non-members, and between the "ov-
er-$5,000" and "under-$5,0Q0" income groups
was less than $1.00 per month. A definite varia-
1425
OPINION STUDY OF PREPAID MEDICAL CARE COVERAGE IN MICHIGAN
tion occurred with the "sixty-years-and-over” age
group where the average was $5.94.
Benefits desired by "self and
spouse" respondents
1. Of the benefits desired in the "Medical-
Surgical Services in Hospital" category those cited
most often were: surgical benefits 97 per cent,
x-ray diagnostic 85 per cent, medical visits in the
hospital 71 per cent, and diagnostic other than
x-ray 71 per cent. Of the remaining benefits listed
each received less than 60 per cent mention.
2. Of the benefits desired in the "Services in
the Doctor's Office" category those cited most
often were: "Emergency and first aid" 66 per
cent, and surgical treatments 53 per cent. Of the
remaining benefits listed, each received less than
45 per cent mention.
3. Forty-one per cent wished to have ambu-
lance service added to the list of benefits and
36 per cent wanted home calls.
4. When the benefits desired were separated
on the basis of whether the respondent's employer
presently pays "all," "part," or "none" of the
premium, relatively minor percentage differences
were indicated for inclusion of selected benefits.
Monthly costs of premiums for benefits
selected under self and spouse coverage
contracts or plans
1. The average monthly premium cost for the
benefits selected by those respondents wishing cov-
erage for themselves and spouse, was $8.75. This
figure varied by no more than $1.00 per month
regardless of whether the average was taken from
the replies of union members or nonunion members,
the over-or under-$5,000 income groups, or wheth-
er the employer of the respondent presently paid
"all," "part," or "none" of the premium.
2. When asked to eliminate benefits that were
least important in order to reduce the total month-
ly premium cost, eight cut of ten persons (77 per
cent) were willing to pay the costs of the benefits
selected rather than to eliminate items.
3. The benefit receiving the highest percentage
of mention for elimination was x-ray out-patient
diagnostic. This was cited by one out of ten per-
sons (!0 per cent) of the total number of persons
choosing the self and spouse plan. Eight per cent
would eliminate calls for medical cases in the
doctor's office. Other benefits received even
smaller percentages.
4. Monthly premium cost of the final selected
plan (after eliminating certain coverages to bring
the cost down) was an average of $7.65 per month.
Variations of this cost between union members and
nonmembers, between the "over-$5,000" and "un-
der-$5,000" income groups, and between the va-
rious age groups was less than $1.00 per month.
Benefits desired by " single " plan respondents
I. Of the benefits desired in the "Medical-
Surgical Services in Hospital" category those
1426
cited most often were: surgical benefits 98 per
cent, x-ray diagnostic 84 per cent, and medical
visits in hospital 77 per cent. Of the remaining
benefits listed each received less than 66 per cent
mention.
2. Of the benefits desired in the "Services in
the Doctor's Office" category that cited most of-
ten was: "emergency and first aid," 70 per cent.
Of the remaining benefits listed each received
less than 52 per cent mention.
3. Fifty-two per cent wished to have ambulance
service added to the list of benefits and 48 per
cent wanted home calls.
4. When the benefits desired were separated
on the basis of whether the respondent's employer
presently pays "afl," "part," or "none” of the
premium, relatively minor percentage differences
were indicated for inclusion of selected benefits.
Monthly costs of premiums for benefits selected
under "single" coverage contracts or plans
1. The average monthly premium cost for the
benefits selected by those respondents wishing cov-
erage for self only, was $3.26. This figure varied
by no more than 50 cents per month regardless of
whether the average was taken from the replies of
union members or nonunion members, the over- or
under-$5,000 income groups, or whether the em-
ployer of the respondent presently paid "all,"
"part," or "none" of the premium.
2. When asked to eliminate benefits that were
least important in order to reduce the total month-
ly premium cost, nine out of ten persons (91 per
cent) were willing to pay the costs of the benefits
selected rather than to eliminate items.
3. The benefit receiving the highest percentage
of mention for elimination was calls for medical
cases at the doctor's office. This was cited by 3
per cent of the total number of persons choosing
the "single" plan. Two and seven tenths per cent
would eliminate x-ray outpatient diagnostic, 2.3
per cent would eliminate home calls.
4. Monthly premium cost of the final selected
plan (after eliminating certain coverages to bring
the cost down) was an average of $3.12 per month.
Variations of this cost between union members and
nonmembers, between the "ovei -$5,000" and "un-
der-$5,000" income groups, and between the va-
rious age groups was less than 50 cents per month.
Should plans or insurance cover major costs
of illness, or minor expenses, too?
1. Six out of ten persons (63 per cent) felt
that both major and minor costs should be cov-
ered by medical care coverage.
2. Nearly seven out of ten union members (68
per cent) favored coverage for both major and
minor costs exceeding nonmembers in this respect
by 7 per cent.
3. The "under-$5,000" income group favored
this coverage by 67 per cent, a margin of 6 per
cent over the income group which earned in ex-
cess of $5,000.
TMSMS
SUMMARY
Attitude toward paying a deductible amount
of the expense of each illness or disability, in
order to reduce the monthly cost of coverage
1. Five out of ten persons (47 per cent) fav-
ored paying a deductible amount in order to re-
duce coverage rates.
2. Four out of ten union members (44 per cent)
in the "over-$5,00Q" group favored this plan com-
pared to five out of ten nonunion members (54
per cent) in the same income group.
3. A comparison of those in the "under-$5,000"
income group, indicated four out of ten union
members (42 per cent) were in favor of deductible
with the same number of nonmembers (4! per
cent) favoring.
4. When the employer presently paid all of
the monthly premium for respondents, nearly five
out of ten persons (46 per cent) favored a de-
ductible plan. When the employer presently paid
part of the monthly premium, the five out of ten
persons (49 per cent) favored the deductible fea-
ture. In cases where all the premium costs were
borne by the respondent, five out of ten persons
(47 per cent) favored a deductible feature.
Amount of deductible expense persons
are willing to pay
1. Of those favoring a deductible feature five
out of ten (47 per cent) were willing to pay the
first $25.00 of the cost of each illness in order to
reduce their monthly premiums.
2. Three out of ten (33 per cent) favored a
$50.00 deductible.
3. One out of ten ( I I per cent) favored a
$100.00 deductible.
4. Of union members who favored the deduct-
ible idea, six out of ten (57 per cent) voted for
the $25.00 deductible, compared to four out of
ten (42 per cent) of nonmembers of unions.
5. The "under-$5,Q00" income group favored
by five out of ten (56 per cent) the $25.00 amount
compared to four out of ten (4! per cent) by the
"over-$5,000" group.
Attitude toward methods of paying benefits,
payment to doctor or insured
I. Nearly eight out of ten persons (78 per
cent) expressed the opinion that payment should
be made directly to the doctor. Two out of ten
(19 per cent) felt that the insurance or plan
should pay the insured who in turn would pay the
doctor.
Attitudes — favorable or unfavorable —
toward Blue Shield plans
1. Eight out of ten Blue Shield subscribers (8!
per cent) had a favorable opinion of Blue Shield.
2. Of the total number interviewed, six out of
ten (63 per cent), when asked their attitude to-
ward Blue Shield, expressed a favorable opinion.
3. Six out of ten union members (66 per cent)
expressed a favorable opinion of Blue Shield com-
pared to an equal number (62 per cent) of non-
members of unions.
4. Six out of ten persons (66 per cent) of those
expressing an unfavorable attitude toward Blue
Shield (19 per cent), did so because of rates.
People in Wayne County felt more strongly (80
per cent) on this than did out-state residents (57
per cent).
5. Three out of ten (33 per cent) of those
having an unfavorable feeling, gave "poor cov-
erage” as their reason. Two out of ten persons
(18 per cent) said that "poor claim paying rec-
ord" was responsible for their unfavorable atti-
tude.
Attitudes — favorable or unfavorable- —
toward insurance company plans
1. Two representative companies were selected
for this summary. The attitudes toward other
companies were basically similar in both content
and degree.
2. Company A
(a) Nearly eight out of fen Company "A" pol-
icy holders (77 per cent) had a favorable
opinion of Company "A."
(b) Of the total number interviewed, two out of
ten (25 per cent), when asked their atti-
tude tov/ard Company "A," expressed a fa-
vorable opinion.
(c) Of the total number interviewed, one out of
ten (12 per cent) had an unfavorable opinion
of Company "A." Sixty-two expressed no
opinion.
(d) Of the total number of those persons having
an unfavorable attitude toward Company
"A," five out of ten (54 per cent) thought
that the Company "misrepresented the pol-
icy" and five out of ten (53 per cent) be-
lieved the carrier had a "poor claim paying
record." Other categories of comment were
"poor coverage," "high rates," and "lack of
recognition by doctors and hospitals."
3. Company B
(a) Five out of ten Company "B" policy holders
(50 per cent) had a favorable opinion of
Company "B,"
(b) Of the total number interviewed, one out of
ten (14 per cent), when asked their opinion
toward Company "B," expressed a favorable
opinion.
(c) Of the total number interviewed, one out of
ten (10 per cent), had an unfavorable opin-
ion of Company "B." Seventy-six expressed
no opinion.
(d) Of the total number of those persons having
an unfavorable attitude toward Company
"B," five out of ten (56 per cent) thought the
Company had a "poor claim paying record"
and three out of fen (35 per cent) believed
that the Company "misrepresented the pol-
icy." Three out of ten (32 per cent) gave
"poor coverage" as the reason for their un-
favorable attitude.
November, 1957
1427
OPINION STUDY OF PREPAID MEDICAL CARE COVERAGE IN MICHIGAN
Summary of Survey of Consumer Opinion
on Medical Care Protection
This survey was undertaken in order to enable
a very large number of Michigan citizens to ex-
press their views on medical-surgical coverage. By
means of a mailed questionnaire to more than 60,-
000 households, this end was achieved.
Inevitably, the accuracy of this type of survey
is factored by the relatively large number of per-
sons who do not respond. This is not the case
with the Opinion Survey of Prepaid Medical Care
Coverage and Related Costs — a personal inter-
view survey where 100 per cent response is ob-
tained through individual contact. However, the
two surveys herein reported do tend to support
one another in their results, although in some in-
stances to varying degrees. When such is the
case, of course, the results of the interview sur-
vey is to be given preference over the mail Survey
of Consumer Opinion on Medical Care Protection.
Question 1. Do you have any kind of insurance
or plan that pays all or part of your family's med-
ical and surgical expenses? Nine out of ten of the
respondents indicated they did have some sort of
medical expense coverage. A higher percentage
of urban residents were covered than rural res-
idents, 94 per cent versus 88 per cent. When per-
centage of coverage was compared between the
over-$5,000 family income group and the under-
$5,000 family income group the former registered
95 per cent, the later 89 per cent.
Question 2. Would you indicate why you and
your family are not now covered by medical-surg-
ical insurance, if this is the case? The most fre-
quently mentioned reason for noncoverage was
"too expensive" which accounted for 41 per cent
of the answers. The next reason listed by 20 per
cent of the respondents was "self reliant," those
who were able to cover costs on a pay-as-you-go
basis. Only 13 per cent were not covered be-
cause of previous unsatisfactory experience with
insurance.
Question 3. With what medical-surgical plan
or insurance company are you or your family now
covered in whole or in part? Seven out of ten of
the respondents were Blue Shield subscribers. Of
those having medical-surgical coverage, 84 per
cent had one contract or policy, 15 per cent had
two, and one person had three policies.
Question 3a. Is any part or all of the premium
cost of this policy or policies paid by your em-
ployer? Of the total insured, about 10 per cent
had all of their coverage cost paid by their em-
ployer, 50 per cent had part of the cost paid, and
49 per cent had none of the cost paid by their
employer. [Note: These percentages total more
than 1 00 because some respondents had more
than one policy.)
1428
Question 3b. Does this plan(s) cover Self Onlyt
Husband & Wife, of Family? Of six out of ten
of the total insured carrying family protection, 25
per cent were covered for husband and wife, and
18 per cent were covered for self only.
Question 4. Have you ever had to call upon
your insurance company(ies) to pay benefits? In
answer to this question, 76 per cent of the peo-
ple said they had used their medical insurance.
A greater percentage of those insured under the
Family Plan (84 per cent) received benefits than
those covered under Single and Couple plans.
Question 5. The last time you used your med-
ical insurance, were there any medical or surgical
expenses that were NOT covered by your insur-
ance? Of the 5,138 responses to the question, 6i
per cent said that there were medical expenses
not covered by insurance benefits when the policy
was last used.
Question Sa. What were the medical expenses
not covered by your policy the last time you used
your medical insurance? Doctor fees were the
largest single item mentioned as not being cov-
ered completely by respondents' medical-surgical
insurance or plan. X-ray received 19 per cent of
the total mentions. Other items requiring pay-
ment, over and above insurance benefits, were
maternity 8 per cent, and anesthesia and office
calls, both 7 per cent.
Question 5b. About how much did you pay in
extra medical expense the last time you used
your medical insurance? Twenty-three per cent of
the respondents said they paid less than $25.00 for
extra medical expense and 18 per cent indicated
they paid between $26.00 and $50.00, and 12 per
cent between $51.00 and $75.00. Percentages of
persons paying from $75.00 to $100 was just un-
der 10 per cent.
Question 6. The benefits normally covered by
many medical insurance policies for services pro-
vided in the hospital are listed below. (These do
not include hospitalization expenses). Such a pol-
icy would cost your family approximately $5.00 a
month or $ 55.00 per year. . . . SURGICAL, FRAC-
TURES AND DISLOCATIONS, MATERNITY,
EMERGENCY FIRST AID, ANESTHETIC, X-RAY.
Which of the following benefits would you MOST
like to have ADDED TO THE COVERAGE OF
THE ABOVE POLICY? Of the total respondents,
5,731 answered this key question. More than 50
per cent wished to add x-ray benefits for out-pa-
tients— this item receiving the most mentions.
Next highest noted for inclusion was emergency
house calls, gaining 47 per cent of the total men-
tions. X-ray in the doctor's office received the
next highest vote with 45 per cent. No other L
JMSMS |
SUMMARY
benefit reached the over-40 per cent mark. In
almost every case, the desire for additional bene-
fits, over and above the typical basic coverage,
was relatively equal when compared between re-
spondents whose employers paid "all," "part," or
"none" of the cost of their present. For example,
under the category of Medical Treatment in the
Doctor's Office, respondents whose employers paid
■"all" of the insurance premium voted 29 per cent
for the addition of surgery in the doctor's office.
This compared to a 3 I per cent vote by persons
whose employers paid part of the premium and
29 per cent of those whose employers paid none
of the premium. When responses were compared
by age grouping, there was no significant differ-
ence in their desire for added services. The top
four benefits compared between members of farm,
labor and business and professional organizations
are as follows:
Labor
Farm
Business &
Professiona
Per cent
Per Cent
Per Cent
Emergency House
Calls 45
21
32
Diagnostic Service
(Doctor's Office)
42
18
34
X-Ray Out Patient
.Hospital)
40
21
46
X-Ray Diagnostic
(Doctor's Office)
36
18
39
When answers of the respondents were broken
down according to income groups, those persons
earning under $5,000, percentagewise, wished to
include more items than any other income group
or membership group (farm, labor, or business,
professional).
Question 7. If the benefits you checked in ques-
tion 6 were added to such a policy, how much in-
crease in premium per month do you think you
would be willing to pay? The average increase
that respondents indicated they were willing to
ay for the benefits they had added to the original
asic coverage in Question 6 was $2.36. When
average increases were taken from those persons
whose employers paid "all," "part," or "none,"
the figures were $2.72, $2.10, and $2.53 in that
order. There was only a 50 cents per month dif-
ference between the lowest and highest averages
of persons in the various income groups, from
under $2,500 to over $7,000. Farm organization
members were willing to pay the least monthly in-
crease, $1.61; labor topped the organization
groups with $2.79.
Question 8. In order to keep down the prem-
ium cost of added benefits, would you want to
drop any of the benefits normally included? About
three out of ten persons wished to eliminate some
of the additional benefits originally selected. Of
these items, maternity led the list with 18 per cent
wishing to drop that benefit. Emergency first aid
was next in line for exclusion, with 7 per cent elim-
inating.
Question 9. In order to reduce the monthly cost
of medical-surgical insurance would you favor pay -
November, 1957
ing a deductible amount of the expense per each
illness or disability (similar to deductible feature
of automobile insurance)? Fifty-two per cent of
those replying said "yes" and 48 per cent were
opposed. Members of organizations favored pay-
ing a deductible amount for each illness, with la-
bor being most strongly in favor, 64 per cent.
Business, professional followed with 62 per cent
and farm trailed with 54 per cent favoring the
idea. Other breakdowns of responses according
to income and amount of premium paid by em-
ployer showed little variation.
Question 9a. If you do favor the deductible
idea, how much deductible expense would you be
willing to pay? Of those favoring the deductible
plan, 52 per cent were willing to pay a $25.00 de-
ductible amount. Thirty-six per cent favored pay-
ing a $50.00 amount and 12 per cent preferred a
$ 100-deductible policy. Six out of ten of both
farm and labor organization members selected
the $25.00 plan, while only four out of ten of the
business, professional group did so. The under-
$5,000 income group preferred the $25.00 plan
by six to ten. Fewer in the $5,00Q-$7,000 group
favored this amount and only 45 per cent in the
over $7,000 group selected this figure.
Question 10. Should prepaid medical and surg-
ical plans or insurance cover only the major cost
items of an illness or operation, or should they
cover all minor items as well? Over 6,400 persons
responded to this question, and nearly seven out of
ten (67 per cent) believed that both major and
minor costs of an illness should be covered. Three
out of ten believed that only major costs should
be covered. Complete breakdowns of the re-
sponses by income, occupation, and according to
amount of premium paid by the employer showed
little variation from the overall average reported
in the preceding paragraph. When cross-tabu-
lated according to organization memberships the
results disclosed that the business, professional
group were about evenly divided on the question.
Farm Bureau respondents favored both major and
minor by two to one. And eight out of ten of
Labor members wished coverage for both major
and minor costs.
Questions 11 , 12, 13, Description of Respondents.
A majority of respondents, 81.2 per cent, were
males and 84.6 per cent were married. Thirty-
seven per cent had no children, 40 per cent had
one or two children. The majority of the sample
were in the age groups between 25 and 53, with
6 per cent under 24 and 6 per cent over 64 years
of age. About 20 per cent of sample resided in
a city over 500,000 and equal percentage lived in
a strictly rural area. Two out of ten came from
towns with a population between 25,000 and 1 00,-
000 and 15 per cent from cities between 100,000
and 500,000. The most frequently mentioned fam-
ily income was the $5,000-$6,999 group, next in
order were $2,500-$4,999 (26 per cent) and $7,-
000-$9,999 (22 per cent).
1429
OPINION STUDY OF PREPAID MEDICAL CARE COVERAGE IN MICHIGAN
An occupational breakdown of the respondents
showed about 4 per cent retired and the same
percentage of farmer and farm worker. Executive,
professional accounted for about 25 per cent,
white collar employees 20 per cent, and hourly-
rated workers 33 per cent. Eight per cent of the
response of those belonging to organizations was
in the farm group, 54 per cent, labor and 37 per
cent business, professional.
Summary of Survey of Doctor Opinion
on Prepaid Medical Care Plans
Respondeni identification
1. Three out of every ten doctors (35 per cent)
answering the questionnaire said they were in gen-
eral practice.
(a) Another third of the respondents were about
evenly divided between internists (13 per
cent) and surgeons ( 12 per cent).
(b) The remaining four out of each ten were
identified with seventeen other specialties.
(c) Three out of ten (33 per cent) live in cities
of over half a million population.
(d) Less than one out of ten (6 per cent) live in
cities of less than 2,500 people.
(e) The other six out of ten were evenly divided
in cities of 2,500 to 24,999 (19 per cent),
25,000 to 99,999 (2i per cent) and 100,000
to 500,000 (21 per cent).
2. Eight of every ten doctors (80 per cent)
participate in at least one of the two Blue Shield
contracts.
(a) Seven of those eight (68 per cent) participate
in both Blue Shield income-limit contracts.
Administration and supervision
1. More than seven out of ten doctors (75 per
cent believe that the profession is qualified to
solve the economic problems in present-day med-
ical practice.
(a) The physicians over age 54 express a slightly
higher (82 per cent) degree of confidence
in this respect.
2. When asked who should administer the ma-
jor medical and surgical prepayment plans in
Michigan, three out of ten (33 per cent) specified,
"qualified laymen retained by the medical profes-
sion," another three out of ten (30 per cent) said,
"the medical profession itself," and three more out
of the ten (28 per cent) said the medical profes-
sion and the commercial insurance companies
should offer policies on a competitive basis.
(a) Less than one of the ten (8 per cent) believe
that the field should be dominated by the
insurance companies alone.
(b) Less than I per cent indicate a combined
preference for governmental agencies and
labor unions (.5 per cent and .4 per cent re-
spectively).
3. More than six out of every ten (64 per cent)
doctors believe the profession is not presently
given sufficient voice at the local level in the de-
termination of Blue Shield policy.
(a) Only five out of ten (50 per cent) believe
the same is true on the state level.
(b) When this was broken down into age group-
ings, it was revealed that less than six out of
ten (54 per cent) in the "over-54" group are
dissatisfied with present conditions on the
local level. Only four out of ten (43 per
cent) in this same age group believe the
same is true on the state levei.
(c) Of all the doctors expressing dissatisfaction
with present policy-making on the local level,
half of them (49 per cent) indicate that more
voice should be given to county medical so-
cieties.
(d) Four out of these ten (41 per cent) believe
more voice should be given specialty groups.
(e) On the state level only four out of ten (43
per cent) favor increased consideration to
county medical societies, and nearly half (46
per cent) say that specialty groups should
have more voice in Blue Shield policy-making.
(f) Or. both the local and state levels less than
one in ten (7 per cent) indicate a desire to
see more voice on policy matters vested in
the hospital staffs.
(g) All of these replies were then sorted accord-
ing to home town population. In cities un-
der 100,000 about six out of ten (59 per cent)
favor the county medical societies and three
out of ten favor the specialty groups. In
cities over the 100,000 figure only three out
of ten (32 per cent) indicated the county
medical societies as their principal choice,
and six out of ten (59 per cent) favor giving
more voice to the specialty groups.
(h) The widest departure from an even balance
in this respect was indicated in returns from
cities having less than 2,500, more than eight
out of ten (84 per cent) favor more voice
given to county medical societies, as opposed
to only one out of ten (15 per cent) desig-
nating the specialty groups.
4. Seven out of each ten respondents (73 per
cent) believe that the Blue Shield Board of Direc-
tors should continue to be elected by the MSMS
House of Delegates.
(a) Only in the "over-50" age group did this
percentage vary, and in this case it increased
to eight out of ten (80 per cent).
(b) Of the 27 per cent who did not believe the
Board of Directors should continue to be
elected by the House of Delegates, six out of
ten respondents (61 per cent) feel such elec-
tion should be a function of county medical
societies.
1430
TMSMS
SUMMARY
(c) Two out of ten (17 per cent) indicate special-
ty groups, and the remaining two out of ten
are equally divided between hospital staffs
(8 per cent) and councilor districts (8 per
cent) in their choices.
(d) Preferences were broken down into popula-
tion groupings. In cities of under 100,000,
seven out of ten "votes" (70 per cent) were
for county medical societies with one out of
ten (13 per cent) indicating the specialty
societies.
(e) In cities of over 100,000, only six out of ten
(61 per cent) indicated the county medical
societies, while two out of ten (22 per cent)
favored the specialty groups.
5. Six of every ten doctors (60 per cent) be-
lieve that the Board of Directors of Blue Shield
should include representation from groups other
than the medical profession.
(a) This ratio changed little when broken down
into age groupings. Only in the "over-54"
group did this drop, and in that instance to
about five out of ten (54 per cent).
(b) Nearly eight out of ten (76 per cent) believe
that management should be represented on
the Board of Directors.
(c) Seven out of ten doctors (71 per cent) be-
lieve that labor should also be represented.
(d) Oral surgeons and osteopaths are the next
choices, with 18 per cent and 17 per cent,
respectively.
(e) One in ten ( I I per cent) indicate they believe
state government should be represented.
6. When asked whether some supervisory con-
trols should be placed over the rendering of med-
ical care under insurance or service plans, eight
out of ten doctors (79 per cent) said, "yes."
(a) More than half of these (53 per cent) state
that such controls should be exercised by rep-
resentatives of the medical profession.
(b) About four out of ten (45 per cent) say a
combined board of lay persons and doctors
should handle such controls.
(c) Less than I per cent believe that govern-
mental agencies should perform this super-
vision.
(d) In answer to, "Where should the controls be
exercised?," four of ten (38 per cent) say,
"On the doctor." three (32 per cent) say
"On the hospital," and three (30 per cent)
say "On the patient."
7. Blue Shield utilization committees on the
community level are favored by seven out of ten
doctors (75 per cent).
(a) Little variation from this ratio was found when
these replies were sorted according to pop-
ulation, age and "generalist-specialist" group-
ings.
(b) Six out of ten doctors (59 per cent) believe
that such a committee should be a standing
function of county medical societies.
(c) Three out of ten (34 per cent) say hospital
staffs should have that responsibility.
November, 1957
8. More than four out of ten doctors (44 per
cent) object to the present necessity of asking their
Blue Shield patients about their income status in
order to make proper charges to under-income
patients.
(a) More than seven out of ten (73 per cent)
doctors say they would not object to having
their Blue Shield patients sign "claim forms,"
and 90 per cent of these say they would not
object if their patients were required to indi-
cate their income status on the doctor's re-
porting form.
(b) Six out of ten replying doctors (61 per cent)
want Blue Shield to inform the doctor of the
income category of the patient, such as with
varicolored cards.
9. As reported under the heading "payment
for services" later in this summary, the doctors
were asked to give their opinions regarding Blue
Shield policy as related to osteopaths. The 412
physicians who, by their answers to that broad
question, indicated that osteopaths should be per-
mitted to become participating physicians (two
out of each ten answering the question), were then
asked whether they thought osteopaths should be
represented on the Blue Shield Board of Directors.
Of that number, nearly eight out of ten (76 per
cent) agreed that they should.
10. Slightly less than half (48 per cent) of the
doctors believe that Blue Shield subscribers should
be provided with rosters of participating doctors,
even if such could be done ethically.
(a) This was broken down by population group-
ings, where highest approval of such a pro-
posal, six out of ten doctors (60 per cent),
was found in the "less-than-2,500" group
and the lowest ratio was four out of ten
(44 per cent), found in the "25-34" croup.
(b) Five out of ten (53 per cent) in the "over-
54" group approved.
I !. Seven out of ten doctors (72 per cent) say
that they would actively oppose the institution of
closed panel types of practice in their community,
such as is currently being undertaken in Detroit.
(a) Two out of ten doctors ( 17 per cent) say they
would ignore it.
(b) One out of every twenty-five doctors replying
(4 per cent) state they would join and sup-
port such a plan, if proposed in their com-
munity.
(c) This question was sorted into population
Groupings and by tvpe of practice.
(d) The percentage of those who would oppose
such a plan remains about the same in all
size cities, except in the "! 00,000-500,000"
ones, where it increases to eight out of ten
(79 per cent) .
(e) The larqest areas of support for such plans
lie in the "under-2,500" (5.8 per cent) and
the "over-500,000" (5.7 percent).
(f) The ratio of opposition and support for such
plans, when broken down into generalists and
1431
OPINION STUDY OF PREPAID MEDICAL CARE COVERAGE IN MICHIGAN
specialists, remains the same as on the over-all
level.
12. Four out of ten doctors, (39 per cent) be-
lieve that the medical profession, through Blue
Shield, should not contract with the government
to supply coverage for special groups, such as
with Medicare.
(a) Three out of ten (28 per cent) believe they
should, but only on the state level.
(b) Two out of ten doctors (23 per cent) think
such contracts should be on the local level.
(c) One out of every ten ( 10 per cent) prefer the
federal level for such contractual arrange-
ments.
13. Six out of ten physicians (59 per cent) fa-
vor increasing MSMS dues, if necessary, to pro-
vide for means and facilities to carry on contin-
uous economic studies on health insurance and
allied matters.
Service vs. indemnity
1. Two out of ten physicians (17 per cent) be-
lieve that the Blue Shield's medical service prin-
ciple should be available only to low-income
groups, with income less than $5,000.
(a) Eight out of ten (83 per cent) do not believe
that the service principle should only be avail-
able to those low income categories.
2. Four out of ten doctors (41 per cent) stated
that Blue Shield should be a service company.
(a) Less than two out of ten (16 per cent) be-
lieve it should be an indemnity company.
(b) More than four out of ten (43 per cent) did
not indicate their preference between the
two types of operations.
Changes in contracts
1. More than four out of ten doctors (43 per
cent) indicate that Blue Shield should offer a
contract that would include all professional serv-
ices rendered by any doctor of medicine.
(a) When this was sorted by type of practice the
same ratio of generalists, four out of ten
(43 per cent), agreed with the total group.
(b) The specialists were a little less inclined to
agree (42 per cent).
2. The doctors were asked whether they be-
lieve benefits for medical consultations should be
covered in Blue Shield contracts. These replies
were sorted by type of practice.
(a) On the over-all compilation more than seven
out of ten (74 per cent) feel that itiey should
be.
(b) Fewer of the generalists, as a group, concur
(88 per cent).
(c) More of the specialists, as a group, agree
that they should be (78 per cent).
3. The doctors are divided about half-and-
half (51 per cent and 49 per cent, "yes" and "no")
on whether the present twenty-four-hour limitation
on first aid treatment should be increased.
(a) Of the doctors who do favor an increase, six
out of ten (62 per cent) recommend it be
changed to forty-eight hours.
(b) Three out of those ten (32 per cent) feel it
should be increased to "over 48 hours."
(c) Less than one out of ten (6 per cent) indicate
a preference for a thirty-six hour limit.
4. Four out of ten (42 per cent) doctors think
Blue Shield should not offer hospitalization cov-
erage on an indemnity basis in addition to the
present medical service coverage.
(a) More than three out of ten (33 per cent) feel
it may possibly be advisable in the future.
5. Seven out of every ten (70 per cent) physi-
cians do not believe that Blue Shield should ar-
range agreements with insurance companies, en-
abling them (Blue Shield) to offer the subscriber
life, disability protection, and other types of in-
surance with the present service policies.
6. Little more than half (55 per cent) of the
doctors believe Blue Shield should develop a
variable premium system whereby high-utilization
subscribers would be up-graded into a higher rate
bracket.
7. More than seven out of ten doctors (72 per
cent) agree that Blue Shield should provide
"policy riders" in addition to the basic contracts,
at specific extra rates for the additional cover-
ages.
8. Eight out of ten doctors (82 per cent) be-
lieve that Blue Shield should offer separate con-
tracts, in addition to "full-pay policies," as de-
ductible or co-insurance policies.
9. In reply to whether Blue Shield should in-
stitute a system for post-payment for excessive
major medical expenses whereby Blue Shield would
pay the additional costs to the doctor and sub-
sequently be repaid by the subscriber by an addi-
tional premium over a period of time, a little
less than half of the replying doctors (49 per cent)
said, "yes."
Income limits
1. Three out of ten doctors (32 per cent) in-
dicate satisfaction with the present $5,000 fee
schedule and would continue to accept it in full
payment for services to under-income subscribers.
(a) Less than one in ten (7 per cent) would like
to see the income limits raised, but desire
to see the fee schedule remain unchanged.
(b) Six out of ten doctors (60 per cent) recom-
mend raising the fee schedule as well as the
income limits.
(c) When these replies were sorted according to
population groupings, this pattern followed
the same genera! ratio.
2. More than three doctors out of ten (34 per
cent) say that Blue Shield should add a $7,500
contract to the two no w being offered the public, j
(a) Two out of ten (19 per cent) believe that
only a $7,500 contract should be offered.
(b) Two more out of the ten (19 per cent) favor
only the $5,000 contract.
(c) The other three of the ten are divided be-
tween offering just the present $2,500 one,
1432
JMSMS
SUMMARY
a new $10,000 one (15 per cent) and some-
thing else, unnamed in the replies,
d) When these figures were sorted according
to population groupings, all areas followed the
pattern generally, except the "under-2,500"
group, where nearly five out of ten (46 per
cent) favored the issue of all three contracts,
and only one in ten (13 per cent) felt only
the $5,000 one should be offered.
3. Seven out of ten doctors (68 per cent) fa-
or placing the income limit in a new contract at
7,500, providing the present $5,000 fee sched-
iles are raised by 32 per cent and used as the
17,500 fee schedule.
4. Seven out of ten doctors (70 per cent) be-
ieve the present $2,500 contract should not be
iliminated from Blue Shield offerings.
5. Nearly six out of ten (56 per cent) do not
>elieve that the $2,500 contract should be con-
inued as an indemnity contract, as basic coverage
or larger-income groups.
* ayment for Services
1. Half of the doctors (49 per cent) replying
o the questionnaire state that if Blue Shield were
o add outpatient diagnostic benefits to its con-
racts, such benefis should be paid for when freat-
nent is given in any doctor's office.
(a) Four out of ten (38 per cent) suggest that
payment be made only when treatment is in
hospital outpatient department and in certi-
fied laboratories.
(b) The remaining one out of ten respondents
(14 per cent) would stipulate payment only
when treatment is in the hospital outpatient
department, and not in certified laboratories.
(c) There was little deviation from this ratio
when these figures were grouped by type of
practice.
(d) More than two out of ten doctors (24 per
cent) list "x-ray, diagnostic" as the most im-
portant category of service to be paid for in
any expansion of service benefits.
2. Four out of every ten doctors (41 per cent)
do not believe that the "income limits" in the
Jlue Shield contracts should be dispensed with
ind a standard premium charged with a standard
ee paid.
a) Nearly three out of ten (27 per cent) feel the
opposite.
b) Nearly two out of ten (16 per cent) say
"no," if no additional charge is permitted
by participating doctors."
c) 12 per cent say "yes, if a higher scale of fees
is paid to the specialist."
d) The greatest departure from this pattern of
answers occurred when the replies were brok-
en down by type of practice into generalists
and specialists categories. Compared to the
12 per cent average of both groups, only 2
per cent of the generalists and 18 per cent
of the specialists said, "yes, if a higher scale
of fees is paid to the specialist."
ovember, 1957
3. When the doctors were asked if they would
object to reporting their total charges for each
case on the service report, eight out of ten (83
per cent) said, "no."
(a) This was sorted by population, age and type
of practice groupings, and little deviation
was noted from the average pattern.
4. More than six out of ten doctors (63 per
cent) believe that the most important factor in
their determination of their fees is, "the usual fee
in the community as representing the value of the
services rendered."
(a) Two out of ten doctors (21 per cent) say that
"their personal evaluation of their profes-
sional ability" is the basis for setting their
fees.
(b) The "economic potential of the patient to
pay" is third with 14 per cent of the doctors
indicating it as their determining factor.
(c) The "physician's years of experience in prac-
tice" is used by less than 3 per cent of the
doctors as a basis for determining charges.
(d) When these figures were sorted by population,
age and type of practice groupings, there
was no outstanding deviation from this ratio.
5. More than six out of ten doctors (65 per
cent) believe that Blue Shield fee schedules should
be raised on a selective basis.
(a) Two of the ten (23 per cent) believe that they
should be raised on a certain percentage
basis across the board.
(b) One in ten (13 per cent) believe they are
reasonable now.
(c) When these figures were sorted by population
groupings the "under-2,500" cities reflected
a 2-out-of-IO (21 per cent) ratio of doctors
who feel fees are reasonable now.
(d) In the "over-500,000" cities, this dropped to
less than one in ten (8 per cent).
6. Seven out of ten doctors (69 per cent) be-
lieve that Blue Shield should adjust its premiums
and fee schedules as living costs vary.
(a) These figures were broken down info age
groupings, but no general deviation from th 
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